A SYSf'llM OF SURGERY; PATHOLOGICAL, DIAGNOSTIC, THERAPEUTIC, AND OPERATIVE. BY SAMUEL D. GROSS, M.D., LL.D., D.C.L.Oxon., LL.D. Cantab., TH- EM ER ITU 3 PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE. ILLUSTRATED BY UPWARDS OF SIXTEEN HUNDRED ENGRAVINGS. SIXTH EDITION, THOROUGHLY REVISED AND GREATLY IMPROVED. IN TWO VOLUMES. VOL. II. PHILADELPHIA: HENRY C. LEA’S SON & CO. 1882. Entered according to the Act of Congress, in the year 1882, by HENRY C. LEA’S SON & CO., in the Office of the Librarian of Congress, at Washington. All rights reserved PHILADELPHIA : COLLINS, PRINTER. CONTENTS 0E VOL. II. PART SECOND. SPECIAL SURGERY; OR, DISEASES AND INJURIES OF PARTICULAR ORGANS, TEXTURES, AND REGIONS. CHAPTER I. INJURIES AND DISEASES OF TIIE HEAD. PAGE Sect. I. Lesions of the Scalp . . . . . . . .19 1. Wounds and contusions . . . . . . .19 2. Abscesses ......... 21 3. Tumors ......... 22 II. Affections of the Cranial Bones and their Appendages . . . .25 1. Pericranitis ......... 25 2..Contusion of the cranial bones . . . . . .26 3. Caries, necrosis, and fistule . . . . . . .26 4. Tumors . . . . . . . . .27 5. Malformations . . . . . . . .30 III. Cerebral Affections . . . . . . . .33 1. Concussion of the brain . . . . . . .33 2. Contusion of the brain . . . . . .36 3. Compression of the brain . . . . . . .38 4. Irritation of the brain . . . . . . .46 5. Traumatic encephalitis . . . . . . .47 6. Abscess of the brain . . . . . . . .50 7. Extravasation of blood . . . . . . .53 IV. Fractures of the Skull ........ 56 1. Simple linear fracture without depression . . . . .57 2. Simple fracture with depression of bone . . . . .58 3. Simple fracture with depression, and symptoms of compression . . 58 4. Compound fracture ........ 59 5. Fracture of the base of the skull . . . . . .60 6. Punctured fracture . . . . . . . .62 7. Fracture of only one of the tables . . . . . .63 8. Depression without fracture . . . . . . .64 9. Fracture of the frontal sinuses . . . . . .64 10. Fracture of the walls of the orbit . . . . . .65 11. Separation of the sutures . . . . . . .65 12. Apparent depression . . . . . . . .66 13. Intra-uterine fractures . . . . . . .67 V. Gunshot Injuries of the Head . . . . . . .68 VI. Sword and Arrow Injuries of the Head . . . . . .75 VI CONTENTS OF VOL. II. PAGE VII. Wounds of the Brain and its Membranes . . . . .77 VIII. Fungus of the Brain ........ 78 IX. Injuries of the Cerebral Nerves . . . . . . .79 X. Intercurrent Effects ........ 80 Xl. Causes of Death ......... 82 XII. Secondary Affections ........ 82 XIII. Trephining ......... 85 XIV. Bandages for the Head . . . . . . . .89 CHAPTER II. DISEASES AND INJURIES OF TIIE SPINAL CORD, VERTEBRA, AND BACK. Sect. I. Concussion ......... 90 II. Sprains .......... 92 III. Wounds .......... 93 IV. General Effects of Injuries of the Spine . . . ... 94 V. Meningitis and Myelitis ........ 99 VI. Deformities of the Spine . . . . . . . . 101 1. Lateral curvature . . . . . . . .101 2. Posterior curvature . . . . . . . .108 3. Anterior curvature . . . . . . . .110 4. Angular curvature, tuberculosis, caries, or Pott’s disease . . .112 VII. Psoas Abscess . . . . . . . . .120 VIII. Hydrorachitis . . . . . . . . .122 IX. Hysterico-neuralgic Affections . . . . . . .125 X. Malignant Tumors of the Vertebras ...... 126 XI. Tumors of the Back ........ 127 CHAPTER III. INJURIES AND DISEASES OF THE FACE. . . .129 CHAPTER IV. DISEASES AND INJURIES OF THE EYE. Examination of the eye ......... 139 Refraction and accommodation . . . . . . . .144 Foreign bodies in the eye . . . . . . . . .152 Displacement of the ball of the eye . . . . . . . .154 Wounds and contusions . . . . . . . . .155 Diseases of the conjunctiva ......... 156 Diseases and injuries of the cornea . . . . . . . .166 Diseases and injuries of the sclerotica . . . . . . .173 Diseases and injuries of the iris . . . . . . . .175 Iridectomy and artificial pupil . . . . . . . .177 Diseases of the chambers of the eye . . . . . . . .182 Diseases and injuries of the crystalline lens and its capsule . . . . .183 Cataract ........... 183 Dislocation of the crystalline lens . . . . . . .197 CONTENTS OF VOL. II. PAGE Affections of the vitreous humor . . . . . . . .197 Diseases of the retina . . . . . . . . .198 Diseases of the choroid ......... 202 Glaucoma . . ....... 204 Strumous diseases ... ...... 206 Neuralgia of the eye . . . . . . . . . .210 Pyophthalmitis . . . . . . . . . .212 Oscillation of the eye . . . . . . . . .212 Immobility of the eye . . . . . . . . .212 Malignant diseases of the eye . . . ... . . .213 Extirpation of the eye . . . . . . . . .215 Artificial eye . . . . . . . . . . .216 Diseases and injuries of the lachrymal apparatus . . . . . .217 Injuries and diseases of the lids . . . . . . . .221 Ptosis ........... 229 Epicanthus ........... 230 Strabismus ........... 230 Affections of the orbit ......... 233 CHAPTER V. DISEASES AND INJURIES OF TIIE EAR. Examination of the Ear . . . . . . . . .237 Sect. I. Affections of the External Ear ....... 239 II. Affections of the Auditory Tube ....... 241 1. Malformations . . . ' . . . . .241 2. Foreign bodies ........ 242 3. Accumulations of Wax . . . . . . 244 4. Polypoid, fungous, parasitic, and other growths .... 245 5. Inflammation ........ 249 6. Boils or furuncles ........ 249 7. Herpetic affections ........ 250 8. Chronic inflammation of the external auditory canal . . . 250 9. Hemorrhage . . . . . . . . .251 III. Diseases of the Membrane of the Tympanum . . . . .251 1. Wounds and lacerations . . . . . . .251 2. Inflammation ........ 252 3. Abscess and gangrene ....... 253 4. Ulceration and otorrhcea ....... 253 IV. Acute Inflammation of the Cavity of the Tympanum .... 255 Y. Diseases of the Eustachian Tube . . . . . . .257 VI. Nervous Deafness ......... 261 VII. Deafness from Disease of the Tympanum and other Causes . . . 264 VIII. Affections of the Mastoid Cells ....... 266 IX. Otalgia .......... 267 X. Noises in the Ear ......... 268 CHAPTER VI. DISEASES AND INJURIES OF TIIE FRONTAL SINUS. . . 269 CONTENTS OF VOL. II. CHAPTER VII. INJURIES AND DISEASES OF THE NOSE AND ITS CAVITIES. PAGK Sect. I. Affections of the Nose ........ 271 1. Congenital defects . . . . . . . .271 2. Wounds . . . . . . . . .272 3. Furuncular inflammation . . . . . . .272 4. Syphilitic ulceration . . . . . . . .272 5. Epithelioma . . . . . . . . .272 6. Discoloration . . . . . . . .273 7. Varicose veins ........ 273 8. Nrnvus ......... 273 9. Sebaceous tumor ........ 273 10. Lipomatous tumor . . . . . . . .274 11. Fibrous tumor ........ 274 12. Hypertrophy of the skin . . . . . . .274 13. Naevoid elephantiasis ........ 274 14. Accidental deformities—Rhinoplasty . . . . .275 II. Affections of the Nasal Cavities . . . . . . .279 1. Rhinoscopy ......... 279 2. Cleansing and medication of the nasal passages .... 280 3. Discharge of serous fluid ....... 280 4. Deviations of the septum ....... 281 5. Hemorrhage . ....... 281 6. Abscess ......... 283 7. Ulceration ......... 284 8. Necrosis ......... 285 9. Hypertrophy ........ 285 10. Calculi ......... 286 11. Foreign bodies ........ 286 12. Polyps ......... 287 13. Exostosis ......... 294 14. Chondroma ......... 294 15. Malignant tumors ........ 294 CHAPTER VIII. DISEASES AND INJURIES OF THE AIR-PASSAGES. Sect. I. Examination and Medication of the Larynx ..... 295 II. Congenital Defects ........ 298 III. Laryngitis .......... 299 IV. Chronic Laryngitis . . . . . . . 300 V. (Edema .......... 302 VI. Erysipelas .......... 304 VII. Ulceration .......... 304 VIII. Stricture .......... 306 IX. Tumors or Morbid Growths ....... 306 X. Carcinoma . . . . . . . . . .311 XI. Spasm .......... 312 XII. Paralysis . . . . . . . . .312 IX CONTENTS OF VOL. II. PAGE XIII. Fistules .......... 314 XIV. Incurvation of the Epiglottis . . . . . . .314 XV. Tracheocele . . . . . . . . .314 XVI. Injuries .......... 315 XVII. Foreign bodies ......... 318 XVIII. Asphyxia .......... 334 XIX. Bronchotomy . . . . . . . . .338 XX. Introduction of Tubes ........ 340 XXI. Laryngectomy ......... 342 CHAPTER IX. INJURIES AND DISEASES OF THE NECK. Sect. I. Wounds .......... 343 II. Wryneck or Torticollis ........ 345 III. Clonic Spasm of the Cervical Muscles ...... 348 IV. Diseases of the Thyroid Gland ....... 350 V. Tumors of the Neck ........ 358 VI. Abscesses and Fistules of the Neck ...... 364 VII. Affections of the Hyoid Bone ....... 366 CHAPTER X. INJURIES AND DISEASES OF THE CHEST. Sect. I. Wounds of the Chest and Lungs ....... 366 II. Hemothorax . . . . . . . . .373 III. Pneumothorax . . . . . . . . .374 IV. Hydrothorax and Pyothorax . . . . . . .375 V. Pulmonary Abscesses and Caverns . . . . . .379 VI. Wounds of the Heart, Pericardium, and Large Vessels .... 380 VII. Hydropericardium ......... 384 VIII. Wounds and Rupture of the Diaphragm ...... 385 CHAPTER XI. DISEASES AND INJURIES OF THE JAWS, TEETH, AND HUMS. Sect. I. Affections of the Superior Maxillary Bone ..... 386 Excision of the upper jaw ....... 398 Tumors of the spheno-maxillary fossa ...... 402 II. Affections of the Inferior Maxillary Bone ..... 402 Excision of the lower jaw . . . . . . .412 III. Affections of the Teeth ........ 415 IV. Affections of the Gums 429 X CONTENTS OF VOL. II. CHAPTER XII. DISEASES AND INJURIES OF THE MOUTII AND THROAT. PAOE Sect. I. Affections of the Lips ........ 433 II. Affections of the Tongue ........ 444 III. Affections of the Salivary Glands ....... 456 Parotid gland ......... 456 Submaxillary gland . . . . . . . .462 Sublingual gland . . . . . . , .463 IY. Affections of the Floor of the Mouth ...... 465 V. Affections of the Palate . . . . . . . .466 YI. Affections of the Tonsils ........ 474 VII. Affections of the Uvula ........ 483 VIII. Affections of the Pharynx and (Esophagus ...... 484 CHAPTER XIII. HERNIA. Sect. I. General Observations . . . . . / . . .501 1. Reducible hernia ........ 504 2. Irreducible hernia . . . . . . . .515 3. Strangulated hernia . . . . . . . .519 II. Hernia of Particular Regions . . . . . . .539 Inguinal hernia ......... 539 Scrotal hernia . . . . . . . . .547 Femoral hernia . . . . . . . . .551 Umbilical hernia ......... 558 Ventral, pelvic, and diaphragmatic hernia . . . . .561 CHAPTER XIV. DISEASES, INJURIES, AND MALFORMATIONS OF THE ANUS AND RECTUM. Examination of the anus and rectum ....... 565 Injuries of the rectum ......... 568 Hemorrhage of the rectum . . . . . . . . .569 Foreign bodies in the rectum ........ 569 Atony of the rectum . . . . . . . . .571 Abscesses of the anus . . . . . . . . .572 Fistule of the anus . . . . . . . . . .572 Ulceration ........... 576 Fissure of the anus . . . . . . . . . .577 Sacs of the anus 578 Prolapse of the rectum . . . . . . . . .579 Hemorrhoids . . . . . . . . . .582 Varicose hemorrhoidal veins ......... 590 Anal and perianal tumors . . • . . . . . . . 590 Morbid growths .......... 591 Stricture of the rectum and anus ........ 592 Carcinoma of the anus and rectum ........ 595 Neuralgia of the anus and rectum . . . . . . . .599 XI CONTENTS OF VOL. II. PAGE Spasm of the sphincter muscles of the anus ....... 600 Pruritus of the anus and nates . . . . . . .601 Trichiasis of the anus ......... 602 Malformations .......... 602 CHAPTER XY. INJUKIES AND DISEASES OF THE ABDOMEN AND ITS CONTENTS. Sect. I. Wounds and Contusions of the Walls of the Abdomen .... 605 II. Wounds, Contusions, and Inflammation of the Peritoneum . . . 606 III. Wounds of the Stomach and Intestines . . . . . .608 IV. Gunshot Injuries of the Abdomen . . . . . . .615 Y. Foreign Bodies in the Stomach and Bowels . . . . .616 YI. Gastrectomy . . . . . . . . .617 VII. Intestinal Obstruction . . . . . . . .618 VIII. Artificial Anus and Lumbar Colotomy ...... 625 IX. Affections of the Omentum and Mesentery . . . . .628 X. Affections of the Pancreas ........ 629 XI. Injuries and Diseases of the Liver ....... 630 XII. Injuries and Diseases of the Gall-bladder . . . . . . 634 XIII. Injuries and Diseases of the Spleen ...... 636 XIV. Abscesses within the Wall and Cavity of the Abdomen . . . .637 XV. Tumors in the Wall of the Abdomen ...... 641 XVI. Ascites or Dropsy of the Abdomen ...... 643 XVII. Paracentesis or Tapping of the Abdomen ...... 645 XVIII. Fistules of the Abdomen . . . . . . . .647 XIX. Affections of the Umbilicus ....... 650 XX. General Diagnosis of Abdominal Affections ..... 652 CHAPTER XVI. diseases and injuries of the urinary organs. Sect. I. Affections of the Kindeys and Ureters ...... 655 II. Affections of the Bladder . . . . . . . .667 Examination of the bladder and urethra . . . . .667 Malformations ......... 668 Wounds . . . . . . . . . .671 Rupture .......... 673 Inflammation . . . . . . . . .674 Irritability or morbid sensibility ....... 682 Neuralgia ......... 684 Gout and rheumatism ........ 685 Paralysis ......... 686 Hemorrhage ......... 688 Tumors or morbid growths ....... 689 Tuberculosis ......... 692 CONTENTS OF VOL. II. ' PAUE Cystocele or hernia . . • • • . . . G92 Retention of urine . . . . . . . .692 Catheterism ......... 699 Tapping of the bladder . . . . . . . .702 Incontinence of urine . . . . . . . .704 Morbid conditions of the urine ....... 706 Urinary deposits . . . . . . . .71] Stone in the bladder . . . . . . . .715 Treatment of stone in the bladder . . . . . .727 1. Medical means . . . . . . . .727 2. Extraction of calculi through the urethra ..... 729 3. Rapid lithotrity . . . . . . .730 4. Lithotomy ......... 737 General results of the different methods of lithotomy . . . .762 Stone in the bladder of the female . . . . . .762 Foreign bodies in the bladder . . . . . .764 III. Diseases and Injuries of the Urethra . . . . . .765 Malformations . . . . . . . . .765 Congenital malformations . . . . . . .765 Wounds and lacerations . . . . . . .766 Hemorrhage . . . . . . . . .767 Foreign bodies ......... 767 Morbid sensibility . . . . . . . .769 Neuralgia . . . . . . . . .770 Fibrous tumors . . . . . . . . .770 Spasmodic stricture . . . . . . . .771 Org anic stricture . . . . . . . .773 Infiltration of urine ........ 784 Abscess . . . . . . . . . .785 Urethral fistule ......... 786 False passages . . . . . . . . .788 Carcinoma and tubercle ........ 788 IV. Diseases and Injuries of the Prostate Gland ..... 789 1. Acute prostatitis ........ 789 2. Abscess ......... 789 3. Ulceration . . . . . . . . .790 4. Hypertrophy . . . . . . . .790 5. Prostatorrhcea . . . . . . . .794 6. Tumors or morbid growths . . . . . . .796 7. Tuberculosis ......... 797 8. Hemorrhage . . . . . . . . .797 9. Concretions and calculi . . . . . . .798 10. Sacciform disease and fistule . . . . . . .799 CHAPTER XVII. DISEASES AND INJURIES OF TIIE MALE GENITAL ORGANS. Sect. I. Affections of the Testicle . . . . . . . .799 II. Affections of the "Vaginal Tunic . . . . . . .811 Acute inflammation . . . . . . . .811 Hydrocele . . . . . . . . .811 Hematocele . . . . . . . . .817 III. Affections of the Scrotum . . . . . . . .818 CONTENTS OF VOL. II. IV. Affections of the Spermatic Cord ....... 825 V. Affections of the Penis ........ 830 VI. Affections of the Prepuce ........ 836 VII. Gonorrhoea ......... 841 VIII. Non-specific Urethritis ........ 852 IX. Spermatorrhoea—Masturbation ....... 853 X. Satyriasis .......... 856 XI'. Impotence .......... 857 XII. Sterility .......... 860 CHAPTER XVIII. DISEASES AND INJURIES OF THE FEMALE GENITAL ORGANS. Sect. I. Affections of the Uterus ........ 862 Examination and mode of medication . . . . . .862 Malpositions . . . . . . . . .867 Wounds .......... 872 Laceration of the cervix . . . . . . .872 Inflammation and ulceration . . . . . . .874 Hypertrophy . . . . . . . . .877 Stricture and occlusion—Retention of the menstrual fluid . . .879 Dysmenorrhoea ......... 880 Neuralgia ......... 880 Collections of gas ........ 881 Dropsy .......... 881 Hemorrhage ......... 882 Myomatous and fibro-myomatous tumors ..... 882 Polyps .......... 886 Carcinoma ........ 890 Sarcoma .......... 898 Caesarean hysterectomy ........ 898 Rupture of the uterus ........ 900 II. Affections of the Ovary ........ 901 Inflammation . . . . ... . • • 901 Displacements ......... 902 Tumors .......... 902 Oophorectomy—Battey’s operation ...... 922 Ovario salpingeotomy—Tait’s operation ..... 923 III. Diseases of the Fallopian Tubes and Broacl Ligaments .... 924 IV. Extrauterine Pregnancy and Dermoid Cysts ..... 925 V. Affections of the Vagina . . . . . . . .926 VI. Affections of the Hymen . . . . . . . .931 VII. Affections of the Vulva ........ 932 VIII. Gonorrhoea in the Female ....... 943 IX. Vesico-vaginal Fistules ........ 946 X. Vesicorectal Fistules ........ 955 XI. Laceration of the Perineum ....... 956 Perineal bandage ........ 958 XIV PAGE XII. Retrouterine Hematocele ........ 958 XIII. Pelvic Cellulitis ......... 959 XIV. Separation of the Pelvic Symphyses ...... 960 XV Impotence and Sterility . . . . . . . .961 XYI. Affections of the Mammary Gland ...... 962 Mammitis ......... 962 Abscess .......... 963 Gangrene ......... 965 Lacteal engorgement ........ 965 Syphilitic affections . . . . . . . .966 Neuralgia ......... 966 Hypertrophy . . . . . . . . .967 Atrophy ......... 968 Fistule .......... 968 Calcareous concretions . . . . . . . .968 Apoplexy . . . . . . . . .168 Cysts .......... 969 Benign tumors ......... 971 1. Fibrous tumors . . . . . . . .971 2. Myxomatous tumors ....... 972 3. Adenomatous tumors ....... 973 Malignant tumors . . . . . . . .973 1. Sarcoma ......... 973 2. Scirrhus ......... 976 3. Encephaloid ........ 979 4. Colloid and melanosis ....... 980 . Treatment ......... 980 Diseases of the nipple and its areola ...... 984 Diseases of the breast in the male ...... 985 Diseases of the breast in the infant ...... 986 Affections of the mammary region . . . . . .987 General diagnosis of mammary tumors . . . . . .987 Excision of the breast ........ 990 Bandages for the breast . . . . . . . .991 CHAPTER XIX. DISEASES AND INJURIES OF TIIE EXTREMITIES. Gunshot wounds .......... 993 Affections of the nails ......... 1000 Onyxitis ........... 1001 Sect. I. Superior Extremity ........ 1002 1. Affections of the hand and fingers ...... 1002 Congenital irregularities of the fingers ..... 1002 Wounds of the hand and fingers ...... 1003 Hypertrophy of the fingers ...... 1005 Thumb sucking ........ 1005 Contraction of the hand and fingers ..... 1005 Concussion and contusion of the fingers ..... 1009 Clubhand ......... 1010 Removal of rings from the fingers . . . . .1010 Whitlow ......... 1010 Syphilitic affections of the fingers ..... 1012 CONTENTS OF VOL. II. CONTENTS OF VOL. II. XV PAGE Aneurism and naevus of the fingers ..... 1013 Bursal swelling of the fingers ...... 1013 Phlegmonous inflammation and abscess of the hand . . . 1014 Scrivener’s palsy ........ 1014 Tumors of the hand and fingers ...... 1016 Ankylosis ......... 1018 Bursal enlargement of the wrist . . . . . .1019 2. Affections of the elbow . . . . . . .1019 3. Affections of the shoulder ....... 1020 4. Affections of the axilla ....... 1023 5. Bandages for the superior extremity . . . . .1025 II. Inferior Extremity ........ 1026 1. Affections of the foot and toes ...... 1026 Congenital and other deformities of the toes .... 1026 Wounds of the feet and toes ...... 1028 Inflammation ........ 1028 Bunions ......... 1028 Inversion of the nail of the great toe ..... 1030 Exostosis of the great toe . . . . . .1031 Neuralgia of the foot . . . . . . .1031 Clubfoot ......... 1032 Flatfoot ......... 1043 Perforating ulcer ........ 1043 Podelcoma ........ 1044 Pododynia ........ 1044 Tumors ......... 1045 2. Affections of the leg ....... 1045 Bowed leg ........ 1045 Varix ......... 1047 Aneurismal varix ........ 1049 Laceration of the tendo Achillis ...... 1049 Dislocation of the tendon of the peroneal muscle . . . 1050 Rupture of the muscles of the leg ..... 1050 Fibro-cellular enlargement ...... 1051 3. Affections of the knee . . . . . . .1051 Ankylosis ......... 1051 Knockknee ........ 1052 Laceration of the ligament of the patella .... 1054 Housemaid’s knee ....... 1055 Venous tumor ........ 1056 4. Affections of the ham ....... 1056 5. Affections of the thigh ....... 1057 6. Affections of the nates ....... 1060 7. Affections of the coccyx ....... 1063 8. Affections of the groin ....... 1064 9. Ankylosis of the hip-joint ....... 1067 10. Operations on the sciatic nerve ...... 1067 11. Bandages for the inferior extremity . . . . .1068 CHAPTER XX. SPECIAL EXCISIONS OF THE BONES AND JOINTS. 1. Trunk ........... 1069 Excision of the clavicle ........ 1069 Excision of the scapula ........ 1070 PAGE Excision of the ribs ......... 1072 Excision of the sternum and ensiform cartilage ..... 1073 Excision of the pelvic bones . . . . . . . .1073 2. Superior Extremity . . . . . . . . .1074 Excision of the bones of the hand . . . . . . .1074 Excision of the wrist-joint . . . . . . . .1074 Excision of the bones of the forearm . . . . . .1075 Excision of the olecranon . . . . . . . .1077 Excision of the elbow-joint . . . . . . . .1077 Excision of the humerus ........ 1080 Excision of the shoulder-joint ....... 1080 3. Inferior Extremity ......... 1083 Excision of the bones of the foot ....... 1083 Excision of the ankle-joint ........ 1088 Excision of the knee-joint ........ 1089 Excision of the patella ........ 1094 Excision of the bones of the leg ....... 1094 Excision of the hip-joint ........ 1095 Excision of the great trochanter ....... 1098 CHAPTER XXI. SPECIAL AMPUTATIONS. 1. Superior Extremity ......... 1099 Amputation of the hand ........ 1099 Amputation at the wrist . . . . . . . .1102 Amputation of the forearm . . . . . . . .1102 Amputation at the elbow-joint . . . . . . .1103 Amputation of the arm . . . . . . . .1104 Amputation at the shoulder-joint . . . . . . .1104 Amputation above the shoukler-joint . . . . . . .1106 2. Inferior Extremity . . . . . . . . .1107 Amputation of the foot ........ 1107 Amputation at the ankle . . . . . . . .1111 Amputation of the leg . . . . . . . .1113 Amputation at the knee-joint . . . . . . . .1116 Amputation of the thigh . . . . . . . .1119 Amputation at the hip-joint . . . . . . . .1122 CONTENTS OF VOL. II LIST OF ILLUSTRATIONS TO VOL. II. FIG. PAGE 1. Fibrous Tumor of the Scalp . . . . ... . .24 2. Epithelial Ulcer of the Scalp . . . . . . . .24 3. Syphilitic Caries of the Skull . . . . . . . .26 4. Ivory-like Exostoses of the Skull . . . . . . .27 5. Syphilitic Enostosis of the Skull . . . . . . .28 6. Syphilitic Exostosis of the Inner Surface of the Skull . . . . .28 7. Encephalocele . . . . . . . . . .31 8. Chronic Hydrocephalus . . . . . . \ . .32 9. Skull of Hydrocephalic Child . . . . . . . .32 10. Trocar for Puncturing the Cranium . . . . . . .33 11. Diagram for Cranio-Cerebral Topography . . . . .42 12. Extravasation of Blood between the Skull and Dura Mater . . . .53 13. Large Blood Cyst attached to Parietal Arachnoid . . . . .53 14. Simple Fracture of the Skull . . . . . . . .57 15. Fracture of the Skull with Depression . . . . . . .58 16. Fracture of the Base of the Skull . . . . . . .60 17. Punctured Fracture of the Skull . . . . . . .62 18. Fracture of the Inner Table of the Skull . . . . . .64 19. Extensive Shell Fracture of the Skull . . . . . . .69 20. Fracture with Complete Detachment of the Inner Table of the Frontal Bone . .70 21. External View of Punctured Fracture of Frontal Bone . . . . .70 22. Internal View of the Same . . . . . . . .70 23. Gunshot Fracture of the Mastoid Process . . . . . .74 24. Indian Arrow penetrating Temporal Bone . . . . . .75 25. Sabre Cut of Parietal Bones . . . . . . . .75 26. Fungus of the Brain after Fracture . . . . . . .78 27. Application of the Trephine. . . . . . . . .85 28. 29, 30, 31, 32. Trephining Instruments . . . . . . 86, 87 33, 34, 35, 36. Bandages for the Head ...... 89, 90 37. Fracture of the Dorsal Vertebrae by a Conoidal Ball . . . . .94 38. Knife Wound of the Spinal Cord . . . . . . .94 39. 40. External Characters of Lateral Curvature of the Spine . . . .103 41. Lateral Curvature of the Spine . . . . . . . .104 42. Barwell’s Sloping Seat . . . . . . . . .106 43. Barwell’s Support for Lumbar Curvature ...... 106 44. Apparatus for Self-Suspension ........ 106 45. Barwell’s Support for Dorsal Curvature ....... 106 46. Apparatus for Lateral Curvature ....... 108 47. Posterior Curvature of the Spine . . . . . . .108 48. Apparatus for Relief of Posterior Curvature . . . . . .110 49. Anterior Curvature of the Spine ....... Ill 50. Apparatus for the relief of Anterior Curvature . . . . . .111 51. Caries of the Vertebrae . . . . . . . . .113 LIST OF ILLUSTRATIONS TO VOL. II. FIG. PAGE 52. Angular Curvature of the Spine from Caries . . . . . .113 53. Section of Spinal Cord in case of Paraplegia with Angular Curvature of Spine . 114 54. 55. Angular Curvature of the Spine . . . . . . .114 56. Abscess of the Spine from Caries of the Vertebrae . . . . .115 57. Angular Curvature and Ankylosis of the Spine, with Spontaneous Cure . .117 58. Sayre’s Suspension Apparatus . . . . . . . .119 59. Apparatus for Suspending the Head . . . . . . .119 60. Hydroraehitis of the Neck . . . . . . . .123 61. Bifid Spine, the Sac being laid open . . . . . . .123 62. Bifid Spine, showing the Disposition of the Nerves . . . . .124 63. Pendulous Fatty Tumor . . . . . . . .127 64. Paneoast’s Operation for Neuralgia . . . . . . .133 65. 66. Venous Tumor of the Lip and Cheek ...... 136 67. Congenital Foetal Tumor ........ 137 68. Epithelioma of the iCight Cheek . . . . . . .138 69. Liebreich’s Ophthalmoscope ........ 139 70. Mode of conducting an Ophthalmoscopic Examination .... 140 71. Healthy Appearance of the Eye . . . . . . .140 72. Inflammatory Deposits on the Retina ....... 141 73. Extravasations of Blood on the Retina ...... 141 74. Lateral Illumination of the Eye ....... 142 75. 76. Different Forms of Lid Elevators . . . . . . .143 77. Strabismometer . . . . . . . . . .143 78. Diagrams showing Convex Lens ....... 145 79. Diagram showing Emmetropic Eye . . . . . . .146 80. Diagram showing Myopic Eye . . . . . . . .147 81. Diagram showing Hypermetropic Eye ....... 148 82. Green’s Test Objects ......... 149 83. Thomson’s Optometer . . . . . . . . .150 84. Black Tin Disc for determination of Astigmatism ..... 151 85. Diagram showing Hypermetropia and Myopia ...... 152 86. Spud ........... 153 87. Simple Conjunctivitis ......... 156 88. Chemosis, or swelling of the Conjunctiva . . . . . .157 89. Acute Purulent Ophthalmia . . . . . . . .158 90. Purulent Ophthalmia in the Newly-born Infant . . . . .158 91. State of the Lids in Gonorrhoeal Ophthalmia ...... 159 92. Granular Lid .......... 160 93. Pterygium .......... 163 94. Double Pterygium ......... 163 95. Operation for Pterygium . . . . . . . .164 96. Dermoid Tumor ......... 164 97. Eneanthis .......... 165 98. Corneitis .......... 167 99. Syphilitic Permanent Teeth ........ 168 100. Opacity of Cornea; an example of Albugo . . . . . .171 101. Spherical Cornea . . . . . . . . .171 102. Conical Cornea . . . . . . . . . .171 103. Critchett’s Operation for Staphyloma . . . . . . .172 104. Staphyloma of the Sclerotic Coat, seen in Profile . . . • .173 105. Sclerotitis . . . . . . . . . .174 106. Sclerotitis extending to the Internal Tunics . . . . . .174 107. Congenital Fissure of the Iris . . . . . . . .175 108. Cystic Tumor of the Iris . . . . . . . .175 109. Acute Iritis . . . . . . . . . .177 110. Iritis, showing the Characteristic Vascularity of the Globe . . . .177 LIST OF ILLUSTRATIONS TO VOL. II. XIX PI9- PAGE 111. Prolapse of the Iris . . . . . . . . .179 112. Stop Speculum . . . . . . . . . .179 113. Toothed Forceps ......... 1§0 114. Curved Keratome ......... 180 115. Straight Keratome . . . . . . . . .180 116. Iris Forceps .......... 180 117. Broad Needle .......... 180 118. Tyrrell’s Hook . . . . . . . . . .180 119. Iris Scissors .......... 181 120. Iridesis ........... 181 121. Artificial Pupil .......... 181 122. Wecker’s Scissors . . . . .. . . . .181 123. Cellular Hydatid in the Anterior Chamber of the Eye . . . .183 124. Operation of Solution of Cataract . . . . . . .189 125. Scarpa’s Needle ......... 189 126. Hay’s Knife-needle ......... 189 127. Keratonyxis .......... 189 128. 129. Depression of Cataract . . . . . . . .191 130. Conjunctiva Forceps ......... 192 131. Beer’s Knife .......... 192 132. Superior Section of the Cornea ....... 192 133. Internal and Inferior Section of the Cornea ...... 192 134. External and Inferior Section of the Cornea . . . . . .192 135. Curette with Silver Scoop . . . . . \ . .193 136. Lens passing through Incision of the Cornea ...... 193 137. Curved Cornea Knife . . . . . . . . .193 138. Probe-pointed Scissors . . . . . . . . .194 139. Graefe’s Cataract Knife ........ 194 140. Graefe’s Corneal Incision . . . . . . . .195 141. Cystotome, with Caoutchouc Spoon . . . . . . .195 142. Levis’s Wire Loop for Extraction of the Lens . . . . . .195 143. Dislocation of the Lens into the Anterior Chamber of the Eye . . .197 144. Scrofulous Ophthalmia ......... 206 145. Glioma in its Earlier Stages . . . . . . . .213 146. Glioma after Ulceration ........ 213 147. Melanotic Sarcoma of the Eye . . . . . . . .214 148. Melanotic Sarcoma of the Eyeball ....... 214 149. Artificial Eye .......... 216 150. Anel’s Probe .......... 218 151. Anel’s Syringe .......... 218 152. Canaliculus Knife ... ..... 220 153. Lachrymal Fistule in its Chronic Stage ...... 221 154. Snellen’s Clamp ......... 222 155. Fibrous Tumor of the Lower Lid ....... 223 156. Epithelioma of the Lower Lid ........ 224 157. Cysticerce of the Lower Lid ........ 224 158. Entropion of both Lids . . . . . . . .224 159. Entropion Forceps . . . . . . . . .225 160. Graefe’s Operation ......... 225 161. Ectropion of the Lower Eyelid ....... 225 162. 163. Operation for Ectropion ........ 226 164, 165, 166. Plastic Operations on the Eyelid ...... 227 167. Trichiasis . . . . . . . . . .228 168. Epicanthus .......... 230 169. Cystic Tumor of the Orbit ........ 234 170. Anastomotic Aneurism of the Orbit ....... 234 XX LIST OF ILLUSTRATIONS TO VOL. II. FIO- PAGE 171. Ivory Exostosis of the Orbit ........ 235 172, 173. Ear Specula ......... 237 174. Forehead Mirror ......... 238 175. Ear Syringe .......... 238 176. Basin used in Syringing the Ear ....... 239 177. Clinical Tuning Fork ......... 239 178. Fibrous Tumor of the Ear ........ 240 179. Deformity and Induration of the Ear from Chronic Eczema .... 241 180. Toothed Forceps for Foreign Bodies in the Ear ..... 243 181. Instrument for the Removal of Foreign Matter from the Ear .... 243 182. Gelatinoid Polyp of the Ear ........ 246 183. Lobulated Polyp of the Ear ........ 246 184. Microscopical Characters of a Sarcomatous Polyp ..... 246 185. Ear Forceps .......... 246 186. Cotton-holder .......... 246 187. Sexton’s Polyp-snare . . . . . . . . .247 188. Fully developed Fruit Stalks of Aspergillus . . . . . .247 189. Molluscous Tumor of the Ear ........ 248 190. 191, 192. Fissures of the Membrane of the Tympanum .... 252 193. Paracentesis Knife . . . ... . • . . 253 194. Catheter for the Eustachian Tube ....... 259 195. Auscultation Tube ......... 259 196. Insertion of the Eustachian Catheter . . . . . . .259 197. Fixation of the Eustachian Catheter in Position ..... 260 198. Politzer’s Method of Opening the Eustachian Tube ..... 261 199. Politzer’s Air-bag for Inflating the Middle Ear . . . . .261 200. Necrosis of the Internal Ear ........ 265 201. Necrosis of the Mastoid Process and Petrous Portion of the Temporal Bone . . 266 202. Bifid Nose .......... 271 203. Epithelioma of Tip of the Nose ....... 273 204. Lipoma of the Nose . . . . . . . . .274 205. Naevoid Elephantiasis of the Nose ....... 275 206. 207. Paneoast’s Tongue and Groove Suture ...... 276 208, 209. Rhinoplasty and its Results 277 210. Tagliacozzi’s Operation of Rhinoplasty . . . . ' . . 278 211. Duplay’s Nasal Speculum . . . . . . . .279 212. Frankel’s Nasal Dilator ........ 279 213. Metz’s Nasal Speculum ........ 280 214. Duplay’s Rhinoscope ......... 280 215. Nasal Douche ......... 280 216. Bellocq’s Canula ......... 282 217. Plugging of the Nose ......... 283 218. Nasal Douche .......... 285 219. Gelatinoid Polyp of the Nose . . . . . . . .287 220. Fibrous Polyp of the Nose ........ 288 221. Frog-face, from Nasal Polyps ........ 288 222. Polyp-forceps .......... 290 223. Mode of Extracting a Nasal Polyp . . . . . . . 290 224. Double Canula . . . . . . . . . .291 225. Mode of Ligating a Nasal Polyp ....... 291 226. Carcinoma of the Nose ........ 294 227. Laryngoseopic Mirror . . . . . . . . .295 228. Mode of Conducting a Laryngoseopic Examination ..... 296 229. Sponge-probang for the Larynx ....... 297 230. Cohen’s Laryngeal Sponge-carrier . . . . . . .297 231. Lente’s Porte-caustique ........ 298 LIST OF ILLUSTRATIONS TO VOL. II. XXI FIG. ' PAGE 232. Laryngeal Syringe ......... 298 233. False Membrane of Croup ........ 299 234. CEdema of the Larynx ......... 302 235. Knife for (Edema of the Larynx ....... 303 236. Ulceration of the Larynx ........ 305 237. Ulceration of the Epiglottis ........ 305 238. Double Stricture of the Windpipe ....... 306 239. Papillary Growths of the Larynx ....... 307 240. Polypoid Fibroma of the Larynx ....... 307 241. Prolapse of Laryngeal Sac ........ 308 242. Mackenzie’s Cutting Laryngeal Forceps ...... 309 243. Mackenzie’s Rectangular Laryngeal Forceps ...... 309 244. Gibbs’s Laryngeal Ecraseur . . . . . . . .310 245. Stoerck’s Laryngeal Guillotine ........ 310 216. Cockle-bur from the Air Passages ....... 318 247. Ear of Grass from the Air Passages . . . . . . .318 248. Shawl-pin from the Air Passages . . . . . . .318 249. Artificial Teeth from the Air Passages ....... 319 250. Puff-dart from the Air Passages . . . . . . .319 251. Trachea Forceps •. . . . . . ... . 330 252. Trousseau’s Forceps ......... 331 253. Blunt Hook for Extracting Foreign Bodies from the Air Passages . . . 331 254. Probe for Exploring the Air Passages . . . . . . .331 255. Sponge Mop for Removing Extraneous Matter from the Larynx . . .331 256. Perforation of the Larynx ........ 334 257. Leroy’s Compressor ......... 336 258. Leroy’s Tube for Inflating the Lungs ....... 337 259. Leroy’s Bellows for Inflating the Lungs . .... 337 260. Tracheotomy ..... .... 339 261. Trachea Tube .......... 340 262. Cohen’s Tube .......... 341 263. Wryneck .......... 345 264. Tenotome .......... 347 265. Kolb6’s Apparatus for Torticollis ....... 347 266. Hypertrophic Goitre . . . . . . . . 351 267. Cystic Degeneration of the Thyroid Gland ...... 352 268. Ossified Thyroid Gland ........ 352 269. Cystic Goitre .......... 355 270. Fibrous Tumor of the Neck ........ 360 271. Sarcomatous Tumor of the Neck ....... 362 272. Counteropening in Abscess of the Chest . . . . . .372 273. General Emphysema of the Whole Surface, after Wound of the Chest . . 374 274. Trocar for Tapping the Chest ...... . 377 275. Shot Wound of the Heart ........ 382 276. Roberts’s Aspirating Pericardial Trocar ...... 385 277. Perforation of the Antrum ........ 388 278. Pope’s Antrum Drill ......... 388 279. Corkscrew-like Perforator ........ 388 280. Coleman’s Four-sided Perforator ....... 388 281. Forceps for Cutting Away the Alveolar Process in Neuralgia of the Jaw . . 390 282. Cysts of the Antrum ......... 391 283. Eneephaloid Sarcoma of the Upper Jaw ...... 395 284. Carcinoma of the Antrum, Encroaching upon the Face . . . .397 285. Carcinoma of the Antrum, Encroaching upon the Mouth .... 397 286. Excision of the Upper Jaw ........ 399 287. 288, 289. Different Forms of Bone-forceps ...... 400 LIST OF ILLUSTRATIONS TO VOL. II. FIG. PAGE 290. Clawed Forceps . . . . . . . . .401 291. Chronic Abscess of the Lower Jaw ....... 403 292. 293. Chin Retractors ......... 405 294. Scultetus’s Lever for Separating the Jaws ...... 406 295. Lever for Separating the Jaws ........ 406 296. 297. Plastic Operation on the Cheek ....... 408 298, 299. Cystic Tumor of the Lower Jaw ....... 409 300. Dentigerous Cyst of the Lower Jaw ....... 410 301. Epulis, in its Earlier Stages. . . . . . . . .412 302. Epulis,-in its More Advanced Stages . . . . . . .412 303. 304. Saws for Dividing the Jaw-bone ....... 414 305, 306. Elevators for Removal of Lower Jaw . . . . . .415 307, 308. Coleman’s Gag . . . . . . . .416 309. Vicious Position of the Wisdom Tooth . . . . . .417 310. Fusion of the Wisdom Tooth and Last Grinder ..... 418 311. Three Specimens of Germination of Teeth . . . . . .418 312. Malformation of the Fangs ........ 418 313. Supernumerary Teeth in Upper Jaw of a Youth . . . . .419 314. Permanent Teeth of Unusually Large Dimensions ..... 419 315. Honeycombed Teeth of the Upper Jaw . . . * . . 419 316. 317, 318. Different Forms of Caries of the Teeth ..... 421 319. Fungous Vegetations of a Tooth ....... 422 320. Fungous Tumor of a Tooth . . . . . . . 422 321. 322. Sac of Alveolar Abscess ........ 422 323. Purulent Cyst of a Molar Tooth . . . . . . .423 324. Osteoma of a Molar Tooth ........ 424 325. Scaling Instruments for Removing Tartar from the Teeth .... 425 326. Gum Lancet .......... 426 327-331. Tooth-forceps ......... 427 332. Application of the Same to a Tooth ....... 427 333. Tooth Elevator ......... 428 334. Tooth Hook .......... 428 335. Screw for Extracting Roots ........ 428 336. Hypertrophy of the Gums ........ 431 337. Papilloma of the Gum ......... 432 338. Cystic Tumor of the Lower Lip . . . . . . . 434 339. Epithelioma of the Lower Lip in its Earlier Stages ..... 436 340. Epithelioma of the Lower Lip in an Advanced Stage ..... 436 341. Papilla taken from an Epithelioma ....... 436 342. Elliptical Incision for Excision of Epithelioma . . . . .437 343. Excision of Epithelioma of Lip . ....... 437 344. Double Lip .......... 438 345. Single Harelip .......... 438 346. Double Harelip .......... 438 347. 348. Deformity of the Jaw in Harelip ....... 439 349. Malgaigne’s Operation for Harelip ....... 440 350. Harelip Sutures. . . . . . . . . .440 351. Hainsby’s Cheek Compressor ........ 442 352. Fissure of the Cheek ......... 443 353. Lines of Incision in Cheiloplasty ....... 443 354. Cheiloplasty .......... 443 355. Dobell’s Forceps for Holding the Tongue ...... 444 356. Glossitis .......... 444 357. Hypertrophy of the Tongue . . . . . . . .448 358. Microscopical Characters of Hypertrophy of the Tongue .... 448 359. Expansion of the Jaw from Pressure by the Tongue ..... 451 LIST OF ILLUSTRATIONS TO VOL. II. FIO. PAHE 360. Papillary Tumor of the Tongu-e ....... 451 361. Removal of the Tongue with the Rcraseur ...... 454 362. Lines of Incision in Regnoli’s Operation ...... 454 363. Seton for the Cure of Salivary Fistule ....... 462 364. Salivary Calculus ......... 463 365. Epithelioma of the Sublingual Gland ....... 464 366. Cleft Palate .......... 468 367. Whitehead’s Gag and Tongue Depressor ...... 469 368. Mears’8 Mouth Gag ......... 469 369. Needle-forceps for Cleft Palate . ....... 470 370. Spiral Needle .......... 470 371. 372. Arrangement of the Sutures in Staphylorraphy . . . . .470 373. Forceps for Staphylorraphy ........ 471 374. Unclosed Fissure in the Palate after Staphylorraphy ..... 472 375. 376. Knives for Uranoplasty ........ 472 377. Lines of Incisions in Uranoplasty ....... 472 378. Fissure of the Hard Palate . . . . . . . .473 379. Fissure of the Hard Palate closed by Sutures . . . . . .473 380. Obturator for the Palate . . . . . . . .474 381. Tongue Depressor ......... 475 382. Handball Spray-producer . . . . . . . .475 383. Inhaler ........... 475 384. Enlarged Tonsils ......... 478 385. Hypertrophy of the Tonsils ........ 478 386. Volsella .* . . . . . . . . .479 387. Fahnestock’s Tonsillotome ........ 480 388. Probe-pointed Bistoury ......... 480 389. Tonsil Rcraseur .......... 481 390. Forceps Scissors for the Uvula ........ 483 391. Sponge-holder .......... 486 392. Stricture of the (Esophagus ........ 490 393. (Esophageal Dilators ......... 491 394. Epithelioma of the (Esophagus ........ 494 395. Ulcerated Epithelioma of the (Esophagus ...... 494 396. 397. (Esophageal Forceps ........ 497 398. Instrument for extracting Foreign Bodies from the (Esophagus . . . 498 399. Horsehair Probang ......... 498 400. Hernial Sac .......... 503 401. Chase’s Truss .......... 506 402. Sheldon’s Truss .......... 506 403. Wutzer’s Instrument for the Radical Cure of Hernia ..... 510 404. Agnew’s Instrument for the Radical Cure of Hernia . . . . .511 405. Hernia Needle . . . . . . . • • .511 406. Invagination of the Sac in Wood’s operation for the Radical Cure of Hernia . .512 407. Passage of the Needle behind the Sac in the Same. ..... 512 408. Wood’s Operation as Completed . . . • • • .512 409. Wood’s Rectangular Pins . . . . . • • .513 410. J. Collins Warren’s Rubber Bag . . . . • • .517 411. Air Tube .......... 517 412. Strangulated Hernia ......... 520 413. Strangulated Bowel 522 414. Operation for Strangulated Hernia 529 415. Grooved Hernia Director ....•■•• 529 416. Searching for the Seat of Stricture ....... 529 417. Hernia Knife of Sir A. Cooper 530 418. Plan of Inguinal Hernia ....•••• 539 LIST OF ILLUSTRATIONS TO VOL. II. FI8, PAGE 419. Onlental Inguino-scrotal Hernia . . . . . . .541 420. Cross Body Truss ......... 541 421. Double Inguinal Truss ......... 543 422. Truss Applied .......... 543 423. Scrotal Hernia .......... 548 424. Scrotal Hernia; showing the usual relation of the Sac to the Vaginal Tunic . . 549 425. Infantile Scrotal Hernia ........ 551 42G. Ordinary Site and Appearance of Femoral Hernia ..... 552 427. Plan of Femoral Hernia ........ 552 428 Femoral Hernia, of very large size ....... 553 429. Strangulated Femoral Hernia ........ 553 430, 431. Hard Rubber Truss ........ 555 432. Femoral Tumor, Sac laid open . ....... 557 433. Umbilical Truss ......... 560 434. Umbilical Truss Adjusted ........ 5G0 435. Modified Sims’s Speculum ........ 5G6 436. Keen’s Speculum ......... 566 437. Dome-headed Speculum ........ 566 438. Rectum Bougies ......... 567 439. External Openings in Anal Fistule ....... 573 440. Mode of Exposing and Dividing the Parts in Anal Fistule .... 575 441. Mode of Operating in Anal Fistule ....... 575 442. Sacs of the Rectum ......... 579 443. Partial Prolapse of the Rectum ....... 580 444. Complete Prolapse of the Bowel ....... 580 445. Flexible Bandage for Prolapse ........ 582 446. External Hemorrhoids ......... 583 447. Hemorrhoidal Vein opening into Hemorrhoidal Tumor .... 583 448. Minute Structure of Internal Hemorrhoidal Tumor ..... 584 449. Internal Hemorrhoids . . . . . . . . 585 450. Protruding Hemorrhoids ....... 585 451. Smith’s Hemorrhoidal Clamp ........ 589 452. Polyp of the Rectum—External Appearance ...... 591 453. Polyp of the Rectum—Internal Structure ...... 591 454. Sricturc of the Rectum ......... 593 455. Stricture of the Anus, probably Syphilitic ...... 593 456. Epithelioma of the Rectum ........ 596 457. Epithelioma of the Anus ........ 596 458. 459. Imperforate Rectum and Anus ....... 603 460.461. Operations for Malformation of Rectum ...... 605 462. Wounds of the Intestine with Eversion of the Edges . . . . .611 463. Wounded Bowel with Adherent Omentum ...... 612 464. Continued Suture of the Bowel ....... 613 465. Ligature of Bowel Partially Detached . . . . . . .613 466. Lembert’s Suture ......... 613 467. Gely’s Suture .......... 613 468. Intussueeption of the Bowel ........ 619 469. Amussat’s Operation for the Formation of an Artificial Anus .... 626 470. Hypertrophied Omentum . . . . . . . .628 471. Mode of Puncturing Pelvic Abscesses ....... 641 472. Morton’s Trocar ......... 646 473. Operation of Tapping the Abdomen ....... 646 474. Dupuytren’s Enterotome Applied ....... 649 475. Enterotome of the Author ........ 650 476. Dilatation of the Ureter and Pelvis of the Kidney ..... 667 477. Exstrophy of the Bladder . . . . . . . .669 LIST OF ILLUSTRATIONS TO VOL. II. fig. - . , PAGE 478. Urinal ggg 4<9. Maury’s Operation for Exstrophy of the Bladder ..... 670 480. AVrood’s Operation for Exstrophy •.....; 670 481. Coluraniforra Bladder ....... 679 482. Sacculated Bladder ...... 679 483. Keyes’s Apparatus for Washing out the Bladder ..... 681 484. Multiple Papilloma of the Bladder ....... 689 485. Benign Vesical Papilla ...... 689 486. Carcinomatous Vesical Papilla ........ 690 487. Gouley’s Tunnelled Catheter ....... 695 488. Tapping the Urethra in the Perineum ....... 695 489. S. W. Gross’s Prostatie Catheter ....... 696 490. Overcurved Gum Catheter ........ 696 491. Prostatic Gum-elastic Catheter . . . . . . .696 492. Blood Catheter ...... 697 493. 494. Different forms of Catheters ....... 699 495, 496. French Gum-elastic Catheters ....... 700 497. Catheter for Washing out the Bladder ....... 700 498. Mode of securing the Catheter in the Bladder . . . . . .701 499. Holt’s Catheter ....... 70? 500. Rectal Tapping of the Bladder ....... 702 5<>1. Suprapubic Tapping of the Bladder ....... 702 502. Tube to be worn after Suprapubic Tapping . . . .. . . 703 503. Epithelium from the Bladder, Ureter, and Pelvis of the Kidney . . .708 504. Blood Corpuscles ...... y98 505. Pus Corpuscles ......... 709 506. Spermatozoa ......... 709 507. Urinometer ....... 710 508. Uric Acid ........ 711 509. Amorphous Urates . . . . . . .711 510. Oxalate of Lime . . . . . . . 511. Triple Phosphates . . . . . . 714 512. Cystine Deposit ......... 715 513. Calculus with a Cork for a Nucleus ....... 717 514. Thorny Calculus ......... 718 515. Urinary Calculus . . . . . . . .718 516. Uric Calculus ......... 719 517. Oxalic Calculus ......... 719 518. Hemp-shaped Calculus . . . . . . . . .719 519. Phosphatic Calculus . . . . . . t . .719 520. Ammoniaeo-magnesian Calculus . . . . . . .719 521. Fusible Calculus ........ 72o 522. 523. Cystic Calculus ......... 720 524. Urostealith Calculus ......... 721 525. Encysted Calculi ......... 721 526. Ordinary Sound . . . . . . .723 527. Hollow Sound .......... 723 528. Abruptly-curved Sound ........ 724 529. Sounding for Stone in Sacculated Bladder ...... 725 530. Sounding for Stone in Enlarged Prostate ...... 726 531. Calculus Breaking Spontaneously, and causing Death by Inflammation . . 727 532. Sir Astley Cooper’s Stone Forceps ....... 729 533. Weiss and Thompson’s Lithotrite ....... 730 534. Bigelow’s Lithotrite ......... 731 535. 536, 537. Different Forms of Lithotrite Blades ..... 731 538, 539. Blades of Bigelow’s Lithotrites ....... 731 XXV XXVI LIST OF ILLUSTRATIONS TO VOL. II. FIG. PAGE 540. Bigelow’s Evacuator, with Stand ....... 732 541. Bigelow’s Evacuating Catheters ....... 732 542. Seizure of the Stone in the Bladder ....... 734 543. Civiale’s Method of Seizing the Stone ...... 734 544. Position of Stone for Crushing ....... 735 545. Bandage for securing Patients in Lithotomy ...... 738 546. Grooved Staff .......... 739 547. Author’s Lithotomy Knife ........ 739 548. Beaked Knife . . . . . . . . . .739 549. Lateral Operation for Stone ........ 740 550. The Finger and Knife in the Groove of the Staff ..... 740 551. Lithotomy Forceps . . . . . . . . .741 552. Mode of Seizing the Stone with the Forceps ...... 741 553. Lithotomy Scoop ......... 741 554. Scoop and Finger Grasping the Calculus ...... 742 555. Left Lobe of the Prostate, as it is Divided in the Lateral Operation . . . 742 556. 557. Prostate at Four and Twelve Years ...... 743 558. Stone Crusher .......... 744 559. Lithotomy Crusher and Drill ........ 744 560. Physick’s Artery Forceps ........ 745 561. Author’s Arterial Compressor ........ 745 562. Canula for Plugging the Wound in Lithotomy ...... 745 563. Chemise for Hemorrhage after Lithotomy ...... 746 564. Brown’s Tampon ......... 746 565. Guyon’s Tampon ......... 746 566. Physick’s Gorget ......... 753 567. N. R. Smith’s Lithotomy Instruments ....... 753 568. Single Lithotome . . . . . . . -. .754 569. Double Lithotome ......... 754 570. Bilateral Operation of Lithotomy . . . . . . .755 571. Line of Incision in the Prostate . . . . . . .755 572. James 11. Wood’s Bilateral Gorget ....... 755 573. Little’s Director ......... 756 574. Mode of guiding the Finger into the Bladder ...... 756 575. Lithotomy with the Rectangular Staff . . . . . . .757 576. Briggs’s Cystotome ......... 758 577. Dolbeau’s Perineal Lithotrity ........ 761 578. Author’s Urethral Dilator . . . . . . . .762 579. Female Staff .......... 763 580. Forceps for Extracting Foreign Bodies from the Bladder . . . .764 581. Contorted Bougie in the Bladder ....... 764 582. Epispadias .......... 765 583. N61aton’s Operation for Epispadias ....... 766 584. Bonnet’s Articulated Scoop ........ 768 585. Hunter’s Forceps . . . . . . . . .768 586. Forceps for Extracting Foreign Bodies from the Urethra .... 769 587. Polyp and Fibroma of the Urethra . . . . . . .771 588. Papilloma of Urethra . . . . . . . . .771 589. Linear Stricture of Urethra . . . . . . . .773 590. Annular Stricture of the Urethra . . . . . . .774 591. Bridle Stricture of the Urethra . . . . . . .7 74 592. Bulbous Bougie . . . . . . . . .775 593. Stricture of the Urethra, with Dilatation of the Tube behind the Obstruction . 7 76 594. Stricture of Urethra, with Dilated Prostatic Ducts . . . . .776 595. Disease of the Kidney, Ureter, and Prostate Gland, from Stricture of the Urethra . 776 596. Porte-caustique . . . . . . . . .778 LIST OF ILLUSTRATIONS TO VOL. II. FIG. PAGE 597. Otis’s Urethrometer ......... 778 598-601. French Flexible Bougies . . . . . . . .7 79 602. Filiform Bougies . . . . . . . . .779 603. Richardson’s Tunnelled-handled Dilator ...... 780 604. Conical Steel Bougie ......... 780 605. S. W. Gross’s Dilator ......... 780 606. S. W. Gross’s Urethrotome ........ 781 607. Otis’s Divulsing Urethrotome ........ 781 608. Author’s Urethrotome ......... 781 609. Syme’s Staff . . . ... . . . . . 782 610. Gouley’s Grooved and Tunnelled Catheter Staff . 782 611. Grooved Director . . . . . . . . .783 612. Author’s Fluted Catheter . . . . . . . .783 613. Urethral Abscess, with Stricture and False Passages . . . . .786 614. Urinary Fistules ......... 786 615. 616, 617. Urethroplasty ........ 787 618. Stricture of the Urethra, with False Passage . . . . . .788 619. Abscess of the Prostate . . . . . . . .790 620. Hypertrophy of both Lobes of the Prostate . . . . . .791 621. General Hypertrophy of the Prostate . . . . . . .791 622. Hypertrophy of the Prostate, with Mammillary Enlargement of the Middle Lobe . 791 623. Angular Curvature of the Urethra from Hypertrophy of the Prostate . .793 624. Sarcoma of Middle Portion of Prostate . . . . . .797 625. Prostatic Concretions ......... 798 626. Concentric Concretions in Prostatic Duct . . . . . .798 627. Prostatic Calculus ......... 798 628. Acute Orchitis .......... 801 629. Strapping of the Testicle ........ 802 630. Elastic Compressor for Orchitis ....... 802 631. Abscess of the Testicle ........ 803 632. Fungus of the Testicle ......... 803 633. Fibrous Degeneration of the Testicle ....... 804 634. Microscopical Characters of Syphilitic Orchitis ..... 804 635. Calcareous Matter in the Testicle ....... 805 636. Fatty Degeneration in the Testicle ....... 805 637. Cystic Testicle .......... 805 638. Tuberculosis of the Testicle ........ 806 639. Excision of the Testicle ........ 809 640. Gum-elastic Suspensory . . . . . • • .810 641. Mayor’s Suspensory Apparatus ....... 810 642. Hydrocele of the Vaginal Tunic ....... 812 643. Operation for Tapping a Hydrocele ....... 813 644. Encysted Hydrocele . . . • • • • • .816 645. Hydrocele associated with Hernia . . . . . • .817 646. Hematocele of the Vaginal Tunic of the Testicle ..... 818 647. 648. Cystic Tumor of the Scrotum ....... 820 649. Fibrous Tumor of the Scrotum . . • • • • .821 650, 651. Elephantiasis of the Scrotum . . • • • • .822 652. Varix of the Scrotum and Penis ....... 824 653. Chimney-sweeper’s Cancer ........ 824 654. Henry’s Scrotal Forceps ....•••• 825 655. Encysted Hydrocele of the Cord ....... 826 656. Diffused Hydrocele of the Cord ....... 826 657. Encysted Hematocele of the Cord ...•••• 826 658. Varicocele ....•••••* 827 659. Morgan’s Suspensory ....••••• 828 LIST OF ILLUSTRATIONS TO VOL. II. FIG. PAGE 660. Method of obtaining Constant Tension by Rubber Spring .... 829 661. Fatty Tumor of the Spermatic Cord ....... 830 662. Sarcoma of the Penis ......... 834 663. Warts on the Penis ......... 836 664. Phimosis .......... 837 665. Operation for Phimosis ......... 838 666. 667. Paraphimosis ......... 838 668. Reduction of the Same ........ 839 669. Syringe Catheter ......... 854 670. Conjoined Manipulation of the Uterus ...... 862 671. Trivalve Speculum ......... 863 672. Cylindrical Speculum ......... 863 673. Sims’s Speculum ......... 863 674. Simpson’s Sound ......... 864 675. Jenks’s Elastic Sound ......... 864 676. Hard-rubber Cylinder for Dry-cupping the Neck of the Uterus . . . 864 677. Sponge-tent with Thread passing through it ...... 866 678. Wilson’s Dilator ......... 866 679. Retroversion of the Uterus ........ 867 680. Anteversion of the Uterus ........ 868 681. Sims’s Operation of Elytrorraphy ....... 869 682. Inversion of the Uterus . . . . . . ... 869 683. White’s Repositor ......... 870 684. Hawk-bill Scissors ......... 873 685. Sutures passed after Denudation of Cervix ...... 874 686. Tenaculum Forceps ......... 874 687. Follicular Disease of the Uterus ....... 876 688. Stump after Amputation of the Cervix ...... 878 689. Ellwood Wilson’s Needle ........ 878 690. Flaps Secured by Sutures ........ 878 691. Stricture of the Uterus ........ 879 692. Myomatous Tumors of the Uterus ....... 883 693. Fibromyomatous Tumor of the Uterus ...... 883 694. Thomas’s Spoon-saw or Serrated Scraper ...... 886 695. Yarrow’s Enucleator ......... 886 696. Emmet’s Enucleator . . . . . . ... . 886 697. Diagram representing Tumor imbedded in Posterior Wall of Uterus . . • 887 698. Heywood Smith’s Wire-rope Eeraseur ....... 889 699. Aveling’s Polyptome ......... 889 700. Carroll’s Knot-tier ......... 889 701. Cauliflower Excrescence of the Uterus ...... 891 702. Carcinoma of the Neck of the Uterus, ending in the Production of Recto-vesico- vaginal Fistule ......... 892 703. Volsella for Pulling Down the Uterus ....... 894 704. Amputation of the Neck of the Uterus with the Eeraseur .... 894 705. Simon’s Scoop .......... 895 706. Sutures after Porro-Miiller Operation ....... 899 707. Unilocular Ovarian Cyst ........ 903 708. Section of a Multilocular Ovarian Tumor ...... 904 709. Section of a Colloid Tumor of the Ovary ...... 905 710. Unilocular Ovarian Cyst, uncovered ....... 906 711. Microscopical Characters of the Fluid of an Ovarian Tumor .... 906 712. Granulations of an Ovarian Cyst ........ 910 713. Mears’s Trocar ......... 914 714. Wells’s Trocar .......... 914 715. Thomas’s Clamp ......... 915 XXIX PIG. PAGE 716. Skene’s Needle ......... 915 717. Dropsy of the Fallopian Tube ........ 924 718. Prolapse of the Vagina ........ 929 719. Hematometra and Imperforate Hymen . . . . . .931 720. Plexus of Veins of the Vestibule and Labium . . . . . .932 721. Follicular Disease of the Vulva ....... 934 722. Varicose Veins of the Vulva ........ 935 723. Encephaloid Sarcoma of the Nymplne and Clitoris . . . . .937 724. Hypertrophy of the Clitoris and Nymph® ...... 938 725. Skene’s Endoscope . . . . . . . . .939 726. Vascular Excrescences of the Urethra ....... 939 727. One of the Modes of Holding the Female Catheter ..... 943 728. Varieties of Urinary Fistules . . . . . . . .947 729. Bozeman’s Button ......... 948 730. Position of the Patient in the Operation for Vesico-vaginal Fistule . . . 948 731-735. Instruments for Vesico-vaginal Fistule ...... 949 736. Needle-holder .......... 949 737. Hook for Making Counterpressure ....... 950 738. Application of the Sutures ........ 950 739. Suture-adjuster ......... 950 740. Adjustment of the Sutures ........ 950 741. Application of the Button ........ 950 742. Instrument for Securing the Button ....... 951 743. Slipping down the Crotchets ........ 951 744. Suture Completely Adjusted ........ 951 745. The Cervix Slit Up to Expose the Fistule Above, with the Sutures in Position . 951 746. Simon’s Double Sutures in Position ....... 952 747. Sims’s Catheter ......... 953 748. Simon’s Method of Obliterating the Vagina ...... 954 749. Denudation for Repair of Perineum ....... 957 750. Surfaces denuded and Sutures in position . . . . . .957 751. Jenks’s Operation of Colpoperineorrhaphy ...... 957 752. Perineal Bandage ......... 958 753. Retro-uterine Hematocele ........ 958 754. General Hypertrophy of the Mammary Gland . . . . .967 755. Cystic Disease of the Breast . . . . . . . .970 756. Proliferous Fibroma of the Mamma . . . . . . .972 757. Adenoma of the Mamma . . . . . . . .973 758. Retraction of the Nipple in Scirrhus . . . . . . .976 759. Section of Scirrhous Tumor of the Breast . . . . . .976 760. Scirrhous Mamma Laid open to show its Lobulated Structure .... 977 761. Section of a Scirrhous Nodule . . . . . . . .977 762. Ulceration of a Scirrhous Breast ....... 978 763. Secondary Scirrhous Nodules ........ 978 764. Encephaloid of the Mammary Gland, of the Hematoid Variety . . . 980 765. Diagram of Elliptical Incision ....... 990 766. Excision of the Breast ........ 990 767. Strapping of the Breast ........ 992 768. Sling for the Breast ......... 992 769. Ball Imbedded in the Head of the Humerus ...... 996 770. Bones of the Knee Fractured by an Impacted Round Ball .... 996 771. Perforation of the Femur with Fissure into the Joint ..... 996 772. Partial Longitudinal Fracture of the Femur by an Impacted Conoidal Ball . . 997 773. Comminution of the Humerus by a Conoidal Ball ..... 997 774. Consolidated Gunshot Fracture, with Shortening ..... 998 LIST OF ILLUSTRATIONS TO VOL. II. XXX no. PAGE 775. Onyxitis of the Big Toe ........ 1001 77G. Onyxitis of the Index Finger . . . . . . .1001 777. Supernumerary Thumb ........ 1002 778. Webbed Fingers ......... 1003 779. Contraetion of the Thumb / ...... 1006 780. Deformity of the Fingers from Contraction of the Palmar Fascia . . . 1006 781. Contraetion of the Palmar Aponeurosis ...... 1006 782. Adams’s Apparatus, applied ........ 1008 783. Keen’s Modification of Adams’s Apparatus, for Dupuytren’s Contraction . . 1008 784. Vicious Cicatrices of the Fingers ....... 1009 785. Clubhand .......... 1010 786. Paronychia of the Thumb . . . . . . . .1011 787. Necrosis of the Bones in Whitlow . . . . . . .1011 788. Varicose Aneurism of the Fingers ....... 1013 789. Apparatus for Scrivener’s Cramp ....... 1016 790. Mathieu’s Apparatus for Writer’s Cramp ...... 1016 791. Velpeau’s Apparatus for Scrivener’s Cramp ...... 1016 792. Chondroma of the Index Finger ....... 1017 793. Gouty Deposits in the Joints of the Fingers and Burse of the Elbow . . 1018 794. Chondroma of the Shoulder and Arm ...... 1022 795. 796. Bandages for the Hand and Fingers ...... 1025 797. Roller for the Superior Extremity ....... 1025 798. Bandage for the Axilla ........ 1026 799. Spica for the Shoulder and the Upper Part of the Arm .... 1026 800. Deformity of the Second Toe ....... 1027 801. Deformity of the Great Toe from Inflammation of the Metatarso-phalangeal Joint . 1027 802. Bunion .......... 1029 803. Apparatus for the Treatment of Bunion ...... 1029 804. Excision of Inverted Toe-nail ....... 1030 805. Exostosis of the Distal Phalanx of the Great Toe . . . .1031 806. 807. Varus .......... 1033 808. Valgus .......... 1034 809, 810. Equinus .......... 1034 811. Calcaneus .......... 1035 812. Clubfoot Apparatus ......... 1037 813. Apparatus for Calcaneal Clubfoot ....... 1038 814. Tenotome . . . . . . . . . 1038 815,816. Shoes for the After-treatment of Clubfoot ..... 1040 817. Morton’s Shoe ......... 1040 818. KolbCs Walking Shoe for Talipes ....... 1041 819. Effect of the Operation of Clubfoot ....... 1041 820. 821. Kolb6’s Clubfoot Stretcher ....... 1042 822. Flatfoot .......... 1043 823. Podelcoma .......... 1044 824. Bowed Leg, in a High Degree ....... 1046 825. Bigg’s Apparatus for Lateral Curvature of the Leg ..... 1046 826. Ivolb6’s Apparatus for Bowed Leg ....... 1046 827. Apparatus for Anterior Curvature of the Leg ..... 1046 828. Gum Elastic Stocking ........ 1047 829. Obliteration of Varicose Veins by Ligation ...... 1048 830. Twisted Suture for the same ........ 1048 831. Subcutaneous Ligation of a Varicose Vein with Silver Wire .... 1048 832. Monro’s Apparatus for Ruptured Tendo Achillis ..... 1050 833. Extension Apparatus for Ankylosis of the Knee ..... 1051 834. Knockknee .......... 1052 835. Apparatus for Knockknee ........ 1053 LIST OF ILLUSTRATIONS TO VOL. II. LIST OF ILLUSTRATIONS TO VOL. II. XXXI FIG. PAGE 836. Ogston’s Operation ......... 1053 837. Housemaid’s Knee ......... 1054 838. Interstitial Absorption of the Neck of Thigh-bone ..... 1060 839. Congenital Cyst of the Nates ........ 1061 840. Fibrocystic Tumor of the Nates ....... 1062 841. Microscopic Characters of the Same ....... 1063 842. Roller Applied to the Foot and Leg ....... 1068 843. Bandage for the Knee . . . . . . . .1069 844. 845. Bandages for the Groin ........ 1069 846. Osteosarcoma of the Scapula ........ 1072 847. Yon Langenbeek’s Extension Apparatus ...... 1075 848. Caries of the Elbow-joint ........ 1076 849. Excision of the Elbow-joint ........ 1078 850. Heath’s Splint in Excision of the Elbow-joint ' . . . . . 1079 851. Front View of an Excised Elbow-joint ...... 1079 852. Appearance of the Wound after Excision of the Head of the Humerus . . 1081 853. Lossen’s Extension Apparatus for Resection of Shoulder .... 1082 854,855. Flap Operations in Excision of the Head of the Humerus . . . 1082 856. Caries of the Head of the Humerus ....... 1083 857. Excision of nearly the Upper Half of the Humerus for Gunshot'Injury . . 1083 858. Excision of the Caleaneum ........ 1085 859. Caries of the Ankle-joint ........ 1088 860. Caries of the Inferior Extremities of the Tibia and Fibula .... 1088 861. Excision of the Knee-joint ........ 1090 862. Upper End of the Tibia Excised ....... 1090 863. Lower End of the Femur Excised ....... 1090 864. Butcher’s Box for After-treatment in Excision of the Knee .... 1091 865. Brice’s Apparatus for After-treatment in Excision of the Knee . . . 1092 866. An Excised Knee Swung in Salter’s Apparatus . . . . .1092 867. Esmarch’s Apparatus for Resection of the Knee-joint .... 1092 868. Excised Knee-joint, for Gunshot Injury ...... 1093 869. Shortening after Excision of the Knee ...... 1093 870. Appearance of Excised Knee two years after Operation .... 1093 871. Ravages of Hip-joint Disease ....... 1096 872. Excision of the Hip-joint ........ 1096 873. Portion of Femur removed for Hip-joint Disease ..... 1096 874. Fergusson’s Apparatus for After-treatment in Excision of the Hip-joint . . 1097 875. Appearance of the Limb twelve years after Excision of the Hip-joint . . 1098 876. Excised Head and Neck of the Femur ...... 1098 877. Amputation of the Finger at the Distal Articulation ..... 1099 878. Amputation of the Finger at the Metacarpo-phalangeal Joint . . . 1100 879. Removal of the Bone with the Pliers . . . . . . .1100 880. Amputation of the Index and Little Fingers ...... 1100 881. Amputation of the Thumb and Metacarpal Bone ..... 1101 882. Appearance of the Hand after Amputation of the Thumb . . . .1101 883. Amputation through the Metacarpal Bones . . . . . .1101 884. Amputation at the Wrist ........ 1102 885. Wrist, Carpal, and Metacarpal Joints ...... 1102 886. Flap Amputation of the Forearm ....... 1103 887. Short Stump of the Forearm . . . . . . . .1103 888. Amputation of the Arm ........ 1104 889. Larrey’s Amputation ......... 1105 890. 891. Amputation at the Shoulder ...... 1105, 1106 892. Amputation of the Toe at its Metatarso-phalangeal Joint . . . .1108 893. Amputation of the Big Toe through the Metatarsal Bone .... 1108 894. Appearance of the Parts after Amputation of the Big Toe .... 1108 FIG. PAGE 895. Key’s Amputation . . . . . . . . .1109 896. Stump after the Same . ........ 1109 897. Chopart’s Amputation . . . . . . . .1110 898. Stump after the Same . . . . . . . .1110 899. Lines of Incision in Amputations of the Foot . . . . . .1110 900. Amputation of the Ankle . . . . . . . .1111 901. Mode of removing the Calcaneum in Symc’s Operation . . . .1111 902. Stump after Syme’s Operation . . . . . . .1111 903. Mode of Sawing the Calcaneum in Pirogoff’s Amputation .... 1112 904. Amputation of the Leg at its Inferior Third . . . . . .1114 905. Stump after the Same . . . . . . , . .1114 906. Teale’s Amputation of the Leg at its Lower Part ..... 1114 907. Amputation of the Leg above its Middle . . . . . .1115 908. S6dillot’s Amputation of the Leg ' ....... 1116 909. Stump after the Same . . . . . . . . .1116 910. Stump after Amputation of Upper Part of the Leg ..... 1116 911. Amputation of the Knee with Lateral Flaps . . . . . .1117 912. Appearance of the Stump in Smith’s Amputation ..... 1118 913. Amputation of the Thigh ........ 1120 914. Stump after the Same . . . . . . . .1120 915. Amputation at the Hip-joint ........ 1123 916. Abdominal Tourniquet . . . . . . . .1124 917. Lister’s Aorta Tourniquet ........ 1124 918. Stump after Amputation at the Hip-joint . . . . . .1125 919. Amputation at the Hip-joint . . . . . . . .1125 LIST OF ILLUSTRATIONS TO VOL. II. PART SECOND. SPECIAL SURGERY; OB, DISEASES AND INJURIES OF PARTICULAR ORGANS, TEXTURES, AND REGIONS. A SYSTEM OF SURGERY. SPECIAL SURGERY; OR, DISEASES AND INJURIES OF PARTICULAR ORGANS, TEXTURES, AND REGIONS. CHAPTER I. INJURIES AND DISEASES OF THE HEAD. Injuries of the head have always been objects of the deepest interest and study with the surgeon. Independently of the frequency of their occurrence, they merit the greatest attention, on account of the obscurity of their diagnosis, the stealthy character of their progress, the difficulty of their management, and the uncertainty of their termination. It was long ago remarked by Mr. Pott, and the observation has been verified a thousand times since, that there is no lesion of the head so trifling, on the one hand, as not to en- danger life, or so severe, on the other, that it may not be followed by recovery. SECT. I LESIONS OF TIIE SCALP. 1. WOUNDS AND CONTUSIONS. Wounds of the scalp exhibit the same general features as wounds in other regions. The only actual difference is their great liability to be followed by erysipelas, neuralgia, arachnitis, cerebritis, and various other secondary affections. Incised Wovnds, of whatever extent or depth, should always be treated with reference to the production of immediate reunion. With this view, as soon as they have been divested of blood and foreign matter, their edges should be neatly approximated with a suitable number of twisted sutures, the threads being carried from one pin to another, so as to obviate the necessity for the application of adhesive plaster. When the cut is very slight, contact may often be effectually maintained by tying together at their base a few little locks of hair on each side of it; the threads should be very fine, and well waxed, otherwise it will be difficult for them to retain their hold until the adhesive process is sufficiently advanced to admit of their removal. When the wound is very large, the scald should be well shaved, as a preliminary step, but under opposite conditions such a pre- caution will generally be unnecessary. It is difficult, at this day, to conceive why so much opposition should have been made in former times to the use of sutures in wounds of the scalp. In reading the accounts of some of the older surgeons of this mode of treatment, one is almost tempted to conclude that they must have thought that there was something peculiarly poisonous in it; a vio- lent war was waged against it for nearly half a century, and it is questionable whether its influence has yet altogether disappeared. However this may be, it cannot be doubted that sutures of the scalp, in whatever form they may be used, are as harmless as any mode of dressing of which it is possible to form any conception. If they were formerly a source of irritation, a circumstance which can hardly be doubted, the occurrence was in all probability due to the coarseness of their material, and the manner of their introduction. These objections certainly do not exist at the present day, and no one who has once tried them in this situation will ever be likely to dispense with them. These remarks are par- ticularly applicable to the twisted suture, which, in addition to the benefit already ascribed 20 INJURIES AND DISEASES OF THE HEAD. CHAP. I. to it, has the advantage of compressing the orifices of the divided vessels, and of thus effectually controlling hemorrhage. I have repeatedly seen the edges of a wound in the scalp, approximated simply with adhesive plaster, forced apart, and prevented from unit- ing, by the interposition of coagulated blood. When the twisted suture is properly made, no other dressing whatever is needed; the part is constantly exposed to view, and the moment any untoward change arises it is detected, which it cannot be when the ordinary retentive means are employed. The pins should not be withdrawn before the fourth or fifth day. The best material for the interrupted suture is silver wire, retained until there is complete reunion. The Surgical History of the War of the Rebellion gives the par- ticulars of 282 cases of incised wounds of the scalp, of which only G died, death in 3 being due to encephalitis. Lacerated Wounds of the scalp are generally caused by blows or falls on the head, or by the passage of the wheel of a carriage. One of the most severe and extensive injuries of this kind that I have ever witnessed was inflicted by the horns of an infuriated cow. Owing to the manner in which they are produced, more or less foreign matter is usually entangled in these wounds, and, for the same reason, they are often followed by violent inflammation, suppuration, and even gangrene. The rule of treatment is the same as in incised wounds, but special care should be taken not to draw the edges so firmly together, lest the resulting swelling, which will always be considerable, should induce undue ten- sion, and thus necessitate the premature detachment of the sutures. The scalp, too, should always be extensively shaved, and cold water-dressing, either simple or medicated with acetate of lead, freely used, to prevent the untoward occurrences adverted to. With proper attention, it is surprising how much of the wound may, even in apparently the most unpromising cases, unite by the first intention. The scalp is sometimes very seriously injured by machinery in rapid motion, as in a remarkable case which 1 attended in 1869, with Dr. Alfred Jones, of this city, in a woman, twenty-two years old, who, by having her hair caught by a revolving shaft in a macaroni factory, had her scalp completely torn off, along with one of the eyebrows. Although the immense flap was replaced within half an hour after, and most accurately stitched on by sutures, no union whatever occurred, and eighteen months elapsed before the surface was completely cicatrized. The woman, for some hours, labored under severe shock ; but never experienced any brain trouble. Numerous exfoliations of thin plates of bone over the entire head occurred, beginning several months after the accident. Cicatrization, after such an injury, might be greatly promoted by skin grafting. Punctured Wounds of the scalp, apart from their tendency to erysipelas and suppura- tion, are usually very simple accidents. The proper remedy, in the first instance, is cold water-dressing, simple or medicated, followed, if inflammation run high, by the applica- tion of leeches, and emollient poultices. If matter form, or even if there be merely severe tension, appropriate incisions should be made. In Contused Wounds, the rule is, after thorough shaving of the scalp, and the removal of foreign matter, to approximate the edges very lightly with the interrupted suture. Proper allowance is made at the start for swelling and tension, which are often severe. If the edges are shreddy, or tattered, they are neatly trimmed with the scissors, but on no account should any flaps, even if violently bruised and apparently dead, be cut off'; for no one can positively determine, beforehand, whether such a part is really deprived of vitality or not, and it is best, therefore, always to afford nature an opportunity of saving all she can. The leading indication is to circumscribe inflammation, the best remedy for the purpose being the warm water-dressing, rendered slightly stimulating by the addition of a small quantity of laudanum, alcohol, or spirit of camphor. The object is to impart tone to the contused vessels and nerves, to enable them the more readily to withstand the effects of inordinate action. Pencilling the surface immediately around the wound with a weak solution of iodine or nitrate of silver is sometimes beneficial. Contusions, properly so termed, of the scalp, occur in various degrees, from the slightest bruise to a mashed, softened, and pulpified condition of its component elements. They may be superficial or deep-seated, circumscribed or diffused, simple or complicated. Their tendency, even when slight, is to run into violent inflammation, especially the erysipela- tous variety, followed by abscess, and even gangrene. Such events will, of course, be most likely to happen in persons of intemperate habits, or of a broken constitution, although the most healthy individuals do not always, indeed, perhaps, not generally, escape them. Another effect of a severe contusion of the scalp is its liability to produce mis- chief in the brain and its membranes. Two circumstances suggest themselves as likely to bring about this condition. The first is the shock sustained by the cranial contents by CHAP. I • ABSCESSES. the violence of the blow inflicting the contusion; and the other, the disposition in the resulting inflammation to extend to the meninges through the vessels and fibres of the pericranium. Accidents of this kind are occasionally complicated Avith fracture of the skull, detachment of the dura mater, or concussion of the brain. Sometimes, again, a portion of bone is merely bruised, and yet the action consequent upon the lesion is so great as ultimately to cause its death. When the contusion is at all severe, there is usu- ally a considerable effusion of blood, presenting itself generally in the form of a circumscribed tumor; in rare cases the blood is widely diffused, extending, in fact, nearly over the whole head. In either event, if depression exist along with symptoms of compression, or compression without apparent depression, free incisions should at once be made to ascer- tain, if possible, the actual condition of the parts. Contusions of the scalp, however slight, should always be regarded as accidents of grave import. The patient should be cautioned about his diet, the bowels properly regulated, and premature exposure carefully guarded against. Under this management, the affected parts will generally be speedily restored to their pristine condition, without, perhaps, the slightest topical medication, except the use of cold water, or some mildly astringent lotion. When the injury is more extensive, warm water-dressing should be used, with the addition of opium and chloride of ammonium, acetate of lead, alcohol, or spirit of camphor. These ingredients are particularly valuable in such cases, not only by impart- ing tone to the affected tissues, but by promoting the absorption of extravasated blood. Warm applications are nearly always borne better, both by the scalp and the system at large, than cold, whether simple or medicated, and they are also much less likely to cause injurious metastasis to the brain and its membranes. In regard to this matter, however, the surgeon will always do well to consult the feelings of his patient. When the inflam- mation is at all severe, leeches will be demanded, especially in impending cerebral involve- ment, and they should be profusely scattered over the affected surface. Tension and swelling are relieved by multiple punctures, while abscesses must be opened, early and freely, to assuage pain and prevent the diffusion of pus. Wounds and contusions of the scalp are often followed by serious secondary effects, con- sisting, for the most part, of certain nervous symptoms, as numbness of the scalp, partial paralysis of the face, headache, muscular twitchings, strabismus, and neuralgic pains. Occasionally the scalp remains very tender at one particular spot, perhaps not larger than half a dime, so that the individual is unable to bear the slightest pressure of the finger, or even of his hat. At times, again, these injuries are followed by wasting of the affected structures, epilepsy, abscess of the liver, and atrophy of the testes. The treatment of these secondary effects must be by incision, and by protracted pyo- genic counterirritation, more especially when there is great tenderness, of a circumscribed character, depending upon chronic thickening of the periosteum ; by antineuralgic reme- dies, when the pain is periodical, or of a dull, heavy, aching character; and by emetics, purgatives, and a properly regulated diet, when there is disorder of the digestive organs, with irregular action of the muscles. The cold shower-bath, change of air, and, in obstinate cases, slight but persistent ptyalism, will*be beneficial. Dead bone is removed Avith the saw and forceps, and carious bone thoroughly scraped. 2. ABSCESSES. Matter is liable to form upon the head in three different situations, in the subcutaneous connective tissue of the scalp, below the occipito-frontal muscle, and between the peri- cranium and the skull. Most generally it occurs in the first of these localities; least frequently in the last. The most common exciting cause is external injury, as a Avound, blow, fall, or contusion. Sometimes the abscess arises spontaneously, but in the majority of cases, whatever may be the provocation, its formation is preceded and accompanied by erysipelatous inflammation, denotive of disorder of the general health, or of a vitiated condition of the secretions. The symptoms are generally well marked. The pain is severe, and of a throbbing, burning character; the swelling, which is either circumscribed or diffused, pits on press- ure ; and the surface presents an erysipelatous appearance. The concomitant inflamma- tion often extends from the scalp to the eyelids and face, temples, ears, and nape of the neck. The constitutional involvement is generally considerable, not unfrequently running into delirium at an early stage of the attack, especially when the pus is situated beneath the pericranium. Violent rigors sometimes mark the progress of the case. The quantity of matter varies from a few drachms to several ounces. In a case recently 22 INJURIES AND DISEASES OF THE HEAD. CHAP. I. attended by me in a child, eleven years of age, there was nearly half a pint of fluid, of a thick, cream-like consistence. The abscess was situated on the vertex, forming an im- mense projection under the detached and attenuated scalp. The sensation which an abscess in this situation imparts to the finger is peculiar, par- ticularly if some time has elapsed since its development. While the abscess itself freely fluctuates, and perhaps forms a pendulous hag, the base is generally remarkably hard, sharp, and precipitous, evidently from plastic deposits, feeling precisely as if it consisted of the rim of a depressed fracture. This feature is commonly so distinct, in circumscribed abscess of the scalp, that the surgeon, unless fully upon his guard, will be very likely to be deceived in respect to the true nature of the case. In diffused collections the base is less abrupt, and, therefore, the danger of mistake is not so great. When the pus lies beneath the aponeurosis of the occipito-frontal muscle, it is generally very slow in reaching the surface, and, consequently, often causes great mischief by its extensive diffusion, dissecting the parts freely from their natural relations, and forming a large, boggy, purulent bag, with a more or less well-defined boundary. An abscess beneath the pericranium, or between it and the skull, usually occurs as a small, puffy, circumscribed swelling, accompanied with excessive pain and tenderness; it generally follows upon a severe contusion, wound, or fracture, a number of days, not unfrequently as many as ten, twelve, or fourteen, after the accident, and is extremely liable to give rise to caries, if not also to necrosis, of the cranial bones, and inflammation of the brain and its membranes, from the destruction of the connecting vessels and the extension of the morbid action. If the patient die, pus, as stated under the head of pericranitis, will probably be found beneath the dura mater, which is at the same time more or less exten- sively separated from the bone, and in an unhealthy, sloughy condition. Such an abscess is always peculiarly dangerous, from its tendency to produce cerebral complications. The treatment of these abscesses must be strictly antiphlogistic. Leeches, poultices, and water-dressings, medicated with acetate of lead and opium, are more particularly indicated in the earlier stages of the disease, along with the use of purgatives, attention to the secretions, and a proper regulation of the diet. The moment fluctuation is perceived, or even before, if there be much tension, free incisions should be made. Cerebral symp- toms are combated in the usual manner. If matter form beneath the skull, as indicated by the whitish or yellowish aspect of the bone, and disturbance of the brain, the trephine should be employed, although such an expedient will seldom be followed by any perma- nent benefit. 3. TUMORS. a. Sanguineous Tumors—Sanguineous effusions are often met with on the scalp, gen- erally as a consequence of blows, falls, kicks, and other injuries, the blood being extrava- sated into the subcutaneous connective tissue, either as a distinct swelling, or as an infiltra- tion. The accident not unfrequently happens during parturition, from the pressure on the child’s head in its descent through the soft parts of the mother, giving rise to a tumor, termed by Nsegele and other writers, cephahematoma. Contusions of the seal}), however slight, or how'ever induced, are always followed by such an occurrence. The blood may be situated immediately beneath the skin, below the aponeurosis of the occipito-frontal muscle, or beneath the pericranium, in direct contact with the bone. Varying in quantity from a few drachms to several ounces, it is of a fluid, semifluid, or solid con- sistence, and of a dark purple color, according to the period at which it is examined, or the circumstance under which it is extravasated. The most abundant accumulations of this kind usually occur at the sides of the head and the superior part of the occiput, in consequence, apparently, of the greater laxity and vascularity of the tissues there than elsewhere. Immense bags of blood are occasionally formed in both these situations, especially after falls and blows on the head, attended with the laceration of some of the branches of the temporal and occipital arteries. When the tissues of the scalp have been much contused, the extravasated blood is seldom completely coagulated, and it may even remain perfectly fluid, having apparently been devitalized at the moment of the accident. The same thing usually occurs when the collection is very large, although the parts may have suffered comparatively little violence. If the blood be long retained, it undergoes changes similar to those in an apoplectic effu- sion ; it loses its dark color and soft consistence, and is converted into a grayish, fibrinous mass, of varying firmness and density. On the other hand, the solid matter is occasion- ally completely absorbed, all that remains being a pale, serous, or oily-looking fluid. CHAP. I. TUMORS. 23 During the inflammation which supervenes upon the accident, pus is sometimes poured out, and, mingling with the blood, imparts to it its peculiar appearance. The tumor formed by the extravasated blood is either circumscribed and of a rounded or conical shape, or it is diffused and irregular, being, perhaps, flattened at one point and elevated at another. It is always soft and fluctuating at the beginning, and sometimes it even retains this feature throughout, although in most cases it soon becomes comparatively hard and firm, from the coagulation of its contents. When it is caused by external violence, as a blow or fall, it has occasionally a sharp, abrupt, and well-defined margin, and the finger, as it sinks into the centre of the swelling, receives a deceptive impression as if there were a fracture of the skull with depression of the bone. The appearance of the skin is variable; generally it is unchanged, being neither discolored, ecchymosed, nor oedematous. When inflammation arises, the tumor becomes hot, tender, and painful. In cases of long standing, the blood is sometimes surrounded by a distinct cyst, and, in the subpericranial form of the affection, the uplifted membrane has been known to undergo extensive ossification. Accumulations of blood of the scalp, whether circumscribed or diffused, usually dis- appear either spontaneously, or under very simple treatment, as refrigerant, astringent, and sorbefacient lotions, tincture of iodine, blisters, and leeches, the two latter being particularly indicated when the tumor is hot and inflamed. The most efficacious remedy will be found to be a strong solution of chloride of ammonium, as an ounce of the salt to a quart of water, with the addition of a little vinegar. Mild purgatives will often be useful, and proper attention must be paid to the diet. When the case proves troublesome, as it may when the blood is unusually profuse, deep-seated, or deprived of vitality, sub- cutaneous evacuation, followed by systematic compression, will be necessary. 0. Sebaceous Tumors The most common of the tumors of the scalp are the sebaceous, which often exist in considerable numbers, and which are always easily diagnosticated, their tardy development, their semisolid consistence, their great mobility, and the sparsity or entire absence of hair on their surface, being generally sufficiently characteristic of their true nature. Their size ranges from a pea to that of a small orange. Sometimes they are solitary, but more frequently multiple; and I recollect one instance, in a middle- aged man, in which there were upwards of two hundred, many of them of considerable bulk. Examples have come under my observation in which two and even three tumors were inclosed in one cyst. Occasionally they are hereditary, and I have seen a number of cases in which they were traceable through several successive generations. Their contents are generally of a semisolid, suety consistence, and of a whitish appearance, or of the con- sistence and color of honey. The cyst varies much in character; generally, however, it is thick, whitish, dense, and firm, with a smooth, glistening inner surface. In very old cases, especially when the morbid growth has been long subjected to pressure, it is of a fibro-cartilaginous nature, or even partially ossified, and proportionately thick and strong. The adhesions, then, between the tumor and the skin, are also unusually firm. A sebaceous tumor of the scalp occasionally inflames, suppurates, or even ulcerates, its contents, in such an event, being generally excessively fetid, from the contact of the air. The congenital form of this tumor frequently contains hairs, especially when it occupies the region of the eyebrows; and cases occur in which, apparently by its pressure, it indents the skull, causing marked depression in the outer table, if not actual perforation of the inner; attended, perhaps, with perceptible pulsation of the brain beneath. The treatment of the sebaceous tumor is by incision and enucleation, the latter of which is always very easy when there are no firm adhesions. When the tumor is very large, or ulcerated, an elliptical incision is necessary, to get rid of redundant or diseased integu- ment. A few little arteries occasionally require ligation. The edges of the wound are closed with sutures, either interrupted or twisted, the latter in preference, especially if there be much of a gap or marked disposition to bleeding. The chief danger after the operation is erysipelas, which must, of course, be carefully guarded against. Such an occurrence is more particularly liable to happen when the tumor is situated in the lower part of the occipital region. When the tumor has perforated the skull, surgical interference must either be refrained from, or employed with the greatest possible care, lest, the dura mater being exposed, or suppuration established in the wound, the patient should perish from inflammation of the skull, brain, or its coverings. Such a contingency is particularly likely to occur in seba- ceous tumors about the eye. y. Cystic Tumors A cystic tumor, generally congenital, sometimes occurs on the head, either beneath the aponeurosis of the occipito-frontal muscle, or in the substance 24 INJURIES AND DISEASES OF THE HEAD. CHAP. i. of’ the scalp. It is filled with serous fluid, fluctuates on pressure, and is seldom larger than a pigeon’s egg or an almond. In some instances it is multilocular, or composed of a congeries of cysts, closely grouped together. The remedy is extirpation. A singular case of dermoid cystic tumor of the scalp filled with a fluid which had all the properties of that of hydrorachitis, is reported by Giraldes, in his Clinical Lectures. It lay directly over the anterior fontanelle, and bore so close a resemblance to a meningocele that it was for a long time supposed to be of that nature. After repeated but unsuccess- ful efforts at cure by puncture and compression, the tumor was at length exposed by a free dissection, and its contents turned out, when it was discovered that there was no communication whatever with the cranial cavity. 8. Cutaneous Tumors—The cutaneous tumor of the scalp, better known as elephantiasis, is a very uncommon affection, most generally situated at the lower and back part of the head, where it sometimes forms a large, unsightly mass, of the volume of a large fist, transversely rugated, and of a semielastic consistence. It is perfectly indolent, and the only incon- venience which it occasions arises from its bulk and deformity. Its origin is invariably congenital. Thirion has published several cases in which he succeeded in effecting a cure by the joint agency of compression and the application of iodine; but when the mass is uncommonly large, the best plan is to excise it. £. Fatty Tumors Lipoma of the scalp is very uncommon, and seldom attains any great bulk. As in other regions, it is of tardy growth, pain- less, and not always easily distinguishable from sebaceous and fibroid formations. In a case of fatty tumor of the scalp, reported by Dr. Cabot, of Boston, there was a fluctuating feel, with an ap- pearance of translucency, resembling a cyst filled with blood. The chief question, as it respects the diagnosis in such a case, would be between an eneeplmlocele and an oil cyst. £. Fibrous Tumors A fibrous tumor is some- times met with in this situation. Such a growth, removed by Professor Joseph Pancoast at the Clinic of the Jefferson Medical College, in 1858, by means of the eeraseur, is represented in fig. 1. The patient was an elderly man ; and the tumor which occupied the vertex, and was of the volume of a large orange, had been of several years’ standing. Its summit had been invaded by ulceration. y. Vascular Tumors.—Different kinds of vascular tumors, arterial, venous, arterio- venous, and najvoid, sometimes occur on the scalp, and may in time acquire a large bulk and a formidable character. Their diagnosis is easily determined by their history, their congenital origin, their reddish, bluish, or purplish color, their soft consistence, their freedom from pain, their mobility, and their erectility when the patient laughs, cries, or sneezes. The arterial growth, the anastomotic aneurism of John llell, is particularly liable to expand under mental emotion, and nearly always pulsates synchronously with the heart. Vascular tumors of the scalp sometimes ulcerate, and thus give rise to hemorrrhage, the frequent repetition of which may eventually prove fatal. Riddance should be effected as early as possible, the best remedies being the knife, ligature, or twisted suture, composed of two strong pins inserted at right angles. The knife should be employed only when the tumor is very small, and of a venous structure, other- wise serious hemorrhage may arise. Whatever procedure be adopted, the rule is to include every particle of the morbid growth, otherwise there will inevitably be a certain amount of repullulation. When the tumor is seated over the anterior fontanelle, great care must be taken not to wound-the membranes of the brain, as might readily happen, from their close proximity to the scalp, in the hands of an incautious operator. 0. Malignant Tumors.—Primary sarcoma of the scalp is infrequent. It is of rapid develonment. and unattended bv enlargement of the neighboring Ivmnhatic "lands. The Fig. 1. Fibrous Tumor of the Scalp. Fig. 2. Epithelial Ulcer of the Scalp. CHAP. I. most common form of carcinoma is the epithelial, which, usually beginning as a warty excrescence or small shot-like tubercle, in its progress involves the lymphatic glands and occasionally also the cranial bones. The resulting ulcer, fig. 2, is characteristic, having a foul, unhealthy aspect, and being the seat of a sanious, fetid discharge. The only remedy for these growths is early and free excision. Surgical interference in tumors of the scalp should never be attempted without due preparations of the system, as it is extremely liable to be followed by erysipelas and other bad effects, imperilling life. SECT. II AFFECTIONS OF THE CRANIAL BONES AND THEIR APPENDAGES. 1. PERICRANITIS. The pericranium, like the periosteum everywhere else, is liable to inflammation and its consequences, and the disease, especially in its acute form, is particularly worthy of study, from its liability to involve the brain and its envelops. The exciting causes are various. Among the more common are external injury, as blows, wounds and contusions, sudden suppression of the cutaneous perspiration, and a syphilitic taint of the system. Not unfre- quently the affection arises without any assignable provocation, and cases occasionally occur in which it is propagated from the face, neck, nose, or orbit of the eye. Gout sometimes attacks the pericranium. The inflammation may be circumscribed or diffused. The disease, in its milder forms, is originally characterized simply by pain and tender- ness of the scalp, which gradually augment, until, in many cases, they amount to great agony. The swelling is circumscribed, pits slightly on pressure, and has a peculiar shin- ing, glossy appearance. Very frequently the whole scalp feels sore, numb, and heavy. The patient complains of headache, the system is feverish, the appetite is disordered, the secretions are vitiated, the bowels are costive, and the sleep is disturbed by unpleasant dreams. If the disease be not checked, all the symptoms, local and constitutional, in- crease in severity, the mind wanders, matter forms beneath the pericranium, and the scalp is suffused with an erysipelatous blush. Diffused pericranitis is only a more aggravated form of the circumscribed. The in- flammation is either violent from the beginning, or it soon becomes so ; it spreads rapidly, and is accomjwmied by great pain and swelling, with a tendency to pass very speedily into suppuration. The patient is often delirious within the first few hours from the attack ; the cephalalgia is agonizing, and is increased by every movement of the head, which feels like a heavy load; there is great intolerance of light and noise; the pulse is hard, fre- quent, and irregular; and rigors, alternating with flushes of heat, and followed by copious sweats, announce, at no distant period, the formation of pus under the pericranium and the extension of the disease to the dura mater, if not also to the brain and the arachnoid membrane. Such attacks are of the gravest character, and are almost sure, if not soon arrested, to prove fatal, death being preceded by coma, paralysis, and convulsions. Dissection always affords evidence of great structural lesion. The scalp at the focus of the morbid action is soft, boggy, oedematous, and of a purple hue; the pericranium is extensively detached, thickened, spongy, vascular, and infiltrated ; pus of a foul, unhealthy character lies in large quantity in immediate contact with the bone; the bone itself, of a whitish, grayish color, is partially devitalized and emits a peculiar ringing noise on per- cussion with a hammer ; the diploe is highly congested, perhaps here and there ecchymotic and infiltrated with pus; the dura mater is separated and bathed in purulent fluid; and the arachnoid membrane is coated with pus and lymph. In the worst cases the ventri- cles of the brain are distended with serum, and even the brain itself may be implicated in the morbid action. The treatment of pericranitis is sufficiently evident. In the milder forms, leeches, iodine, and saturnine lotions, assisted by active purgation, generally suffice to check the morbid action, and prevent serious mischief. When the disease is widely diffused, it will be necessary, in addition to these means, to make early and free incisions, extending down to the bone, to relieve tension, to give vent to effused fluids, and to protect the brain and its envelops. There must be no temporizing; the case is urgent, and the treatment must be correspondingly vigorous. The sac of the abscess may often be advantageously washed out with lotions of permanganate of potassium, nitric acid, or chlorinated sodium, to promote healthy action. In syphilitic pericranitis, which is generally associated with osteitis, and which, in its worst phases, nearly always occurs in the form of nodes or circumscribed swellings, the PERICRANITIS. 25 26 INJURIES AND DISEASES OF THE HEAD. CHAP. I. chief reliance must be placed upon the exhibition of the iodides with bichloride of mercury, and the application of leeches, iodine, and blisters. The knife is seldom re- quired to let out the matter, as this commonly disappears through the agency of the absorbent vessels. 2. CONTUSION OF THE CRANIAL BONES. Mere contusion of the skull without fracture is frequently an accident of a very grave character, whether viewed with reference to its primary effects or its ulterior consequences. When the blow is very violent, as when it has been inflicted by a bludgeon or a partially spent ball, instant death may be produced by it, apparently from shock, or from shock and concussion of the cerebral tissues. Jn another class of cases, by no means uncommon, a large vessel on the inner surface of the skull may be ruptured, and such an amount of blood may be extravasated as to cause severe, if not fatal, compression. Sometimes blood is poured out into the arachnoid sac, or even into the substance of the brain. Cases have been observed in which the longitudinal sinus was laid open in contusion of the skull, and death was produced by the pressure of the effused blood. Encephalo-menin- gitis is a not infrequent consequence of such accidents. Among the more remote effects are abscesses of the brain, and caries, necrosis, and exfoliation of the cranial bones. Such occurrences are more particularly liable to arise when there has been severe con- tusion of the diploe, leading to suppurative inflammation, occasionally followed by necro- sis of both tables of the affected bone. Injuries of this kind, too, are very liable to give rise to pyemia and to secondary abscesses in the lungs, liver, and other internal organs, from the direct entrance of pus into the circulation through the agency of the diploic veins. The treatment is similar to that of the simple fracture without depression, the great object being the prevention of encephalo-meningitis, and the promotion of cere- bral accommodation. 3. CARIES, NECROSIS, AND FISTULE. Caries of the skull, fig. 3 is usually the result of a constitutional taint, and sometimes attacks every bone, completely riddling both tables, and causing the most frightful suffer- ing; the scalp is studded with ulcers, the discharge is foul and fetid, and the general health is sadly undermined. The affected bone often perishes, sel- dom, however, in its entire thickness, the external table being much more frequently involved than the internal. The treatment must be in strict con- formity with the nature of the exciting cause. Great attention must be paid to cleanliness, fetor is allayed with the chlorides, and dead bone is removed as soon as it is sufficiently detached. Caries and necrosis of the cranium from ordinary causes are uncommon. Serious mischief of this kind may arise from a simple blow upon the head, with or without scalp-wound, provok- ing inflammation and suppuration of the pericranium, which, becoming de- tached, occasions destruction of the os- seous tissue. The effect may be limited or diffused, attacking one or both tables of the bones, and sometimes, although very rarely, involving almost the entire calvaria, as in the remarkable case of Saviard, in which, two years after a blow on the head, the whole skull-cap came away in one mass. Frightful injury is sometimes inflicted upon the cranium in burns, from the accidental fall of the patient into the fire during an attack of epilepsy or a fit of drunkenness. In a case of this kind, under my observation, in 1800, in a man upwards of fifty years of flora flip urtnlp cUnll.rum linrl Bonn nnmnlntnlir rltif ordiml cnmo time nroniniiclv and its nlapfl Fig. 3. Syphilitic Caries of the skull; at a the Bone is Necrosed. TUMORS. 27 CHAP. I. occupied by a new shell of bone, covered with beautiful granulations, bathed in thick, healthy pus. The parts were progressing favorably under simple dressings, the man being in other respects perfectly well. Injury indicted upon the diploe,in which this substance is more or less severely bruised, shaken, or disorganized, is liable to be followed by grave inflammation, acute or chronic, eventuating in the formation of pus, either in its own structure, beneath the pericranium, or between the dura mater and skull, considerable portions of which sometimes perish from the destruction of their vascular connections. The matter that is found in this con- dition in the veins of the diploe is extremely liable to enter the circulation, thus becoming a direct cause of pyemia, often attended with the development of embolic abscesses in the lungs, liver, and other organs. The treatment of these affections is to be conducted upon strictly antiphlogistic prin- ciples, copious leeching, vesication, and free incisions being among the more important measures. Matter must be promptly evacuated, and dead bone removed as soon as it is sufficiently loose. The brain and its membranes are carefully watched, that they may not suffer from secondary involvement. The cranium may be affected with Jistnle, as a result either of injury or of organic disease. The nature of the lesion is generally easily detected with the probe ; or, when this fails, by filling the passage with water, and then, while the opening in the integument is made in the most elevated point, requesting the patient to take a deep inspiration. The water, if a fistule really exist in the bone, will now disappear, but will imhiediately be expelled during forced expiration. The cure of the disease is based essentially upon the removal of the exciting cause. Depressions, cavities, or hollows, of varying size and shape, the result of caries or necrosis of the cranial bones dependent upon chronic syphilitic disease, occasionally occur, and cause more or less disfigurement, especially when situated on the forehead. The treat- ment which I have always found successful in such circumstances consists in raising the skin around the abnormal opening, and uniting the edges after they are freshened with the twisted suture. When the gap is uncommonly large, it may be necessary to borrow a flap of integument from the neighborhood. 4. TUMORS. a. Exostosis and Hypertrophy The cranial bones now and then suffer from exostosis, of which there are two distinct kinds, the ordinary and the syphilitic. The former, which is often caused by external injury, is most common about the forehead, and may, in time, acquire a considerable bulk, although in gen- eral it is small. Its structure is either com- paratively soft and spongy, or hard and dense, like ivory. It seldom extends beyond the outer table of the skull, and has usually a tolerably broad base. Occasionally several such growths occur on the same bone, as seen in fig. 4. When the exostosis extends inwards, or grows from the inner surface of the cranium, inducing neuralgia or epilepsy, and the diag- nosis is sufficiently obvious, the offending structure should be removed with the trephine. An exostosis of the skull is sometimes detached spontaneously, especially if it has a narrow, fibro-cartilaginous base, by being assailed by inflammation, gradually terminating in ulceration, or ulceration and gangrene, of the connective structures. Such an event, however, is very uncommon, on which account operative interference is generally the only resource. A great deal has been written about the danger of excision of such a growth, and some authors have even gone so far as to declare that removal should never be attempted so long as it does not give rise to serious suffering or inconvenience. Instead ot the saw, gouge, chisel, and mallet, they insist upon the use of caustics, on the ground that there will be less danger of intracranial mischief. I cannot share these apprehensions. I have repeatedly employed excision, and have never had any cause to regret it. It mav readily be supposed that such an operation, carelessly performed, might be followed by seri- ous. if not fatal, disease of the brain and its membranes, esneeiallv when the tumor lia< Fig. 4. Ivory-like Exostoses of the Skull. 28 an unusually broad base ; but even in such an event the risk will be greatly diminished if there be no direct interference with the cranial bones. The best instrument for the successful removal of such growths is the burr of the surgical engine. INJURIES AND DISEASES OF THE HEAD. CHAP. i. Fig. 5. Syphilitic Enostosis of the Skull. The syphilitic form of exostosis is occasionally met with as a tertiary symptom, being most common in persons whose system has been injured by the conjoined effects of the syphilitic poison and of mercury. The forehead is the most common site of the morbid growth, which is often multiple, and not unfrequently appears between the tables of the cranial bones. Its base is broad or diffused ; its structure soft and porous. The disease is always accompanied by tenderness on pressure, and by fixed pain, liable to nocturnal exacerbations, which, together with the history of the case, generally readily distinguish it from the ordinary affection. When a tumor of this kind forms on the inner surface of the skull, it must necessarily cause more or less cerebral disturbance. The treatment is similar to that of tertiary syphilis in other parts of the body. The annexed sketches, figs. 5 and G, exhibit the central and peripheral varieties of these for- mations. A species of general hypertrophy of the bones of the skull sometimes occurs, either as the result of external injury, as a blow on the head, or, as more frequently happens, as an effect of the syphilitic virus. It is characterized by extraordinary density of structure, by complete effacement of the diploe, and by great increase of weight and thickness of substance. The treatment must be regulated according to the nature of the exciting cause. 0. Venous Tumors.—A peculiar form of venous tumor, communicating, through one or more openings in the skull, with the superior longitudinal sinus, has been described by Dupont, Middeldorpf, Hutin, Azam, and other observers. Occasionally the result of a fracture, the most common cause of the abnormal communication is spontaneous, pro- gressive absorption of the osseous tissue corresponding with the Pacchionian depressions, when, under the influence of slight traumatism, the blood escapes beneath the pericranium, where it forms a soft, fluctuating, reducible tumor, which augments during forced expiration, flexion of the head, and compression of the internal jugular veins, but diminishes during deep inspiration, and when the head is erect. The venous tumor of the skull is very indolent, and rarely exceeds the volume of a Spanish chestnut. The treatment is entirely palliative, consisting in the protection of the part from accident by the application of a compress and suitable straps. In one instance, in which, through an error of diagnosis, an incision was made into it, the result was fatal. y. Aneurism by Anastomosis The diploe is occasionally the seat of aneurism by anas- tomosis, arising either as a congenital defect, or as a consequence of injury. As the mor- bid growth advances, it causes absorption of the tables of the bones, and in this way a large tumor may ultimately be formed, pulsating synchronously with the heart’s action, diminishing under pressure, and augmenting when the patient cries or makes any violent exertion. Very little can be done for this disease, in the way of treatment, beyond keeping the patient quiet, and obviating all sources of mental excitement. In its earlier stages, trial may be made of gentle pressure or of subcutaneous ligation. The common carotid artery Fig. 6. Syphilitic Exostosis of the Inner Surface of the Skull. CHAP. i. TUMORS. 29 has been tifed for it in a number of cases, but not, so far as I know, in a solitary one with any marked benefit. 8. Pneumatocele.—An emphysematous tumor of the scalp, technically called pneumato- cele, is sometimes met with, and has been studied with great care by Costes, of Bordeaux, and Thomas, of Paris. Fracture of the skull, involving the frontal sinuses, the mastoid cells, or the petrous portion of the temporal bone, is its most common cause; but it may also be induced by necrosis, caries, and other diseased conditions, especially spontaneous, pro- gressive atrophy of the osseous tissue, allowing the air to pass from the nose or the ear beneath the pericranium, where it forms a tumor, varying originally in size from a cherry to a pigeon’s egg, painless, smooth, circumscribed, elastic, non-tiuctuating, and resonant on percussion. During expiration, if the nose and mouth be closed, the air generally escapes with a hissing noise, and the swelling collapses or even completely disappears under pressure, but reappears the moment the pressure is removed. The tumor, which may eventually acquire a considerable bulk, is usually situated in the temporal, mastoid, or frontal region, the air lying immediately beneath the periosteum, which, however, may ultimately give way, thus permitting the fluid to diffuse itself more or less widely through the connective tissue. It has been noticed in some of the reported instances that com- pression of the tumor was provocative of dizziness, lachrymation, cough, suffocative sen- sations, and suffusion of the countenance. Jarjavay, Balassa, and Chavance have each published the particulars of a case in which the tumor was dependent upon fracture of the {•etrous portion of the temporal bone, laying open the cavity of the tympanum. The emphysematous tumor of the head augments slowly, several months often elapsing before it attains any considerable bulk, or manifests any tendency to diffuse itself over the skull, which, in rare cases, it may cover almost in its entire extent. When the dif- fusion is thus generalized, exploration with the fingers, while it diminishes the tumor, detects a remarkable alteration in the cranial bones, consisting in alternate, rounded, or acuminated elevations, with corresponding depressions, evidently due to a deposit of new osseous matter. The general health remains perfect. The treatment consists in applying a firm bandage, or a closely-fitting cap of gutta- percha, the air, as a preliminary measure, having been pressed out with the fingers, if the tumor be reducible, or by a delicate trocar under opposite circumstances. Operative pro- cedure, including incision, excision of the sac, or the insertion of a seton, with a view to the establishment of suppurative action, must be avoided, as they are liable to be followed by serious accidents, if not the death of the patient. *. Sarcoma The only primary malignant tumor of the skull is sarcoma, which may start from the pericranium, the diploe, or the dura mater. The pericranial growths are generally of the spindle-celled variety, and evince a decided tendency to undergo calcifi- cation or ossification. On several occasions I have met with round-celled sarcomas in this situation, which were characterized by great rapidity of growth and softness, and which invariably returned after extirpation. A remarkable case of the recurring spindle- celled variety, extending over a period of twenty-four years, in a man, aged forty-four, has been reported by Billroth. It originally appeared on the back of the head as a firm, painless nodule, which was extirpated when it had attained the volume of a walnut, lie- turning at the cicatrice ten years subsequently, it was allowed to go on for five years, when it also was excised; but new growths soon appeared at the same site, and in three years, when they were removed, they had attained the diameter of a German two-dollar piece. The denuded skull was cauterized with the hot iron, the application being fol- lowed by a superficial exfoliation. Two years after the third operation, the entire occi- pital region was found to be studded with hard tubercles, varying in size from a bean to that of a cherry, and reaching down over the back of the neck. The whole mass, includ- ing enlarged glands and vessels, was now dissected away from the bones and muscles, and in three months the huge wound was perfectly cicatrized. In the mean time, however, new growths sprung up among the cervical muscles and in the new inodular tissue; and, although the actual cautery was freely used, the man, after nearly two years more of cruel suffering, finally succumbed in a state of complete exhaustion. The central sarcomas, or those which originate in the diploe, are usually composed of giant cells, and are most common during childhood as the result of external injury. They are now-and-then pervaded by osseous spicules, and not infrequently attain a large vol- ume. Sarcoma of the dura mater, which was described as “fungus” of that membrane by the older surgeons, usually presents itself as the spindle-celled variety. Taking its rise commonly at the base of the skull, the morbid growth gradually extends until it perforates 30 INJURIES AND DISEASES OF THE HEAD. CHAP. i. the cranium, and appears upon the exterior, spreading for a while underneath the scalp, and then ultimately pushing its way through that structure. Cases have been witnessed in which, instead of making its way through the substance of the skull, it issued at the orbit, the ear, or the nares; in the latter event, perhaps, simulating a nasal polyp. The growth is usually solitary, of small size, seldom exceeding the volume of a pullet’s egg or of a small orange. There are no signs by which such tumors can be distinguished in their earlier stages, or prior to their exit from the cranial cavity. The symptoms up to that time are solely of a functional character, evincive of cerebral disturbance. After the growth, whatever its structure may be, has perforated the skull, it will generally be found to be of an irregu- larly rounded, lobulated shape, hard at first, and afterwards soft and elastic, more or less painful, and the seat of pulsation synchronous with that of the heart. When ulceration lias taken place, there is always more or less discharge of a very fetid, irritating matter, of a thin, ichorous character. The duration of life, in such a condition, is commonly very short, the patient being rapidly worn out by hectic irritation, death being often preceded by paralysis, coma, and convulsions. In regard to treatment, palliation is almost the only thing to be thought of. There are, however, two cases upon record in which a permanent cure is said to have been effected by the operation of trephining and the total extirpation of the tumor, one of these having occurred in the hands of Grosmann and the other in those of Pecchioli. In a case of sarcoma of the frontal bone Kiister removed a portion of the dura mater along with the bone. The disease, however, returned, and the patient underwent a second ope- ration, which, in its turn, was soon followed by repullulation. 5. MALFORMATIONS. a. Meningocele Meningocele is a congenital tumor of the head, most common in the occipital region, but sometimes also met with in the parietal and frontal. It is usually situated at the middle line, and, as the name implies, is filled with cephalo-spinal fluid, protruding along with the membranes of the brain through a small opening in the skull, a fontanelle, or a suture. The tumor, originally, perhaps, not larger than a pea or cherry, is capable of acquiring a considerable bulk, and is generally of an elongated, conical form, with a rather narrow neck. It is free from pain and pulsation, of a smooth, shining appearance, fluctuates more or less distinctly, is in great degree divested of hair, and is rendered tense in crying, sneezing, coughing, or forced expiration. When small, it may be almost completely effaced by pressure. It is essentially composed of the scalp and of the envelops of the brain. Its contents, consisting of cerebro-spinal fluid, are perfectly limpid and uncoagulable. Meningocele must not be confounded with hydrocephalus and encephalocele. The chief points of distinction are, its small size, its conical form, its softness, its translucency, and its partial subsidence under pressure. The prognosis is generally unfavorable. A cure may sometimes be effected when the cranial opening is very small; but under opposite conditions relief is commonly imprac- ticable. The treatment must be by compression or ligation. The former may be conducted by means of a piece of sheet lead, confined by a bandage, the tumor having previously been reduced by puncture with a delicate needle. It should be steadily retained for several months, and be aided by the occasional' application of iodine. Ligation is a dangerous operation, and yet it may be the only resource. The ligature should be firmly applied to the base of the tumor, so as to cause immediate strangulation. In a case of this description, under my charge, in a child, fourteen months old, subjected to this treatment at the College Clinic in 1863, death occurred at the end of the sixth day, from arachnitis. The tumor, which was of a conical shape, grew from the centre of the occiput, and was at birth about the volume of a small hazelnut. It remained nearly stationary until the tenth month, when it rapidly increased in size, and at the time of the operation it was an inch in length by half an inch in diameter. 13. Encephalocele Encephalocele, or hernia of the brain, is a rare congenital malfor- mation, generally associated with meningocele, and always connected with, if not directly dependent upon, a defective state of the cranium. Its most common site is the occipital region, 53 of 79 cases analyzed by Mr. Z. Laurence being in this situation. Occasionally it is met with at the root of the nose, at the frontal suture, immediately over the eye, or at the base of the skull. In the latter event it sometimes projects into the nose or even CHAP. I. into the mouth. Of 39 of the above cases in which the sex is mentioned, 21 were males, and 18 were females. The size of the tumor varies from a small nut to that of a foetal head, according to its age and other circumstances. The contents consist either of a portion of the cerebellum, as in fig. 7, from Bryant, or of the cerebrum, pro- truded through a circular, oval, or triangular opening in the skull, the edges of which are nearly always rounded off, and somewhat thinner than the adjacent bone. The coverings consist of the scalp, epicranial aponeurosis, dura mater, and arachnoid membrane. The form of the tumor is either spherical, oval, or cylindrical. The affection is frequently associated with other malformations, as bifid spine, harelip, cleft j»alate, or club-foot. When it occurs along with meningocele, it constitutes what is called hydrocephalocele. . The history of the case and a careful examination of the scalp are the safest guides to the diagnosis of the affection. The diseases with which it is most liable to be confounded are meningocele, and various morbid formations, as serous, bloody, and other tumors. When the protrusion is solid, it feels hard and faintly elastic, whereas when it is partly fluid and partly solid, it will be soft and fluctuating, or soft at the top and hard at the base. It diminishes under pressure, and increases under mental emotion. In rare cases pulsation, synchronous with that of the heart, is perceptible. The intellect is usually unimpaired, but pressure causes momentary coma, partial paralysis, and other symptoms of cerebral disturbance. Most of the subjects of encephalocele are either stillborn, or they die soon after birth. In the cases collected by Laurence only six reached adult age. Adams met with an in- stance at twenty and Guyenot at thirty-three years. The princqwil remedies are ligation, excision, and compression, conjoined with puncture when the affection is associated with meningocele. These means, however, afford but little prospect of relief, and experience is decidedly in favor of non-interference. In only one instance, so far as I know, was the protruding portion of brain sliced off successfully, the patient making a good recovery. y. Hydrocephalus Hydrocephalus, or dropsy of the brain, is fortunately a rare occur- rence, tor it is nearly always fatal, whatever treatment may be adopted for its relief. In regard to its pathology, my conviction, founded upon a careful observation of a con- siderable number of cases, is that the disease essentially consists in subacute or chronic arachnitis, commencing generally some time before birth, and going on gradually increas- ing until the head attains so large a volume as to cause hideous deformity. It is very likely that the disease occasionally takes place after birth, but such an event must be very uncommon ; for, even when a child thus affected is apparently healthy when ushered into the world, well-marked signs of dropsy usually appear so soon afterwards as to lead in- evitably to the conclusion that its origin was laid during intrauterine life ; probably in some inscrutable vice of the constitution. The fluid, consisting almost wholly of water, with some of the earthy salts and a little sugar, but hardly any albumen, usually occupies the ventricles of the brain, which, as the accumulation augments, is at length completely unfolded, forming a layer, perhaps, not more than from three to six lines in thickness, in which it is difficult, if not impossible, to distinguish any white and gray substance. In some instances, it is situated in the arachnoid sac, on the surface of the brain, which, in consequence of the severe and long-continued pressure of the water, is generally very much atrophied and distorted. I have not met with any examples in which the fluid was lodged between the cranium and the dura mater, and doubt whether it ever occurs here, as this membrane does not possess the power of secreting serum. The quantity of water varies from a few ounces to several quarts. Cases have been reported in which upwards of fifty ounces were drawn off at one operation during life, and more than twice that amount has occasionally been found on dissection. The disease is always chronic, and often continues for years before it proves fatal. The health, however, usually suffers at an early period ; the child becomes thin and emaciated, loses control over its muscles, and requires to be fed, although the appetite may be quite voracious. Convulsive twitchings are of common occurrence, the eyes roll constantly about in their sockets, the pupils are dilated, speech is absent, and the urine and feces MALFORMATIONS. 31 Fig. 7. Encephalocele. 32 INJURIES AND DISEASES OF THE HEAD. chap, i. commonly flow off involuntarily. The head, in the more advanced stages of the disease, is sadly misshapen, and altogether too heavy for the weakened body. The fontanelles are widely open, the cranial bones are abnormally thin and expanded, almost like parchment, and the subcutaneous veins of the scalp are enormously enlarged. The mind is gener- ally idiotic, and existence purely vegetative, the brain being sometimes almost completely absorbed, as in the interesting cases related by Delafield, Glover, Blackman, and others. The peculiar appearances of the head in hydrocephalus are well seen in fig. 8, from one of my clinical cases. Fig. 9 exhibits the state of the bones and fontanelles, divested of their soft parts. Fig. 8. Fig. 9. Chronic Hydrocephalus. Skull of a Hydrocephalic Child. A spontaneous cure of this disease occasionally occurs. Nelaton mentions a case in which the cure was apparently due to a cutaneous eruption attended with diarrhoea and copious perspiration ; and a somewhat similar instance has been recorded by Dr. J. W. Hubbell. Frank attended a child who recovered after an attack of scrofula. The period at which death occurs when the disease is permitted to pursue its course is extremely vari- able. Dr. West, of London, refers to a case in which the patient lived to the age of twenty-nine years, and Baillie to one of fifty-six. In such a disease as this, little, if anything, is to be expected from treatment. In the milder cases, especially in their earlier stages, benefit sometimes accrues from the steady use of sorbefacient applications to the head, as iodinized unguents or lotions, and the exhi- bition of iodide of potassium and bichloride of mercury, aided by an occasional laxative, and a properly regulated diet. Shaving the scalp, and afterwards vesicating it with can- tharides, have sometimes proved useful. No advantage could reasonably be expected from counterirritation by a seton or by an issue in the nape of the neck. Regular, systematic compression has repeatedly been tried, either with adhesive strips, or the roller, or both together, and a few cases have been reported of its supposed efficacy. Usually, however, the cure is only temporary, and it is proper to add that the treatment is often followed by convulsions, thus necessitating its abandonment. What is true of medication and internal applications is equally true of paracentesis, con- cerning which most marvellous statements have been published. Thus, Conquest asserts that by this operation he cured not less than 10 cases out of 19. Of 63 cases collected by Dr. West, 18 are said to have been restored. I doubt, however, very much whether rad- ical relief has ever followed such a procedure. In the only two instances in which I have performed the operation, death in each ensued in less than four days from convulsions; and such, I feel confident, must generally be the result when the accumulation is at all considerable, no matter how carefully the treatment may be conducted after the evacua- tion of the fluid, the maintenance of life being inconsistent with the sudden removal of such an amount of pressure as attends confirmed dropsy of the brain. The operation, originally performed by Le Cat, in 1744, and repeated by Remmet, of England, in 1778, consists in perforating the anterior fontanelle with a very delicate trocar, fig. 10, or an aspi- rating needle, introduced some distance from the longitudinal sinus, the opening being closed CHAP. i. CONCUSSION OF THE BRAIN. 33 as soon as about one-fourth of the fluid has been withdrawn, with collodion and adhesive plaster, applied in such a manner as to make firm and equable pressure upon the collapsed Fig. 10. Trocar for Puncture of the Cranium. cranium, and to prevent the entrance of air. The operation may be repeated once a week. During the after-treatment the child should be kept thoroughly under the influence of opiates, or chloral and bromide of potassium, to promote sleep and to control nervous irri- tation. SECT. Ill CEREBRAL AFFECTIONS. Under this caption may be described certain lesions of the brain, the result of blows and other external injury, accompanied or not, as the case may be, by fracture of the skull, as concussion, contusion, compression, irritation, inflammation, and abscess, or extravasation of pus and other fluids. Fractures of the skull and wounds of the brain will be treated of under separate heads. 1. CONCUSSION OF THE BRAIN. Perhaps as correct a. definition of concussion of the brain as can be given in the exist- ing state of the science is to say that it is a jarring or shaking of the nerve fibres, eventu- ating, at least in the more severe cases, in a certain amount of structural lesion, if not actual laceration. This view of the subject is rendered highly plausible by a consideration of the nature of the exciting causes of the affection, or the manner in which it is produced. In general, it will be found to be the result of direct violence, as a blow or fall upon the head. Now, under such circumstances, it is easy to perceive how the brain must suffer from the vibratory movements communicated to it by the osseous case in which it is inclosed. The force of the injury, instead of being expended upon the skull, is trans- mitted to the cerebral substance, which it jars very much as a bow is jarred in discharg- ing an arrow. When the blow is slight, the effect will be proportionately mild, the patient being, perhaps, merely stunned; whereas, when the force is severe or concen- trated, the result will be different, the substance of the brain being not only shaken, but, it may be, severely contused and even lacerated, the lesion exhibiting itself in the form of a fissure, which is immediately filled with blood, from the rupture of the small vessels. . 1 Similar effects occur when the concussion is occasioned by violence applied indirectly, as when a person falling from a considerable height, alights upon his feet, knees, or but- tocks. Here the force of the injury is transmitted along the bones of the extremities, and thence through the spine to the base of the skull, where, exploding, it is communicated to the brain, very much in the same manner as when the head is struck with a hard body, as a bludgeon, poker, or brick. The effect of this form of concussion may be illustrated by what occurs in the boyish amusement of killing woodpeckers in countries abounding in cherries. To prevent the depredations of these marauders, a slender pole is sunk into the earth, the free end protruding at the top of the tree. When the bird alights, the pole is struck with an axe or a sledge, and the vibratory motion thus transmitted through the fibres of the wood to his body instantly kills him. Now, in this case, death is caused, not by any change of bulk in the brain, nor by any alteration in its consistence, but simply by the jarring of its substance, disqualifying it for the transmission of the vital fluid, and, consequently, also for the maintenance of its circulation. The appearances presented on dissection after death from concussion of the brain must necessarily vary according to the amount of injury inflicted upon the cerebral tissues. In the milder cases, there is generally little, if any, appreciable lesion ; but, as few persons die under such circumstances, our knowledge is of a conjectural rather than of a positive character. In the more severe forms of the accident, especially such as are complicated with symptoms of compression, or in which the patient perishes shortly after the occur- rence of the accident, or in which he remains for a long time in a state of greater or less 34 INJURIES AND DISEASES OF THE HEAD. chap, i. unconsciousness, and then dies, the post-mortem evidences are generally of a marked char- acter, manifesting themselves in punctiform or blotchlike effusions consequent upon the rupture of some of the vessels of the brain, in the presence of minute fissures occupied by clotted blood, and in more or less contusion, if not actual laceration, of the cerebral tissues more especially noticeable upon the surface of the cerebrum and cerebellum. In the very worst class of cases, it is not uncommon to meet with fracture of the skull, lace- ration of the meninges, partial detachment of the dura mater from the cranial bones, or more or less extensive effusion of blood into the ventricles of the brain or into the arach- noid sac. As concussion of the brain may exist in various degrees, so the symptoms which char- acterize it may present various shades of difference, depending upon the severity of the injury; hence it will be proper to study these symptoms with reference to their diagnostic and therapeutic value. It will greatly facilitate the comprehension of the subject if we adopt the division of concussion into the three stages of depression, reaction, and inflam- mation, usually recognized by writers and teachers ; for, although such an arrangement is altogether arbitrary, and, therefore, unnatural, yet something of the kind is absolutely Hiicessnry for the sake of clearness of description. 1. The stage of depression is characterized by symptoms of exhaustion, not unlike those produced by the loss of blood. The system has received a shock, varying from the slightest functional disturbance to complete insensibility, life being suspended, as it were, merely by a feeble thread. In the former case there will probably be only slight pallor of the countenance, a confusion of ideas, a disposition to yawn, and a feeling of nausea. The patient rubs his eyes, stares wildly around, and perhaps vomits ; but, presently recovering his consciousness, he gets up, and goes about his business as if little or nothing had occurred. This is an example of slight concussion, such as happens when a man is pitched gently off his horse, thrown out of his carriage, or struck upon his head. When the lesion exists in a more aggravated degree, these symptoms will not only be much more distinctly marked, but of longer duration, a number of hours, perhaps, elapsing before reaction sets in. The prostration is profound; the countenance is of a deadly pal- lor; the breathing is almost extinct; the pulse is soft, feeble, fluttering, and intermittent, sometimes hardly perceptible; the loss of strength is complete; deglutition is impossible; the stomach, oppressed with nausea, perhaps lazily ejects its contents; the bowels are relaxed, and there are occasionally involuntary discharges; the pupils are usually con- tracted, but still somewhat sensible to light, or one is diminished and the other dilated, or, finally, one is contracted and the other natural; special sensation is in abeyance; the mind is prostrated; and the patient, roused with difficulty, answers, if spoken to, in a drawling monosyllable and immediately relapses into his former condition. The surface of the body soon becomes cold, and is often bathed with perspiration. The condition of the bladder varies ; generally the urine passes off naturally or with more or less dribbling, but in very bad cases it may he retained and require to be drawn of!' with the catheter. The duration of the stage of depression varies from a few minutes to several hours or even days, depending upon the extent and severity of the lesion. When the functional disturbance is slight, it may last only a very short time, otherwise the prostration will be more persistent, and sinking or collapse may occur, with little, if any, effort at reaction. When, in such a case, death occurs, the event is due either exclusively to the injury in- flicted upon the cerebral substance, or, as not unfrequently happens, to lesion of the brain complicated with lesion of the heart, spinal cord, or some other important organ. Bleeding from the ears without any fracture of the base of the skull, simply as the result of a laceration of the vessels of the soft parts is sometimes met with. Of twenty- two cases of concussion recorded by Laurie and King, of Glasgow, twenty recovered, and in only one of the two that died was there any fracture at the base of the cranium. Nasal hemorrhage is by no means uncommon in affections of this kind, especially when the con- cussion has been caused by a blow or fall upon the forehead. The leading indication in the stage of depression is to establish reaction, or to rouse the enfeebled, and, perhaps, flagging energies of life. This object may usually be attained by very simple means, promptly and judiciously employed ; such as placing the patient recum- bent, with his head on a level with the body, or, it the symptoms are at all urgent, even considerably lower, in order that the heart, weakened by the shock, may be enabled to throw the blood with more facility into the exhausted brain, affording tree access of air by opening the doors and windows of the apartment, or by the active use of the fan, and by dispersing any bystanders, or idle spectators, as their presence cannot fail to be pre- judicial to the patient. Any tight garments, especially the collar and pantaloons, must CHAP. i. CONCUSSION OF THE BRAIN. 35 promptly be relaxed, to give full play to the respiratory muscles. Cold water is freely dashed upon the face and chest, smelling bottles are rapidly passed to and fro under the nose, and sinapisms are applied to the extremities and to the precordial region. In the milder forms of concussion, these means are generally amply sufficient for the speedy establishment of reaction ; but when the case is very severe, it may be necessary, in addi- tion, to place sinapisms along the whole length of the spine, and to employ stimulating injections, as water mixed with mustard, turpentine, alcohol, ether, or ammonia. If the feet are cold, they may be immersed in warm water, or rubbed with hot cloths, and afterwards wrapped up in warm flannel and surrounded with hot bottles. As soon as the patient is able to swallow, a little cold water, or water and brandy may be given, the latter being more especially indicated when the system is unusually slow in reacting. Spontaneous vomiting sometimes greatly promotes restoration, particularly if a hearty meal was taken shortly before the accident ; a heavy load being thus removed, the dia- phragm enjoys greater play, the pneumogastric nerves act with increased vigor, and the heart propels the blood with greater force to the paralyzed brain. The relapsing uncon- sciousness which occasionally occurs after partial reaction has taken place generally readily yields to mild stimulants, and is often more alarming in appearance than dangerous. As life returns, color succeeds pallor, warmth coldness, and intelligence confusion of ideas; the pulse resumes its wonted force and activity, the respiration becomes more natural, the stomach is relieved of nausea, the sphincters recover their proper functions, the special senses are again on the alert, and volition is exercised with its accustomed free- dom. The restoration may be rapid or gradual, temporary or permanent; once fully established, however, it rarely recedes, but steadily advances, with a tendency, not unfre- quently, to overaction. In treating concussion of the brain, the inexperienced practitioner is apt to be led into several serious errors, especially if he is surrounded by officious bystanders, and not per- fectly self-possessed. 1st. He may be tempted to draw blood while his patient is in a state of profound exhaustion, unable, perhaps, to crook a Anger or utter a syllable. Nothing is more com- mon immediately after such accidents than for the friends of the patient to insist vocifer- ously upon his being bled ; and if the surgeon, in an unguarded moment, yield to the silly request, he may destroy life on the instant, or render reaction very difficult, if not impos- sible. To bleed a man in such a condition is as absurd and culpable as to bleed him when he is in a state of syncope from the loss of blood. 2d. Great care should be taken in the use of ammonia, and other pungent articles, not to hold them too near the nose, lest they induce spasm of the glottis, and thus suffocate the patient. Moreover, their employment might give rise to inflammation of the nares, fauces, larynx, and trachea. 3d. The practice of pouring drinks into the patient’s mouth, before he is able to swal- low, cannot be too pointedly condemned, as it is fraught with great danger, on account of the liability of the fluid to pass into the windpipe, where even a small quantity might induce suffocation. The patient should, therefore, be sufficiently conscious to know what is being done, or, if he cannot be roused, and the symptoms are very urgent, the fluid should be placed in contact with the fauces, beyond the reach of the larynx, the act of deglutition being thus excited without any risk of injury. 4th. When stimulants are used, due regard must be had to their quality and quantity, as well as to the period of their administration. Brandy or whiskey is generally pre- ferable to anything else, but it should be given sparingly, and its use should be suspended the moment reaction has fairly commenced. The object is to rouse the system gradually, not rapidly, to coax, not to force, the jaded powers of life ; this wish attained, all artificial excitants are refrained from. In ordinary cases no internal stimulants are required, beyond, perhaps, a little wine, or a few drops of aromatic spirit of hartshorn. 5th. The accident may have occurred soon after a hearty meal, and then the question may arise in regard to the propriety of exhibiting an emetic. Nature sometimes decides this for the practitioner, by the institution of spontaneous vomiting; but when this does not happen, and there is no contraindication, as when the concussion is uncomplicated with compression, it may be excited by salt and mustard, ipecacuanha, alum, or zinc, fol- lowed by large draughts of tepid water. During the act of emesis, whether occurring spontaneously or excited artificially, the patient’s head should be inclined forwards, other- wise some of the ingesta, as they are lazily ejected, may drop into the air-passages, and cause fatal asphyxia. 36 INJURIES AND DISEASES OF THE HEAD. CHAP. I. 2. Reaction being established, the surgeon does not fold his arms idly, on the one hand, nor is he overofficious, on the other. Ilis business is to stand as a guard over his patient, carefully watching, and measuring, as it were, every symptom as it arises, in order, if possible, to form a just appreciation of its pathological import, and to seize the earliest moment to counteract any aberration from the healthy action. The great danger now is from inflammation of the brain. Usually, after the patient has completely regained his faculties, it is observed that the functions which were temporarily suspended are performed with a slight degree of excitement; but this is not to be taken as an evidence for active interference ; on the contrary, it generally disappears spontaneously in a few hours, the surface becoming moist, and the pulse1 losing its sharpness and frequency. The diet is light and non-stimulant; perfect quietude of mind and body is enjoined ; and the bowels are moved with gentle laxatives. If the shock has been at all severe, the patient is warned against premature exposure, even if the symptoms have happily passed off; he must still consider himself an invalid, not for days but for weeks, and avoid everything tending to awaken excitement in the recently shattered organ, now peculiarly prone to take on mor- bid action from the slightest causes. The head must be sedulously watched, and any pain of which it may be the seat must be looked upon with suspicion, especially if it be com- bined with irritability of temper, vitiated appetite, obstinate constipation, or a sharp, frequent pulse. A brisk purgative, and a few leeches to the temple, or the abstraction of a little blood from the arm, may avert the threatened evil, and prevent it from passing the normal limits, while the delay, even of a day, may enable it to reach a crisis which may speedily prove destructive to life. 3. Overaction of the system, consequent upon the cerebral lesion, constitutes the third stage of concussion, or the stage of inflammation. The period of its access is variable. Generally it comes on within the first four or five days, sometimes, indeed, within the first four-and-twenty hours; on the other hand, instances not unfrequently occur in which it does not manifest itself for weeks or even months, the patient considering himself all the while out of danger, and fully competent to attend to his daily occupation. In the former case, the disease is usually bold and undisguised; in the latter, it is often latent, its ap- proaches being slow and stealthy, and its progress, consequently, often considerable before its true nature is discovered. Such examples are always peculiarly dangerous, on account of their liability to be overlooked and mismanaged. 2. CONTUSION OF THE BRAIN. Contusion of the brain, first recognized as a distinct lesion by Desault, afterwards more accurately described by Dupuytren, and in recent times elaborately investigated by Prescott Iiewett, Fano, and other observers, may be defined to be a sudden and violent attrition of a portion of its substance, attended with more or less laceration, and an effusion of blood, generally in the form of minute specks or little clots. It may present itself in two dis- tinct varieties of form, the circumscribed and the diffused, the latter, which sometimes involves a large extent of tissue, being by far the less common. Resulting from the same causes as concussion of the brain, with which it is, in fact, almost constantly associated, the more serious cases are commonly the consequence of concentrated force, or of force applied with a pointed weapon. To produce it, however, there need not necessarily be a fracture of the skull, nor, indeed, any injury whatever of the calvaria ; a fall upon the feet, knees, or nates is, at times, quite sufficient to give rise to it. Occasionally it follows apparently very slight blows upon the head. However this may be, the bruise is ordi- narily direct, that is, at the part struck, although it may also be indirect, or at a consider- able distance off, especially when it is caused by contre-coup. In the latter case, indeed, it is often immediately opposite the seat of the blow. The most common situation of the legion is the cerebrum, at its under part, owing, doubtless, to the intimate relation of this portion of the organ with the sharp edges of bone at the base of the skull. The cerebellum, pons, crura, and medulla are compara- tively seldom affected. The extent of the injury varies from a few small patches, so slight, perhaps, as to be hardly distinguishable, to the greater portion of an entire lobe, or even a large portion of one of the hemispheres. The most severe cases are usually connected with fracture of the cranium, with or without depression. Marked evidences of it almost invariably exist in fracture of the base of the. skull, from blows or falls upon the vertex. Occasionally the lesion occurs at several points, more or less remote from each other, as the cerebrum, cerebellum, pons, and fornix, or the cerebrum, fornix, and medulla. CHAP. i. CONTUSION OF THE BRAIN. The contusion varies also in degree. In the circumscribed variety, the patches, in the milder cases, are confined almost exclusively to the gray substance, and are frequently not more than a few lines in diameter; they are of a dark-purplish hue, and are interspersed with minute specks of blood, not larger than pin points, and more or less closely grouped, a section strongly resembling the appearances produced in capillary apoplexy. When the injury has been unusually violent, the discoloration is much deeper, as well as more uniform, and the affected part, torn, softened, and disorganized, is thoroughly infiltrated with blood, small clots of which, generally not exceeding the volume of a pea, are at the same time imbedded in its substance. Both the gray and white structures are implicated, often to a great extent and in a high degree. The slight and severe forms frequently coexist in the same brain. In the diffused variety of the lesion the extravasations are more or less widely dissemi- nated ; their size varies from that of a little dot to that of a millet-seed or a split pea, and they often exist in considerable numbers, although cases occur in which there are so few that, unless a very careful dissection be made, they may altogether elude detection. The cerebral substance around these clots is generally somewhat softened, and occasionally also a good deal discolored. If death occur soon after such an accident, the extravasated blood, whether appearing in minute specks or small clots, is usually found to be soft and of a dark color; after the lapse, however, of a few days, it is generally solid, and often a few shades lighter. At a still later period, it is partially, if not completely, absorbed, and replaced by a minute yellowish spot, containing, not unfrequently, a little serous fluid, precisely as in ordinary apoplexy. The membranes of the brain are variously affected. In the slighter forms of the injury there may simply be an infiltrated, or eechymosed condition of the pia mater in the vicinity of the lesion, but in the more severe cases there is nearly always, in addition to this, more or less laceration of this membrane and of the arachnoid, with extravasation of blood into the sac of the latter, and occasionally also extensive detachment of the dura mater. Hewett, who has studied this subject with great care, states that out of 69 cases of more or less severe contusion of the brain, independently of compound fracture, he found blood poured out in this situation in not less than 52, the quantity in 31 being so large as to cap the brain. The symptoms of this affection are, in general, so vague and ill-defined that it is not surprising that its true nature should often be overlooked. Its recognition is the more difficult because it is nearly always accompanied with concussion, the symptoms of which, running into those of contusion, thus occasion an inextricable blending of the character- istics of the two lesions. Then, again, it is to be recollected that there must necessarily be many cases in which the affection is associated with, and masked by, compression of the brain, the result either of more or less copious extravasation of blood or of fracture of the skull with depression of bone. Hence, if an attempt be made to separate the more simple cases of contusion from the complicated, the number will be found to be exceed- ingly limited. Dupuytren, who, as already stated, was the first to call special attention to this lesion, came to the conclusion, in formulating the results of his experience, that the earliest re- liable phenomena did not appear until about the fifth day, or the usual period for the supervention of cerebral inflammation. More recent observations, however, have led to a different result. In general, it may be inferred, especially in the absence of fracture, that the lesion is one of contusion, when, the first symptoms of shock having passed away, the disturbance of the brain more or less obstinately persists. This conclusion will be rendered so much the more probable when there is pretty complete loss of consciousness, along with an uncommon degree of somnolency, but no stertorous respiration ; when there is extreme agitation or restlessness, the patient tossing continually about in bed ; when there is rigid contraction of one or more of the limbs, especially of the fingers; and, finally, when there is more or less delirium during the first few days after the accident, with a gradual but steady aggravation of all the symptoms. In the milder cases of con- tusion there may merely be some contraction of one of the pupils, partial paralysis of an eyelid, impaired vision, indistinctness of articulation, slight spasmodic twitching of the muscles of the face, partial loss of memory, pain in the head, especially at the seat of the part struck, and defective sensation, or want of control over the action of the sphincters. When the lesion is complicated with fracture of the cranium, whether with or without depression, all effort at discrimination must fail. Finally, it must not be forgotten that, 38 INJURIES AND DISEASES OF THE HEAD. CHAP. I. in the milder forms of contusion, the symptoms must necessarily be proportionately insig- . nificant and evanescent, cerebral accomodation occurring within a short time after the accident. Occasionally there is what may be called a mixed form of contusion and compression of the brain, as in a case recently under my observation in a very stout, heavy, muscular man, upwards of fifty years of age, who, in a rapid drive, was thrown out of his carriage upon the top of his head. lie was picked up in a state of insensibility, in which he re- mained until he expired three days after. Ilis breathing became stertorous some hours after the accident, and his right side paralyzed. There was no wound or abrasion of the scalp, nor any fracture of the skull. The vessels of the pia mater were very much en- gorged, and innumerable little specks of blood, hardly the size of a common pin-head, were scattered through the hemispheres of the brain. The anterior lobes of the cerebrum contained each several clots of blood of the volume of an ordinary bean. Coagulated blood in small quantity was also contained in the lateral ventricles, particularly in the left. The cerebellum and medulla oblongata were sound. The prognosis in contusion of the brain varies with the extent of the lesion, the pre- sence or absence of complications, and the condition of the patient at the time of the acci- dent. The milder cases generally recover with little or no treatment, the effused blood being more or less rapidly absorbed, and the lacerated tissues gradually repaired. When, on the contrary, the contusion is very severe, the worst consequences are to be appre- hended, death happening either soon after the infliction of the injury from structural disorganization, or secondarily from the effects of inflammation of the brain and its envelops. The treatment must be regulated according to the general principles of practice appli- cable toother injuries of the brain and its membranes. The earlier symptoms are usually those of concussion or shock, and should, therefore, be combated by such means as are adapted to favor gradual reaction, as recumbency, access of cold air, the use of the smell- ing bottle, and the administration of ammonia, or, in the more severe cases, of some stronger stimulants. When this object has been attained, the chief duty of the attendant is to watch the patient that he may not, by overfeeding, neglect of his bowels, or prema- ture exertion and exposure, bring on inflammation, the great source of danger after such an occurrence. The period when this may be looked for is, on an average, from the fourth to the sixth day ; up to this period, therefore, as well as for sometime after, his vigilance should rather increase than relax ; every avenue should be guarded with the greatest care, and the slightest approaches of the enemy met with the most vigorous mea- sures. The hard, frequent, quick, and jerking pulse, the intolerance of light and noise, the excessive restlessness and thirst, the suffused eye and flushed cheek, and the wandering intellect, with a tendency to coma, paralysis, and convulsions, are signs of evil import, which it is generally much easier to prevent than to control successfully after they have made their appearance. If the patient is plethoric, blood must be freely taken from the arm or by leeches from the temples and behind the ears; the bowels moved by active cathartics; the head shaved, elevated and cooled with pounded ice ; in short, no effort must be spared to crush out the disease in its incipiency. The more remote effects of the lesion are combated by tonics and alterants, proper regulation of the diet and bowels, and change of air. 3. COMPRESSION OF THE BRAIN. It is very difficult, in the existing state of the science, to give a satisfactory definition of compression of the brain. Every surgeon knows what import to attach to the expression, but to say what compression is, or in what it really consists, are very perplexing questions. The legitimate meaning of the term, and as it is generally understood, is that the cerebral substance is pressed, by some eccentric force, into an unnatural space, or, in other words, that the normal volume of the part pressed upon is diminished. But is this really the case? Is it possible to compress an organ composed of so pulpy a structure as the brain ? I cannot myself conceive of such an occurrence, unless we take a portion of brain and subject it to an amount of artificial pressure such as is altogether inconsistent with what takes place even in the worst cases of compression within the skull. It is easy to con- ceive how the different portions of the brain may be changed in their relations; how one part may be flattened and another part expanded in consequence ; how, for instance, the convolutions of the hemispheres may be pressed out, and how their furrows may be effaced ; CHAP. I. COMPRESSION OF THE BRAIN. 39 how the lateral ventricles may be encroached upon, and even obliterated ; how the vessels of the brain may be flattened and destroyed; but we cannot conceive how the cerebral tissues can be so condensed and squeezed together as to occupy less space than in the natural state. This view of the case, it seems to me, is the only one that is at all admis- sible, and, hence, if it be assumed to be correct, it follows that compression of the brain is merely a change in the relative position of the component portions of the organ, and not what the term really signifies in its etymological sense. Dissection affords daily proof of the correctness of this opinion. The greater part of a whole hemisphere is sometimes flattened by an enormous coagulum, and yet, if the affected portion could be accurately measured, it would be found to occupy as much space as in the normal state, or as it did previously to the accident. The change is observed to depend mainly, if not exclusively, upon the depression of the convolutions and the effacement of the intervening spaces, and not upon any condensation of the cerebral tissues, or any actual reduction of their volume. The pressure exerted by the clot of blood could not act in any other manner, because its force is not sufficient; nor is it possible -for a piece of bone to cause any more efficient pressure, for the moment the force thus applied exceeds the force of the resistance, the brain gives way, and projects up beyond the edges of the depressed bone. Compression of the brain may arise from various causes, but, surgically considered, they may all be referred to four classes, extravasated blood, depressed bone, effused fluids, as serum or pus. and foreign bodies. However induced, the symptoms of compression are always of the same character, and are generally easily recognized, as every organ of the body is affected by the cerebral disorder. The period of their appearance is influenced by the nature of the exciting cause. When the compression is dependent upon depression of bone, the symptoms are usually imme- diate, whereas in compression from extravasation of blood some little time often elapses, especially when there is great shock. In compression from inflammatory deposits, a number of days intervene between the occurrence of the injury and the appearance of the symptoms, the parts being obliged to pass through the several stages of inflammation before they can reach the suppurative crisis. A person laboring under compression of the brain is deprived of sensibility and motion ; he is unconscious of what is passing around him ; if spoken to, he makes no reply, not even in a monosyllable; he cannot hear, nor see, nor taste, nor smell, nor can he articu- late, swallow, or protrude his tongue. The countenance is ghastly pale and devoid of expression ; the eyes are turned up, glassy, and fixed ; the lids are closed ; the pupils are widely dilated, and insensible to light; the breathing is slow, labored, stertorous, and performed with a peculiar whiffing, blowing, or putting sound ; there is hemiplegia, or paralysis of the side opposite to the seat of injury, and, as a necessary consequence, the corner of the mouth is drawn over towards the sound side ; the pulse is slow and oppressed ; the stomach and bowels are torpid ; and the bladder is incapable of expelling its contents. These symptoms do not always exist in the same degree, nor are they all equally well marked in every case. If the compressing cause be slight, the phenomena will be pro- portionately mild. Thus, the patient may only be partially insensible ; his intelligence may be weakened, but not abolished; the special senses may still be able to perform their functions, although very imperfectly; the paralysis may be confined to one limb, or to certain muscles; the pupils, pulse, and respiration may only be slightly altered ; the bowels may be torpid, but only in a moderate degree ; and the bladder may still be able to expel a portion of its contents. If the foot be pinched, the patient will moan or draw it away, thus showing that he has still some feeling, if not motor power. The paralysis which attends this affection is usually on the side opposite to that of the compressing agent, the occurrence being generally supposed to depend upon the decussa- tion of the fibres at the base of the brain. This is doubtless true, and the fact is of great practical importance in relation to any operations that may be required for the patient’s relief. In a few instances, as inexplicable as they are rare, the paralysis exists on the same side as the cause of compression. The state of the pupils is very variable. In general, they are widely dilated, but occa- sionally they are contracted, or one is contracted and the other dilated. A diminution of botli pupils is extremely uncommon. The stertor in this affection is caused by paralysis of the palate, which, hanging like a loose curtain in the throat, flaps to and fro as the air passes in and out of the lungs during respiration. The blowing, whiffing sound, and the distension of the cheeks, are due to the loss of tone in the buccinator and labial muscles. 40 INJURIES AND DISEASES OF THE HEAD. Differential Diagnosis If the cerebral lesions above described were always clearly defined, or, what is the same thing, if they were always uncomplicated, it would be dif- ficult, if not impossible, to confound them either with each other or with other affections ; but such, unfortunately, is not the case. Not unfrequently they are so blended as to ren- der it impossible to determine what the true nature of the lesion is, and what share is due, respectively, to concussion, contusion, or compression. As such an occurrence is always extremely embarrassing, and must, to a greater or less extent, influence the nature of the treatment, it is the duty of the surgeon to study the features of each complaint, in its more simple forms, so that, when he meets with them in association, he may be the better able to discern their various shades of difference. The more important phenomena of concus- sion and compression are here subjoined in tabular form, those of contusion not admitting of such an arrangement. CHAP. I. Concussion. 1. The symptoms are immediate, coming on in- J stantly after the infliction of the injury. 2. The patient is able to answer questions, al- though witli difficulty, and usually only in mono- syllables, as yes or no. 3. Special sensation is still going on, the pa- tient being able to hear, see, smell, taste, and feel. 4. The respiration is feeble, imperfect, and noiseless. 5. The pulse is weak, tremulous, intermittent, and unnaturally frequent. 6. There is nausea, and sometimes vomiting. 7. The howels are relaxed, and there are some- times involuntary evacuations. 8. The power of deglutition is impaired, but not abolished. 9. The bladder retains the power of expelling its contents ; but sometimes, owing to the weak- ness of its sphincter, the water flows off involun- tarily. 10. The voluntary muscles, although much weakened, are still able to contract, there being no paralysis. 11. The pupils are usually contracted, and somewhat sensible to light; the lids, if not open, are movable. 12. In concussion, the mind is in a state of abeyance ; it is weak and confused, not abol- ished. Compression. . 1. An interval of a few minutes, or even of sev- eral hours, sometimes elapses, when the com- pression is caused by extravasation of blood ; in compression from depressed bone it is generally instantaneous. 2. The power of speech is totally abolished; we may halloo in the patient’s ear as loudly as possible, and there will be no response. 3. Special sensation is destroyed. 4. The respiration is slow, labored, stertorous, and performed with a peculiar blowing sound. 5. The pulse is labored, soft, irregular, and unnaturally slow, often beating not more than fifty, fifty-five, or sixty strokes in a minute. 6. The stomach is quiet, and insensible to ordi- nary impressions, even to emetics. 7. The bowels are torpid, and are with diffi- culty excited by the action of purgatives. 8. Deglutition is impossible, and sometimes does not return for several days, 9. The bladder is paralyzed, and, therefore, incapable of relieving itself, the surgeon being obliged to use the catheter. 10. There is always paralysis on one side of the body, generally opposite to that of the com- pressing cause. 11. The pupils are widely dilated, and unaf- fected by light, the lids being closed and im- movable. 12. In compression, the patient is comatose, and the mind is temporarily abolished. Jn regard to the differential diagnosis of contusion of the brain, there are no signs, so far as is at present known, by which this lesion can be distinguished from concussion of this organ, or concussion and the slighter forms of compression. L. J. Sanson, one of the editors of Dupuytren’s works, lays great stress, in the milder varieties of contusion, upon the occurrence of spasmodic twitchings of some of the muscles of the face, the intolerance of light, the contraction of the pupils, and the partial but transient deafness; and, in the more severe, upon the suffused condition of the eyes, the intense restlessness and jactita- tion, the deep, circumscribed, pulsatile pain in the head, the convulsive movements of the limbs, the flexion of the fingers and toes, especially the former, the drowsiness and uncon- sciousness of the patient, and the absence of stertorous breathing. These phenomena, however, as has been conclusively shown by Fano, Hewett, and other writers, are com- mon to this and other lesions of the brain, and are, therefore, of no value whatever in a diagnostic point of view. The first group, indeed, is simply expressive of the milder forms of ordinary concussion, while the other, which rarely comes on before the fourth or fifth day, is clearly denotive of incipient inflammation of the brain, or of this organ and of its envelops. Although it is thus evident that this lesion has no characteristic signs, it may, nevertheless, be assumed, as a rule, that the brain has been more or less violently CHAP. i. COMPRESSION OF THE BRAIN. 41 contused when, after a blow or fall upon the head, the cerebral symptoms are unusually severe, protracted, or indisposed to yield to treatment. The symptoms of these various affections of the brain are sometimes painfully simu- lated by those of intoxication, or it may be that one or more of them may coexist with intoxication, thus increasing the embarrassment. The diagnosis is deduced from the his- tory of the case, the presence of external injury, particularly of the scalp, the habits of the patient, and the state of the breath, which, in inebriation, is alchoholic in its character. The pupil, according to Dr. Macewen, of Glasgow, is contracted, but dilates if the patient be shaken or disturbed without any return of consciousness, and then again very soon con- tracts. When doubt exists, the proper plan is to treat the case as one of cerebral disease, endeavoring, by suitable means, to bring on gradual reaction. A few hours will generally suffice to reveal the true nature of the affection, and this interval is not spent idly by the surgeon, but in a thorough examination of the body, with a view to the prompt detection and rectification of other lesions. Compression of the brain from extravasated blood or depressed bone may be mistaken for apoplexy. Such an error may readily occur from a want of proper knowledge of the history of the case. Thus, a man may be found in the street in a state of insensibility, with all the ordinary phenomena of compression, no one knowing anything of the nature of his disorder, and the most critical examination of his body failing to throw any light upon it. There may not even be a scratch upon the scalp. The man dies, and inspec- tion reveals the existence of a fracture with a large extravasation of blood. The symp- toms of the two affections are, in fact, forcibly alike, and the error is really, practically, of no consequence, unless, as in compression from external violence, the case is accessible to the trephine. The unconsciousness produced by an overdose of opium might be mistaken for compres- sion of the brain from external violence, especially if there be marks of injury of the scalp. The distinction between the two affections is founded mainly upon the condition of the pupil, which in narcotism from opium is greatly contracted, but widely dilated in cerebral compression from extravasated blood or depressed bone. The distinction between compression from extravasated blood and compression from inflammatory eflusion presents no obstacles. In the former case the cerebral symptoms show themselves either instantaneously or within a very short time of the receipt of the injury ; whereas in the latter they are always preceded by those of encephalitis. Com- pression, depending upon fracture of the skull with depression of bone, is usually easily recognized by a careful examination of the head, the finger sinking down at the seat of injury, or detecting, more or less clearly, the irregularity of surface peculiar to such a lesion. In injury of the head the aid of the ophthalmoscope may sometimes be advantageously invoked, more especially when it involves the base of the skull and brain. In ordinary concussion the eye remains sound, but in fracture of the frontal, occipital, and sphenoid bones, and in contusion of the brain with compression, it is not uncommon to meet with dilatation and thrombosis of the veins of the retina, with effusion of blood at the bottom of the eye, and with serous peripapillary infiltration. Similar appearances, with conges- tion and peripapillary oedema, occasionally occur as effects of encephalo-meningitis. It would be interesting, in a physiological point of view, as well as in a practical one, if we could determine, in these various traumatic lesions of the brain, the precise spot that is always affected, in order that the symptoms might be relieved by the trephine. Xhe steps taken in this direction are contained in the following summary, kindly furnished me by I)r. E. C. Seguin, of New York. The surgical anatomy of the head, with reference to its contents, has been developed with remarkable completeness within the last ten years, chiefly by the researches of Broca, Bischoff, Heftier, Turner, and Fere, by which cranio-cerebral topography has been firmly established as a branch of practical anatomy. Acting upon the data thus obtained, Broca, Lucas-Championniere, Weir, and others have successfully trephined for the relief of aphasic and paralytic symptoms. The location of many convolutions and fissures of the cerebrum can be accurately mapped out upon the surface of the skull, or even upon a living head, by the projection of certain lines and measurements from certain points thus obtained, as well as from some natural landmarks. For the projection of these, lines, the head is placed in a particular position, as can be easily done when we operate upon a bare skull; but which can also be approximated when we deal with a living subject, either sitting up or lying in bed. The skull or the 42 INJURIES AND DISEASES OF THE HEAD. chap, i. shaven head should be so placed and held that a line passing from the alveolar process of the superior maxilla just at the insertion of the teeth, and through the lowest part of the occipital bone, shall be horizontal. The greatest care should be used to determine this line,—the alveolo-condyloid line or plane of Broca,—for it is upon it that all other pro- jections and measurements are based. In the annexed figure the skull is represented as resting upon the alveolo-condyloid plane, 1-1. Fig. 11. Diagram for Cranio-Cerebral Topography, made from Heule’s Skull. Next, from the alveolo-condyloid line a vertical line, or one exactly perpendicular to the first, is drawn through the external auditory meatus. At the top of the head this line,—the auriculo-bregmatic line,—A-A, indicates the bregma or true vertex, which is an important landmark, one which should be traced with ink or carmine upon the shaven scalp. Upon the top of the head or skull an imaginary horizontal line, 4-4, parallel with the alveolo-condyloid plane, is projected, and upon this line, 4-4, we measure backward 50 mm. and draw a second vertical line, B-B, parallel to the auriculo- bregmatic line. At the place where this line strikes the convexity of the head is the Rolandic point, R, under which, in average heads, lies the upper or posterior extremity of the fissure of Rolando, the upper ends of the ascending frontal and ascending parietal convolutions, and, within the longitudinal fissure, the paracentral lobule, in other words, the upper part of the motor area of the cerebrum, that which quite probably controls the volitional movements of the legs. The Rolandic point, thus determined, should, on a living subject for operative purposes, be properly marked upon the shaven scalp. A third horizontal line is next to be drawn from the external angular process of the frontal bone, parallel with the alveolo-condyloid plane. This line, 2-2, which may be called the fronto-lambdoidal, as its posterior extremity will usually pass at or near the upper angle of the lambdoidal suture, serves the purpose of determining the situation of some important parts. In the first place the line 2-2 passes about 5 mm. above the upper border of the squamous suture, and under this line, mostly parallel to it, are the anterior two-thirds of the fissure of Sylvius. Secondly, at about 5 mm. above amL behind the intersection of lines A-A and 2-2 is the inferior extremity of the fissure of Rolando bounded by the ascending frontal and ascending parietal convolutions. In the third place, upon this line, 2-2, at a distance of 18 or 20 mm. behind the external angular process of the frontal bone, is the folded part of the posterior extremity of the third frontal con- volution, or Broca’s speech-centre, marked F* on the diagram. Having exactly determined and marked the situation of the Rolandic point at the top of the skull, and the inferior termination of the fissure of Rolando above the ear, these two points are connected by a line which is represented darkly drawn upon the diagram. CHAP. 1. COMPRESSION OF THE BRAIN. 43 This, the Rolandic line, is the guide for nearly all operations intended tor the relief of traumatic spasm or paralysis, since under it and near it lie the so-called motor centres for different parts of the body on the opposite side, as determined by experiments upon monkeys and dogs, and by numerous post-mortem examinations made in cases of tumors and other limited lesions of the brain. As indicated by the dotted lines on the diagram, the motor zone or centre for the lower extremity of the opposite side lies about the Rolandic point, making an allowance of at least 10 mm. to either side of the median line for the interval between the two hemispheres. It also includes the paracentral lobule within the longitudinal fissure; and Dr. Seguin is led to believe, from observation in cases of cerebral tumor, that this part is preeminently the centre for the leg. Below this, reaching quite down to the fronto- lambdoidal line, 2-2, is the motor area of the upper extremity. Forward of this, between the auriculo-bregmatic line A—A and the line C-C, is a part of the second frontal con- volution, which probably has connections with the facial muscles of the opposite side. Finally, at F* is the speech-centre of Broca, which, although not now regarded as the only speech-organ, yet plays an important part in the simpler mechanism which produces language-motions. Other relations of interest are the apex of the sphenoidal or temporal lobe a little beneath the line 2—2, and at about 10 or 12 mm. posterior to the external angular process of the frontal bone ; the situation of the occipito-parietal fissure almost immediately under the posterior end of the line 2-2 at its junction with the vertical line E-E, which also indicates the posterior extremity of the cerebrum ; the anterior end of the brain is marked off by the vertical line F—F. Furthermore, for certain purposes, the limits of the central ganglia of the brain may be estimated as follows : their superior limit is indicated by a horizontal line or plane drawn at a level 45 mm. below the vertex, line 3-3 of the diagram ; their anterior limit, which corresponds to the head of the nucleus caudatus, is traced by the vertical line C—C ; and their posterior limit, or hinder end of the thalamus opticus, by the vertical line B-B. Lastly, it may be stated that the angular gyrus—a part of the cortex which recent autopsies would seem to connect with vision—lies not far from the point of intersection of the lines B-B and 3-3, at the point marked A on the diagram. This, in the living subject, is a little below and behind the parietal eminence. The location of the middle meningeal artery, which so often furnishes the blood which compresses the brain after various injuries of the head, is, surgically considered, of great importance. The course of the two principal branches of the artery is approximately indicated upon the diagram by the branching lines drawn on the anterior inferior angle of the parietal bone. In the living subject, the main trunk of the artery would be found under the horizontal line 2-2, at a point a little posterior to the speech centre, about 30 mm. behind the external angular process of the frontal bone, and in front of the beginning of the fissure of Sylvius. It passes obliquely upwards and backwards almost immediately over the whole of the ascending frontal convolution, from 5 to 10 mm. in front of the Rolandic line. The inferior branch of the artery is nearly horizontal, and almost exactly overlies the fissure of Sylvius. Upon the shaven head of a patient, seated in a chair or lying in bed, the principal landmarks and relations above defined can be mapped out with a great approximation to accuracy by the use of two rulers, or even by one, to mark the alveolo-condyloid plane, and a card-board cut so as to stand astride the skull in the auriculo-bregmatic vertical. A light wooden apparatus could be easily made to indicate these two lines, while the remaining measurements could be taken with a tape, and the points marked with car- mine or black ink. The practical utility of these anatomical data depends upon an acceptance of modern physiological teaching upon the subject of the functions of the brain. The experimental and pathological evidence now accumulated in favor of the connections of the “ centres” marked on the diagram and certain peripheral parts, and between the whole of the motor area, and the whole opposite side of the patient is, according to Dr. Seguin, convincing, and leads him frequently to a very accurate topographical diagnosis in medical cases. The following operations may be referred to as illustrative of the utility of the laws of cerebral localization and of cranio-cerebral pathology :— Broca, in 1871, in a case in which aphasia and paralysis followed a severe lacerated scalp wound, trephined over the left third frontal convolution, or speech-centre, found pus, and slightly relieved his patient. Lucas-Championniere, in 1874, trephined a man in whom coma, partial right hemiple- gia, convulsions, and, as shown during convalescence, aphasia resulted immediately from 44 INJURIES AND DISEASES OF THE HEAD CHAP. i. a slight cranial injury. There was only a slight scalp scar to guide him, but he came in contact with splinters and blood from a fractui’e existing below the point of' apparent injury, and saved his patient. Hueter, of Greifswald, in 1879, in a somewhat similar case, trephined the skull, ligated the middle meningeal artery, and cured his patient. In another case in 1870 he was equally successf ul. Courvoisier trephined, in 1878, a child two and a half years old, who, after an insigni- ficant wound in the left temporal region, had right hemiplegia, coma, and palsy of the left side of the face. He found a fissured fracture, and pus outside the dura mater, as well as a large quantity under it. The operation was followed by recovery with weakness of the right side. Dr. R. F. Weir, of New York, in 1882, operated at Bellevue Hospital, in a case in which coma and slight hemiplegia existed, the patient being a man who had received a blow on the head. There was no very evident external injury, but guided by the various data of cerebral localization, and proceeding according to the rules of cranio-cerebral topography, the trephine was applied, and a small clot found between the brain and dura mater. On incising the latter the brain was seen to be extensively disorganized, and the seat of copious hemorrhage, which was checked by torsion. Although the symptoms were re- lieved by the operation, death occurred within a few days. Up to the present time, so far as I know, there are only three cases in which the rules of cranio-cerebral topography have been applied, from measurements actually made prior to operation. These cases occurred in the practice, respectively, of Broca, Lucas-Cham- pion niere, and Weir. There are probably other examples, but I am unable to particu- larize them. However this may be, there is a large number of recorded instances of relatively or absolutely successful operations performed after cranial injuries, for immediate as well as for secondary effects, without measurements. The indications for trephining after cranial injuries for the relief of symptoms of cerebral irritation, compression or disorganization, may be provisionally stated as follows:— 1. When aphasia supervenes immediately or within a few days or weeks after an injury of the anterior portion of the head on tlie left side. It is extremely probable, in the first case, that a clot or bony spicule will be found compressing the speech-centre ; and in the second that an abscess has formed either in the same part or close to it. 2. AYlien simple hemiplegia, or hemiplegia with hemispasm follows an injury, however slight, in the temporo-parietal region. If the spasm or paralysis be limited to one limb or to the face, the indication to operate is even stronger. Even if the injury be not directly over the motor area the surgeon is justified in such a case in exploring that area. 3. In conditions of coma after cranial injuries, sometimes without external wound, in which meningeal hemorrhage is the cause of death, the discovery of slight hemi- plegia should call for trephining planned according to the rules above laid down, as in AYeir’s case. Dr. Seguin suggests that a latent hemiplegic state might be discovered, at least in some cases, by an increase of peripheral temperature, as of the fingers or toes, on one side, and by the presence of congestion or of an erythematous blush on one buttock. 4. In the very rare cases in which the paralytic phenomena are found on the same side of the body as the cranial injury, it might be proper to trephine on the opposite side of the skull in search of hemorrhage or fracture, the result of contre-coup. 5. In chronic epilepsy after traumatism of the head, the indication for operation is present, but it is not a specific indication, connected with the subject under considera- tion. A lesion of any part of the skull may be a cause of epileptic attacks, irrespective of the motor centres. Contraindications to trephining may be thus enumerated :— 1. AYhenever in apparently favorable cases there are signs indicative of lesion of the base of the brain, such as palsy of several cranial nerves, neuro-retinitis, or Cheyne- Stokes respiration. 2. A\rhen hemiplegia is accompanied by great anaesthesia, rendering it probable that the lesion is beyond the motor area, deeper, and farther back. It should be understood that these indications and contraindications are formulated from the standpoint of the neurologist. The surgeon, upon general grounds, will doubt- less often modify them, and add others. It is obvious that our knowledge of cranio-cerebral topography is not perfect, and, in a practical point of view, very unsatisfactory. As yet, we have broken only a little ground ; the great work remains to be accomplished. In a field so vast as this our progress must necessarily be tardy, and many hands will be required to solve its mysteries. CHAP. I. COMPRESSION OF THE BRAIN. 45 Treatment—The treatment of compression of the brain must be regulated by the nature of the exciting causes, as extravasated blood, depressed bone, foreign bodies, or inflammatory deposits. a. Extravasated Blood.—The blood, in compression of the brain, may occupy the same localities as the matter in purulent effusion or in abscess of the brain in ence- phalitis. Hence, as in the latter affection, it is only accessible in certain situations, as when it lies immediately beneath the inner surface of the cranium, or in the arachnoid sac, the membrane, perhaps, bulging through an opening left by a fracture of the skull, or made with the trephine in the hope of being able to evacuate it. It must not be for- gotten that the most copious extravasations of blood sometimes occur without any appa- parent lesion whatever of the cranium, and such cases must, therefore, as a rule, be treated upon the same general principles as compression from effused blood in ordinary apoplexy; a subject which will be fully discussed in the section on extravasation of blood from injury of the skull. j3. Depressed Bone Depression of bone may exist to a considerable extent with- out compression ; but when it gives rise to this state, the symptoms come on immediately, and continue until the brain has either accommodated itself to its new relations, until the offending portion of the bone has been removed, or until the patient dies from the effects of the injury. The lesion may be one purely of compression from depression of bone, or the accident may, as was previously intimated, be combined with extravasation of blood, caused by laceration of the cerebral or meningeal vessels, either by the offending bone or by the vulnerating body. In the latter case, the compression may be very violent, although the depression itself may be slight. The symptoms in this case, too, may, in the first instance, be imperfectly marked, those of concussion, perhaps, predominating over those of compression, but being speedily succeeded by the latter. In the treatment of this form of compression, which will again come up for considera- tion in the remarks on fractures of the skull, no very definite rules can be laid down for the guidance of the surgeon. Every case must, so to speak, make its own rules. The practice formerly was in compression produced by depression of bone, attended with compound fracture, to trephine at once, on the ground that the operation would not only remove the cause of compression, but place the parts in a much more favorable condition for speedy repair and ultimate safety. The rule now is to refrain from instrumental inter- ference unless there are serious complications indisposed to yield to delay and to ordinary antiphlogistic measures. The question is still an open one, as it respects the treatment of compression from depression, attended with simple fracture. I am fully sensible of the difficulties of the subject, surrounded as it is by doubt and contradiction; but, after the best consideration that I can bestow upon it, I am disposed to regard operative interference as justifiable only in the event of very deep and extensive depression, and I should adopt this plan whether the symptoms of compression were urgent or not, on the ground that the patient would be much less likely to suffer from subsequent cerebral disorder. When the depression is comparatively slight, and, especially, when there is no comminution of the bone, or irregularity of its edges, giving them a rough, spiculated character, the bone should be let alone, and the case treated upon general principles, hoping thereby to pre- vent inflammatory mischief, and ultimate nervous irritation, which are so much to be dreaded in the more severe forms of the accident. There is a species of compression of the brain in children caused by extensive depression of bone without fracture, of which I have witnessed some remarkable examples, and which never requires operative interfer- ence. The bone is simply bent or indented, and usually, by its own resiliency, regains its natural level in a few days under the use of a little purgative medicine, light diet, and cold applications to the head. y. Foreign Bodies Compression of the brain by a foreign body is an unusual occur- rence, and can hardly take place without some concomitant depression of the skull. A large ball, a piece of iron, or a splinter of wood lodging in the cranial cavity, in the cere- bral substance, or in the ventricles, might produce the effect, accompanied, probably, by a more or less copious hemorrhage, thereby seriously complicating the lesion. The symp- toms would be likely to be immediate, as in compression from depression of bone, and the treatment would manifestly resolve itself simply into the extraction of the extraneous body, care being taken, in doing this, to inflict as little injury as possible upon the sur- rounding structures, and to guard the brain and its membranes afterwards against inflam- mation. Such lesions are necessarily fraught with danger, and are rarely recovered from, however judiciously managed. INJURIES AND DISEASES OF THE HEAD. CHAP. i. 8. Collections of Pus An effusion of pus, or of pus and serum, giving rise to com- pression of the brain, can only occur as a secondary effect, coming on at a period varying on an average, from a week to a fortnight from the commencement of the inflammation which precedes its development. Every practitioner, however, meets with eases in which the interval is much longer, and to which we may, therefore, apply the term chronic. In general, the characteristic symptoms set in gradually, the disease bearing a great resemblance, in this respect, to the compression of the brain which follows arachnitis. There can, therefore, be no difficulty in discriminating between it and the other forms of compression already described, where the symptoms appear either immediately, or, at furthest, within a few minutes after the occurrence of the injury giving rise to the com- pression. At first there is evidence merely of inflammation ; by and by, as the disease advances, effusion takes place, and now the chain of morbid action is completed by the supervention of coma, paralysis, convulsions, and death. This steady progressive move- ment, from one point to another, can leave no reasonable doubt respecting the true nature of the lesion, especially if it be coupled with a consideration of the history of the case. In regard to instrumental interference in compression from inflammatory effusions, the same embarrassment is generally experienced as in compression from the extravasation of blood. The great difficulty is where to find the fluid, or, if found, how to evacuate it, so as to afford the patient a chance for his life. The result is that nearly every case of this kind must necessarily be fatal, neither trephining nor general treatment being of any ulterior avail. If, now and then, an instance of an opposite character occurs, it only serves to prove the rule. 4. IRRITATION OF TIIE BRAIN. Injuries of the head are sometimes attended by a remarkable train of morbid phenom- ena, evidently due to irritation of the cerebral tissues, the characteristic sign being hyperaesthesia, or excessive sensibility, mental and corporeal. The affection is either primary, or, as is more frequently the case, it does not come on until several days after the occurrence of the accident. The most common exciting causes are blows, falls, and gunshot injuries of the head, eventuating in concussion of the brain, in contusion of the cerebral tissues, in fracture of the skull with slight depression, or in slight extravasations of blood, either into the substance of the brain, into the arachnoid sac, or between the dura mater and the inner surface of the cranium. A comparatively slight injury is often sufficient to induce it. Not unfrequently it coexists with traumatic lesion of the spine. As a pure, uncomplicated affection, I doubt whether it ever takes place. The patient, in this condition, is in a somnolent or semiconscious state, like a man partially under the influence of liquor; he is disposed to sleep, is excessively irritable, turns and twists about in bed, lies with his eyes closed, is roused with difficulty, answers abruptly and angrily when spoken to, and speedily lapses into his former condi- tion ; his pulse is feeble and calm, except when he is excited or annoyed, when it sud- denly rises in force and frequency; the respiration is easy, and unaccompanied bystertor; the skin is moist, the countenance is pale, the stomach and bowels are natural, the urine is limpid, but passed with great frequency, and the control over the sphincter muscles is perfect. The posture in bed is peculiar. The body is curled up, the limbs are flexed, and the patient invariably lies upon his side. The hands are tremulous, and the fingers are sometimes in constant motion. Muscular twitches of the face and extremities are not uncommon. The eyes are remarkably sensitive to light, and the lids are so firmly closed as to render it difficult to open them. The pupils are firmly contracted. Marked delirium, of a low muttering kind, is often present. In another class of cases, the patient is easily roused, and perfectly sensible, answering questions coherently and rationally so long as his attention is kept awake, but relapsing as soon as he is left to himself, muttering as if his mind were occupied with some imagin- ary object, or engaged in some particular enterprise. In a case recorded by Sir Astley Cooper, the patient, while in this condition, got out of his bed, lathered his face with his blistering salve, and washed his feet with lemonade in the chamber-pot. A patient of my own, a robust, healthy man, upwards of sixty years of age, labored for nearly four days, after a slight concussion of the brain, under all the symptoms of hysteria, attended with frequent paroxysms of laughter, and various mental illusions, along with great irritability of the bladder and an almost constant desire to void his urine. Cerebral irritation is sometimes mainly characterized by stinging or pricking sensations in the head, by spasmodic twitchings of the muscles, especially of those of the face and TRAUMATIC ENCEPHALITIS. 47 CHAP. i. eyes, by violent shooting or darting pains in different parts of the body, by convulsive tremors of the hands and fingers, and by anomalous paralytic phenomena; occurrences which, alternately increasing or diminishing, give the case the appearance at one time of impending death, and at another of approaching convalescence. The intelligence is gen- erally preserved, but special sensation is often perverted. There is no coma, stupor, or lethargy. Irritation of the brain occasionally arises from loss of blood, as after compound fractures of the skull attended with laceration of the organ and its meninges, the cerebral tissues not receiving a sufficient amount of this fluid to enable it to perform its proper functions. The condition is generally easily recognized by muttering delirium, excessive pallor of the countenance, a suffused and wild expression of the eyes, throbbing of the carotid arteries, exquisite sensibility to light, a weak, irritable, and excitable pulse, a moist skin, intense thirst, and inability to sleep, with frequent moaning and sighing, and a disposition to faint. Some of these conditions of the brain are occasionally closely simulated by mania-a-potu, and the difficulty of drawing a distinction between them is greatly augmented in the ab- sence of a history of the case, or when a person habituated to the use of ardent spirits has met with injury of the head. The treatment of this class of affections must be conducted with great care and judg- ment. The danger mainly to be apprehended is from eneephalo-meningitis of the milder grades, of which it is, in many cases, simply an exponent. The patient must, therefore, be watched with extraordinary vigilance, any tendency to overaction being promptly met by suitable measures. The more common cases will usually recover under very simple management, as perfect quietude of mind and body, exclusion of light and noise, cooling drinks, light diet, and an anodyne diaphoretic, as five grains of Dover’s powder, or a little morphia in neutral mixture, every four or five hours ; and, what often answers an excellent purpose, an occasional dose of thirty grains of bromide of potassium along with ten, fifteen, or twenty grains of chloral. When the affection threatens to run into in- flammation, or if inflammation already exist, more active measures will be demanded, as leeches to the temples, counterirritation by blisters to the nape of the neck, active pur- gation, and other antiphlogistic remedies, not forgetting the liberal use of morphia and aconite, to assist in quieting the heart’s action, allaying morbid sensibility, and inducing sleep. Mercury, in minute doses, will often be beneficial, especially the bichloride, given in union with one of the iodides. 5. TRAUMATIC ENCEPHALITIS. Inflammation of the brain, or of the brain and its meninges, however induced, whether by concussion, contusion, extravasated blood, a depressed fracture, the presence of foreign matter, or direct injury of the cerebral tissues, as in the case of a wound, is ordinarily characterized by high febrile disturbance, increase of temperature, intolerance of light and noise, dizziness, vertigo, cephalalgia, difficulty of articulation, ringing in the ears, flushed countenance, suffusion of the eyes, vigilance, excessive thirst and restlessness, heat and dryness of the skin, hurried respiration, coated tongue, loss of appetite, constipation of the bow’els, scanty and high-colored urine, and a quick, hard, and frequent pulse. The patient is easily excited, answering angrily in monosyllables, and draws away his arm when touched, as in feeling the pulse, and turns his back upon his attendant when spoken to. The pupils of the eyes, at first contracted, gradually expand as the inflammatory deposits increase in quantity, and are at length widely dilated and totally insensible to light. The mind wanders at an early period, and, gradually, muttering delirium or maniacal excite- ment sets in. The carotid arteries often beat with great force. As the disease advances the countenance assumes a shrunken, withered appearance, and the patient is seized with spasm, followed by coma, paralysis, and convulsions, which soon close the scene, life usu- ally terminating in from three to six days. On dissection, the brain and its envelops are observed to be in a state of disease, portions of the former being softened, and seem- ingly mixed with blood and pus, and patches of the latter preternaturally vascular and incrusted with lymph. Serum, often in considerable quantity, exists in the ventricles, at the base of the skull, and on the top of the hemispheres. The dura mater is usually free from disease, but the pia mater and arachnoid are almost always involved, as is evinced by the injected condition of the vessels of the former, and the opaque appearance of the substance of the latter. Sometimes the principal evidence of the morbid action exists in the subarachnoid connective tissue, in the form of lymph and pus. 48 INJURIES AND DISEASES OF THE HEAD. CUAP. i. The period of access of traumatic encephalitis is generally very brief, often not ex- ceeding twenty-four hours, or, at furthest, not more than three or four days. Occasion- ally, however, the interval is much longer, and then the disease is usually much more insidious in its approaches, creeping on stealthily and, perhaps, almost imperceptibly, throwing both the patient and his attendants off their guard as it respects the true nature of the attack. In the treatment of this variety of inflammation, the object is to assail the morbid action as early and as vigorously as possible. In an organ so essential to life as this is, there can be no hope of relief if the disease be permitted to obtain the slightest ascend- ency. Few eases recover when structural lesion exists, or inflammatory exudations have taken place. Hence, whatever is done must be done promptly and energetically. The treatment, too, is sulliciently simple. Blood is taken liberally from the arm and temples; the bowels are thoroughly evacuated with calomel and jalap, aided, if need be, by enemas; the head, shaved and elevated, is enveloped in a bladder partially tilled with pounded ice; light and noise are excluded from the apartment; and the patient is kept upon the small- est possible allowance of food, of the most bland and simple character. Cold water, simple or acidulated, constitutes the proper drink. After the violence of the disease has abated, the same means are continued, but in a milder form, antimonial and saline prepa- rations, with occasional leeching, now taking the place of the lancet. Sleeplessness and jactitation are relieved by the cautious use of anodynes, combined, if there be dryness of the surface, with antimony, aconite, or veratrum viride. Counterirritation is sometimes beneficial, but generally much less than has been supposed. Indeed, my experience does not enable me to say anything in its favor. Pustulation with croton oil rubbed behind the ears is, perhaps, the least objectionable mode; it is certainly less painful than vesica- tion of the nape of the neck, and is, I think, quite as efficacious. Occasionally, especially when there is much delirium, a blister may advantageously be applied to the inner surface of each thigh. To prevent effusion, or to promote its removal, if it has already taken place, the use of mercury, in the form of calomel, properly guarded with opium, and given in full doses, is indicated, and should be rapidly pushed to the extent of decided ptvalism. When the calomel is slow in its action, the desired object may often be promptly attained with the aid of suppositories made of strong mercurial ointment, from twenty to thirty grains being inserted into the bowel every six or eight hours. After the influence of the remedy has been fully established, iodide of potassium, either alone or combined with corrosive sublimate may be used as a substitute, to complete the cure, should nature and art be fortunate enough to accomplish it. The treatment of encephalitis by intermittent, digital compression of the carotid arter- ies, as advised by Neudorfer, Vanzetti, and other surgeons, might be worthy of trial in some cases, although from the difficulty of employing it not much is to be expected from it. By cutting off the supply of blood from the affected organ, the inflamed structures could hardly fail to be materially relieved, and the cerebral distress greatly diminished. The pressure might be applied alternately to the two vessels, thus rendering it more sup- portable than if applied simultaneously to both. The value of a strictly antiphlogistic course of treatment in traumatic encephalitis, caused by gunshot injury, has been placed in a very favorable light by recent observa- tions. In the United States Army, in which such a plan was not considered essential, four-fifths of the cases of injuries of the skull and its contents, according to the testimony of Dr. Otis, perished, while of the cases subjected to rigidly antiphlogistic means by the British surgeons in the Crimea, and by the German surgeons in the wars of the Duchies, in 1849 and 1850, more than one-half were saved. Great prejudice exists among practitioners against the employment of anodynes in trau- matic encephalitis, even in its worst forms, on account of their supposed tendency to cause congestion of the brain, thereby increasing the danger of inflammation. I believe that this opinion is not only groundless, but fraught with mischief. In the first place, it is by no means established that opiates, judiciously administered, produce cerebral congestion ; and, secondly, even supposing that they did, the occurrence would be no contraindica- tion to their exhibition. If they produce congestion at all, the congestion is of a passive, not of an active, character, and, therefore, comparatively harmless. But I do not look upon the subject in this light; on the contrary, I am fully satisfied that anodynes, by allaying the heart’s action, exert a direct and positive influence in controlling inflamma- tion of the brain, by placing the organ in a state of repose, so essential in every case of disease and injury, no matter how induced, or where occurring. The brain, in the nor- mal state, rises and descends with every movement of the left ventricle of the heart; in CHAP. I. TRAUMATIC ENCEPHALITIS. 49 injury, this action is greatly increased, becoming often quite tumultuous and overwhelm- ing; the nervous pulp receives a shock at each pulsation; it is never at rest, and has, therefore, no opportunity to repair the mischief under which it labors. Now, the object of anodynes is to insure this result by weakening the heart, and thus rendering it unable to send to the brain the accustomed quantity of blood. If this mode of reasoning be cor- rect, it follows that the wounded organ, receiving less blood than usual, will be less prone to inflammation. Repose can be obtained in no other way. The inflamed hand may be carried in a sling, and splints may be applied to the inflamed leg, but tranquillity of the brain, heart, lungs, stomach, bowels, bladder, and peritoneum can only be insured by the use of anodynes. But these remedies do good in other ways in these conditions. They induce sleep, allay pain, and quiet the mind ; effects which cannot fail to promote re- covery, when, from the frightful nature of the injury, recovery is not impossible. Their action may often be materially aided by the use of chloral and the bromides, especially in very nervous states of the system attended with great vigilance and a tendency to con- vulsions. The influence of anodynes, especially the different preparations of opium, in lessening the amount of blood in the brain, both in health and disease, is distinctly recognized by a number of able writers, and strongly attested by the interesting experiments of Dr. Wil- liam A. Ilammond, of New York. Mr. Durham, of London, has shown by a series of admirably conducted researches that the brain during sleep is in a comparatively anemic condition, and that the blood in the encephalic vessels is not only diminished in quantity, but propelled with diminished force and rapidity. The views of Kelley and others, once so dominant in the schools, that the brain always contains the same amount of blood, are untenable. The more insidious form of inflammation of the brain, consequent upon concussion and other lesions, is by no means uncommon, and is particularly dangerous, for the reason, as was previously mentioned, that it is so very liable to be overlooked at a period when treat- ment can be of any avail. The patient has, perhaps, made a very rapid recovery, and is, therefore, disposed to resume his accustomed occupation, hardly thinking that anything has ailed him. This is particularly apt to happen when the injury has been very slight, or the primary effect very transient. Under such circumstances, it may be quite impos- sible, with all the arguments that the practitioner can adduce, to persuade him to refrain from exercise and food even for a few days. He refuses to regard himself as an invalid. He goes about his business, eats, drinks, and is merry. By and by, he begins to feel un- well ; his head aches ; his temper is easily ruffled, his appetite is capricious, his bowels do not act properly, his sleep is interrupted by unpleasant dreams, he has occasional tits of dizziness or vertigo, his pulse is too frequent, and he cannot apply himself with any satisfaction to his pursuits. Such is the usual prodrome of an event which has cost many a man his life. Mischief is stealthily going on in the brain, or in the brain and its mem- branes, which, if not promptly checked, soon bursts forth like the smothered flame of the incendiary’s fire. In a little time the system is overwhelmed with excitement ; soon delirium follows; then come coma and paralysis, and finally convulsions seal the suffer- er’s doom. Inspection reveals serious lesion of the brain and its envelops, with effusion of lymph and sero-purulent matter on the surface of the latter, and softening and, per- haps, abscess in the substance of the former. The nature of this form of disease, to which the term subacute or chronic may very properly be applied, is, unfortunately, seldom recognized by the practitioner in time to afford his patient the necessary relief. He is generally disposed to make light of it, or it may be that he overlooks it altogether. When at length his suspicions are aroused, he finds to his horror that the case is utterly beyond the reach of his skill. Effusion has taken place, and death is inevitable. The treatment of this secondary affection does not differ materially from that of the primary. As soon as it begins to show itself, the patient must be restricted to the most scrupulous antiphlogistic regimen, and submit to active and steady purgation, with the liberal use of tartrate of antimony and potassium. If head-symptoms exist, blood is taken from the arm and temple; rapid ptyalism is aimed at; and counterirritation is applied to the nape of the neck by blister, issue, or croton oil, its action being much more advan- tageous here than in the acute form of the malady. The treatment is continued for some time after all disease has apparently vanished, the patient slowly returning to his former habits and occupation. 50 INJURIES AND DISEASES OF THE HEAD. CHAP. I. 6. ABSCESS OF THE BRAIN. The matter that is poured out during the progress of encephalitis may, like extrava- sated blood, occupy different situations, and present itself either as pure pus, or as a mixture of pus, lymph, and serum, as when it occurs in the arachnoid sac, upon the sur- face of the brain, or within the ventricles. Not unfrequently the fluid, whatever it may be, is intermingled with blood, the direct result of the injury which caused the inflamma- tion. The fluid may occur as an effusion, properly so called, or as a distinct, circum- scribed abscess, as when it is lodged in the substance of the brain. One of the most common sites of the juts in traumatic encephalitis is the subcranial, or that in which, as the term implies, the fluid is lodged immediately below the inner surface of the skull, in a bag, as it were, formed by the detachment of the dura mater. Large accumulations occasionally form here, amounting to several ounces, especially when the case is somewhat of a chronic character. The fluid is generally thick, of a yellow- greenish color and often quite offensive, particularly when it is long in forming, or when, as not unfrequently happens, it is associated with caries or necrosis of the corresponding portion of the cranial bone, or serious disease of the dura mater, as ulceration, softening, or gangrene. When the matter is situated in the arachnoid sac, constituting what may be called the intra'drachnoid form of the disease, it is always intermixed with lymph and serum, the latter of which is often poured out in large quantities. The effusion is most common on the superior, anterior, and lateral portions of the brain ; but it is also frequently met with at the base of the skull, especially after fractures in that situation. T he occurrence is uncommon in the arachnoid sac of the cerebellum and of the medulla oblongata. Some- times pus, lymph, and serum are poured out in considerable quantity in the subarachnoid connective tissue. Pus is seldom found, at least not to any considerable extent, in the lateral ventricles of the brain, whereas an effusion of serum is very common there ; usually constituting here, as when it occurs in connection with the arachnoid membrane on the surface of the organ, the chief cause of the cerebral trouble. When pus alone exists as the compressing agent, it will be found that it is generally situated either immediately beneath the skull, or in the anterior and middle lobes of the brain, which are, apparently, more liable to suffer in this way than any other portions of the organ. The cerebellum is seldom affected ; and, as to the medulla oblongata, suppuration is among the most un- common of its diseases. When matter forms in the substance of the brain—the intracerebral variety of suppu- ration—it is usually collected into a circumscribed abscess, and is of a yellowish, grayish, or yellowish-white appearance, of moderately thick consistence, and destitute ot odor, especially when it. is of rapid development. The quantity is generally small, not exceeding, on an average, a few drachms. In cases of long standing, however, it may amount to several ounces. The cerebral tissue around is softened and disintegrated, or converted into a diffluent, pultaceous mass, and the minute vessels are distended with black blood. When the abscess is chronic, it is sometimes inclosed in a distinct cyst, of varying thickness and density, more or less vascular, and intimately adherent to the sur- rounding structures. When this is the case, it is possible that the pus may be eventually absorbed, although more generally it remains in its confined situation, from the injurious effects caused by its presence. The matter, instead of being collected into an abscess, is occasionally infiltrated into the cerebral substance, forming a number of minute points, hardly the size of a pin’s head, of a pale yellowish color, interspersed through the softened and disorganized tissues. The white structure is more frequently affected with suppuration after injury than the gray. There are no symptoms by which, in the present state of the science, we can determine the precise situation which the matter occupies, the same difficulty existing here in forming an opinion, as in compression from extravasation of blood. It is only, as a rule, when the matter lies immediately beneath the skull, and when the scalp or bone has sustained considerable injury, that even an approach can be made to anything like a correct diag- nosis. When the pus is deeply buried in the substance of the brain, or lodged in the ventricles, there are no means by which its precise locality can be determined. \Y e may, it is true, usually form a tolerably correct idea as to the side on which the effusion exists, by the hemiplegic condition of the body, the right side, for example, being paralyzed when the matter is seated on the left, and conversely; but to say whether it is situated in the substance of the brain or in its cavities, is an impossibility. In general, it maybe assumed that the matter lies immediately beneath the skull when the compression arises CHAP. I. ABSCESS OF THE BRAIN. 51 from inflammation caused by a bruise or wound of the scalp; when, on the other hand, it follows concussion or fracture of the skull, it will be more likely to occupy the interior of the brain. To this statement, however, there are, of course, many exceptions. From a careful study of the non-penetrating lesions of the skull attended with suppu- ration of its contents, Dr. S. \\ . Gross believes that the seat of the pus may be deter- mined with some degree of accuracy, by noting, in connection with the ordinary phenomena, the period at which the symptoms set in. 11 is views, which may be found in a paper published in the American Journal of the Medical Sciences, for July, 1873, may be con- densed as follows: \Y hen the matter is situated between the dura mater and the skull, the symptoms never appear before the sixth day after the injury; rarely before the eleventh, but usually before the expiration of the fourteenth. When the scalp is merely bruised, a painful, putty swelling forms ; and when there is an open wound it assumes an unhealthy appearance, the pericranium secedes, and the exposed bone is seen to be dead. The gen- eral symptoms are fever, fixed headache, partial stupor, and incomplete paralysis. The signs of pus in the arachnoid sac never appear before the eighth day, and are rarely delayed beyond the twenty-first; the average being the thirteenth day. The most reliable symp- toms are opposite hemiplegia succeeding rigors, intense headache, elevation of tempera- ture, vomiting, obstinate constipation, active delirium, stupor, and general convulsions, followed by coma. In abscess of the brain the symptoms never appear before the thirteenth day, and are most frequent between the fifteenth and twenty-seventh days. Of the indi- vidual signs the most characteristic are defined and intense pain, corresponding with the local lesion, and limited hemiplegia and unilateral convulsions, followed by profound coma, and total destruction of special and general sensation. In several cases aphasia and right- sided paralysis were associated with abscess in the vicinity of the walls of the left fissure of Sylvius. The effusion of matter inducing this species of compression may be the result of con- cussion, sometimes so slight as hardly to attract any attention ; of fracture of the skull, with or without extravasation of blood, and with or without depression of bone ; and, finally, of injury of the scalp, in the form, perhaps, merely of a slight contusion or wound, yet sufficient to jar the skull, and detach the pericranium and the dura mater. It is very curious how an apparently trifling accident may sometimes give rise to the most serious consequences, destined to sweep everything before them. A man receives a concussion of the brain ; his suffering is altogether momentary, and he soon goes about his business ; by and by, lie begins to feel unwell, his head aches, he has no appetite, his bowels do not act properly, and he sleeps badly at night. Soon symptoms of inflammation of the brain set in, and thus the case progresses, from bad to worse, until effusion of pus takes place, fol- lowed by compression. Or, he has met with a fracture, perhaps quite insignificant; he gives himself no trouble about it, and even entirely disregards the,injunctions of his medi- cal adviser. By and by, cerebral symptoms come on ; the disease advances insidiously ; treatment fails to relieve; matter forms, and the patient perishes from compression. Or, a slight bruise has been inflicted upon the scalp, hardly perceptible to the eye, but still sufficient to injure the pericranium ; in a few days erysipelas appears ; gradually a small, puffy tumor forms; rigors, delirium, coma, and paralysis supervene, and the patient finally dies from a collection of pus between the skull and the dura mater, or beneath the dura mater, the inflammation having extended across the bone along the vessels and cellnlo-fibrous connections. Or, lastly, the mischief may have been produced by a small wound of the scalp, the blow by which it was inflicted having, perhaps, detached both the pericranium and the dura mater. Again the case advances insidiously; the ill-boding rigor, delirium, stupor, and paralysis soon appear, and but too clearly indicate the for- mation of pus. Abscess of the brain occasionally supervenes upon a surgical operation from injury inflicted during its performance upon the skull. Many years ago, I examined the body of a stout, athletic man, forty years of age, who had died nearly three weeks after the removal of an osteosarcomatous tiunor of the root of the nose and the upper turbinated bones by the late Professor George McClellan. For the first fortnight the case progressed favorably, when he was suddenly seized with violent rigors, followed rapidly by deep coma, and by death in thirtv-six hours from the commencement of the attack. The necroscopic examination revealed the existence of a large, undefined abscess, filled with thick, fetid pus, on the lower surface of the right anterior lobe of the cerebrum, with partial destruction of the cribriform plate of the ethmoid bone and the corresponding j)ortion of the dura mater. , Abscesses of the brain may supervene at a very remote period after injuries; long, in 52 INJURIES AND DISEASES OF THE HEAD. chap, i. fact, after the patient has ceased to consider himself as an invalid. Thus, Horner men- tions an instance in which the interval between the infliction of the violence, the result of a pistol-shot, and the fatal termination was nearly twelve months; Sir Everard Home met with a case of nineteen months, and Dr. Copland with one of upwards of three years. Similar examples are to be found in the writings of llennen, Guthrie, Larrey, Sir Astley Cooper, and other surgeons. Such abscesses may form suddenly, especially when the exciting cause is some foreign body, shortly terminating in death ; or they may arise very gradually, the matter becoming encysted, and thus remaining for a time comparatively harmless. Eventually, however, the cyst acts as an extraneous substance, giving rise to inflammation and softening in the circumjacent structures, followed by death. Occa- sionally the immediate cause of the fatal event is apoplexy, the blood being infiltrated into the disorganized cerebral tissues. The treatment of abscess of the brain is necessarily most unsatisfactory. When there is reason to believe, from the state of the scalp, and the appearance of the skull at the site of injury, that the matter lies immediately beneath the bone its evacuation with the tre- phine will, of course, be indicated, and the sooner it is resorted to the better will be the chances of saving life. Early interference in this class of cases is frequently successful; when the trephine is applied after hemiplegia and coma have supervened, the prognosis is very grave; and death is the inevitable result if escape for the matter is not afforded. Pott saved 5 out of 8 patients ; and Dr. S. W. Gross has shown that out of 11 operations in army practice 5 recovered. When the pus is seated within the arachnoid sac, the propriety of opening that membrane with a view to its evacuation is unquestioned. In this way Lohmann, Mursinna, La Peyronie, Dumville, Hughes, Wilson, Courvoisier, and Roux preserved the lives of their patients, and Dr. S. W. Gross has demonstrated that one-half of the cases in army practice recover. When the symptoms point to an abscess of the brain, the surgeon should not hesitate to resort to the trephine, since the successful cases recorded by Schumucker, lvnauss, O’Keefe, Pierson, Hutchison, and Watson, in the last three of which a ball was also extracted, demonstrate that a superficial collection of pus may evacuate itself as soon as the opening is made. Three instances of recovery from abscess, complicated by the presence of the blade of a knife, are narrated by Moritz, Reuz, and Rose; and Lafaye cured a man in whom the trouble arose from the head of an arrow imbedded in the brain. When the abscess is deep-seated, whether in the substance of the brain or in the lateral ventricles, and there is satisfactory evidence of its existence, as indicated by a sense of fluctuation, or by the continuance of deep coma after the removal, perhaps, of a large por- tion of depressed bone, a free incision should be made through the superimposed cerebral tissues, in order to afford free vent to the pent-up fluid. Desperate as such a procedure must necessarily be, it clearly holds out the only possible hope of relief. In a remarka- ble case of this kind, Dr. Detmold, of New York, succeeded by means of repeated inci- sions, some of them fully an inch and a half in depth, in preserving the life of his patient for seven weeks. An enormous quantity of pus followed the first operation, the patient immediately recovering his consciousness and pow'er of speech. Dupuytren, in a case of abscess of the brain, consequent upon external injury, was equally successful. A young man was admitted into the Ilotel-Dieu in a state of stupefaction, coming on suddenly two years after he had been struck on the top of the head with a knife, the blade of which, after having perforated the skull, broke in the bone, where its presence was overlooked. Notwithstanding the application of the trephine, the coma continued, and was soon suc- ceeded by paralysis of the opposite side of the body. The dura mater was laid open, but as nothing was found under it, the bistoury was boldly plunged into the substance of the brain, followed immediately by the escape of a large quantity of pus, and the speedy con- valescence of the patient. In similar instances, Weeds, Ilolden, Noyes, Clark, Elcan, and Hulke saved their patients. In the case of Holden, the hemorrhage from a small slit in the longitudinal sinus, made during the puncture, was arrested by a fine ligature. The practice pursued in the remarkable cases of Detmold, Weeds, Holden, Hulke, Noyes, Clark, Elcan, and Dupuytren was unquestionably eminently correct ; and the only reason, probably, why the operation.of Detmold did not succeed was that the brain was too much disorganized before it was performed. When the symptoms after injury of the skull, however slight, are clearly such as to indicate the existence of an abscess in the brain, no time should be lost in affording vent to the pent-up matter, as this affords the only possible chance of relief. Even a few exploratory punctures with a very sharp, narrow bistoury could, in such a condition, do no possible harm, supposing that the fluid could not be found. No surgeon, I believe, has ever been bold enough to tap the ventricles of the CHAP. i. EXTRAVASATION OF BLOOD. 53 brain Avhen distended with inflammatory effusions, and yet it is easy to conceive that prompt relief might follow such a procedure, especially if the operation were performed with the aspirator or a delicate trocar. However this may be, the case could not possibly be rendered worse by it. When the abscess has an external communication, but the open- ing is too small to admit of the free escape of its contents, the latter should be enlarged with the trephine or chisel. By resorting to this expedient, Burns and Middledorpf saved their patients. 7. EXTRAVASATION OF BLOOD. Extravasation of blood is of frequent occurrence, and may exist with or without frac- ture of the skull. It is invariably the result of external violence, acting directly or indi- rectly upon the vessels of the brain and its envelops. The extravasated blood may be situated at five different points : first, between the dura mater and skull; secondly, in the arachnoid sac, on the surface of the brain ; thirdly, beneath the arachnoid membrane, in the furrows of the hemispheres; fourthly, in the substance of the brain; and, lastly, in the lateral ventricles. The first of these sites, fg. 12, from Bryant, is the most frequent, Fig. 12. Fig. 13. Extravasation of Blood between the Skull and Dura Mater, from Rupture of the Middle Meningeal Artery. and, practically speaking, the most important, as it is almost the only one admitting of surgical inter- ference. The quantity of blood poured out here is sometimes very great, especially when it depends upon rupture of the middle meningeal artery. I have seen as many as eight ounces extravasated from this cause ; but, in general, the quantity is much less, not exceeding, perhaps, one-fourth or one-third of that amount. When the effusion is considerable, the blood usually presents itself as an irregular, dark-colored mass, lying in a sac formed by the dura mater and the inner surface of the cranium, the ruptured vessel, it may be, opening directly into it. Large quantities of blood are sometimes observed at the base of the skull and upon the antero-lateral aspect of the cerebral hemispheres, forming broad, cake-like clots, from three to six lines in thickness. Copious effusions may also occur in the ventricles; but in the substance and on the sur- face of the brain they are commonly small, although, from the pressure which they exert upon the nervous pulp, they are hardly less dangerous to the cerebral functions. When blood is extravasated in the cavity of the arachnoid, it is frequently converted into a false membrane, or it may become encysted, as in fig. 13, from Ilewett. These cysts are generally adherent to the parietal arachnoid ; but, as in the cases recorded by Leriche and Quain, they may lie loose in the arachnoid sac. They rarely give rise to symptoms of compression of the brain ; but are liable to induce insanity or epilepsy. The diagnosis of compression of the brain from extravasated blood is often extremely Large Blood-cyst attached to the Parietal Arach- noid ; the Cyst laid open to show its Cavity. INJURIES AND DISEASES OF THE HEAD. CIJAP. i. difficult. Tlie chief causes of embarrassment are, depressed fracture of the skull, apoplexy, and intoxication, in all of which the symptoms are frequently very similar, if, indeed, not almost identical. In compression from extravasated blood, the symptoms, although sometimes immediate, do not generally appear for some little time, the interval being occupied by a state of con- cussion, during which the lacerated vessels, from the exhausted condition of the heart, pour out hardly any blood ; but as soon as reaction begins, the bleeding recommences, and now proceeds with more or less vigor, the fluid running into, and filling up, every acces- sible space. It is now, perhaps before the patient has recovered any consciousness, that compression, for the first time, shows itself, as is evinced by the comatose state of the 1 brain, the stertorous breathing, the slow and laboring pulse, the hemiplegia, or general paralysis, and the dilated and insensible pupil. Occasionally the extravasation results, I apparently, from very trifling causes. A man, for example, receives what he conceives ; to be a slight blow upon the head. lie is somewhat stunned ; but, soon recovering his f consciousness, he gets up, and resumes his work. In a short time, often not exceeding ten, fifteen, or twenty minutes, he is observed to turn deadly pale, to reel, and finally to fall down in a fit, foaming at the mouth, and appearing as if partially asphyxiated. Such an accident is particularly liable to happen when a large artery, as, for example, the middle | meningeal, has been wounded ; the orifice of the vessel, partially closed during the exhaus- l tion of the system consequent upon the injury, now that reaction has ensued, is reopened, : and lets out its contents in a f ull, rapid stream, suddenly overwhelming tin; brain and heart, and literally reducing the sufferer to the condition of a mere automaton. The case of a lad, { twelve years of age, a patient of mine, admirably illustrates the peculiarity of this species l of compression. While rowing on the Schuylkill, a stone thrown from the bank of the river struck the boy on the right parietal protuberance, bruising the scalp, and severely stunning him. As soon as he had fully recovered from the shock of the accident he walked home, although not without much difficulty, a distance of three miles; and shortly after- wards was seized with symptoms of compression of the brain, from the effects of which he died at the end of thirty-six hours. The dissection revealed the existence of a fissure in the parietal and sphenoid bones, and a large clot of blood at the site of the injury, between the skull and the dura mater. There is occasionally what may be called secondary extravasation of blood, inducing compression at a more remote period than in the form of the lesion just described. Cases of this kind are, in fact, not uncommon, and, as they are always remarkably insidious in their character, they are extremely liable to be overlooked. They are most apt to follow injuries of the skull and brain attended with concussion. After the symptoms of shock have passed off, the pulse either remains unnaturally slow, or if, as often happens, it be- ; comes too frequent, it soon sinks again below the normal standard, beating, perhaps, only fifty, fifty-five, or, at most, sixty-five in the minute, at the same time that it is full and laboring. The mind is sluggish and fretful, the pupil torpid and rather dilated, the coun- tenance more or less flushed, and the patient complains of headache, with ringing noises in the ears. If let alone, he gradually sinks into a comatose condition, followed by squint- ing and convulsions, and finally dies under symptoms denotive of cerebritis and hemor- rhagic effusion. The blood often exists in large quantity, and in various degrees of consistence, much of it being quite soft and of a dark color, thus showing that it was poured out only a short time before death, in consequence, apparently, of the softened and lacerated condition of the cerebral tissues at the sight of injury, and the inability of the vessels to protect themselves by the formation of firm clots. In compression from depressed bone, the symptoms, as stated elsewhere, are immediate. ; The only exception to this ride is in slight depression, incapable, of itself, of producing compression, but, when this occurrence ensues from injury done to the soft parts, eventu- ating in effusion of blood, the two causes thus cooperating in bringing about the result. Moreover, extravasation may take place without fracture, or with fracture unattended with depression. Treatment The treatment of this form of compression will depend upon the site of the effused blood, and the absence or presence of' fracture of the skull. When the blood is acces- sible, it is obvious enough that it should be evacuated ; but how is this to be known ? IIow 1 can it be determined whether it is situated immediately beneath the cranial bones, upon the hemispheres of the brain, at the base of the skull, in the cerebral substance, or within the ventricles? Are there any symptoms, any grand landmarks, which will serve to point out the spot where the compressing agent is lodged ? The most subtle pathologist and diagnostician must, in the present state of our knowledge, be at fault here. Especially CHAP. I. EXTRAVASATION OF BLOOD. 55 must this be the case when there is no fracture, or outward evidence of injury. Indeed, even when there is a fracture, we cannot always be certain. A person, to illustrate my meaning, has compression, and the symptoms render it pretty clear that it has been caused by extravasation of blood ; there is no visible fracture, but a contusion on the scalp denotes where the injury was inflicted, and hemiplegia exists on the opposite side. Taking these facts in connection, the presumption is that the effusion is on the side of the brain where the head was hurt, and, acting upon this view, the surgeon, especially if he is fond of operating, may feel inclined to perforate the bone. But is he right in doing so? Possi- bly, he may find the object of his seafch; but he is groping in the dark, and there is quite as much likelihood that he may fail as that he may succeed. The blood may be far be- yond his reach, and thus the patient may have been subjected to a fruitless and dangerous operation. Besides, it must not be forgotten that the blood may be at a point opposite to that upon which the blow was inflicted. A surgeon makes occasionally a fortunate hit. Dr. Physick, in a case of this kind, boldly perforated the skull at the site of injury, and, extracting the clotted blood, saved his patient. But how often has the operation failed? Where one surgeon has succeeded, twenty have been disappointed. A judicious practitioner should have something more than mere conjecture to guide him in such an undertaking. The truth is, the only case in which such a procedure is really warrantable is where the extravasation is associated with, or dependent upon, fracture of the skull, complicated with depression, or serious injury of the soft parts, or where the fracture is situated directly over the course of the middle meningeal artery. But even here the operation does not always succeed, as I know from personal observation. A boy, ten years old, was thrown off a heavy log, which, rolling over him, broke his skull directly over the right temple. The fracture, although not compound, was comminuted, and, as the symp- toms were urgent, I made an incision through the scalp, raised a loose and slightly de- pressed piece of bone, and extracted a large coagulum. No relief followed ; for, as fast as the blood was removed, the spacious osteo-membranous cavity filled up again, and I was finally compelled to close the wound, as best I could, with a compress and a tight roller, to prevent the boy from bleeding to death. As it was, he died without return of con- sciousness in less than forty-eight hours. In private practice and in civil hospitals extravasation of blood between the dura mater and the skull almost invariably coexists with more or less extensive contusion and lacera- tion of the brain, so that trephining is rarely successful. In army practice, on the other hand, injuries by balls and other missiles are less frequently attended with serious con- comitant lesions of the brain, as the force is much more liable to be circumscribed. Of 14 operations for blood effused in this situation, all of which with one exception were examples of depressed fracture, analyzed by Dr. S. W. Gross, (5 recovered, and 8 died, all of the former having followed primary interference, or before inflammation of the brain was lighted up. In 7 of these cases the middle meningeal artery was lacerated, and only 1 survived; in 7 the extravasation depended upon rupture of the small vessels which pass from the dura mater into the cranial bones, and of these 5 recovered. Cases occasionally arise where, after the skull has been perforated, the blood is observed to be seated in the arachnoid sac, beneath the dura mater, lifting up this membrane in the form of a small, bluish swelling. In such a condition, the proper operation, it has been alleged, is to make an opening into the tumor, and let out its contents. But such a pro- cedure must, it is obvious, seriously complicate the case, exposing the patient to the occurrence of inflammation and fungous protrusion, to leave out of the question the possibility, even in a minority of cases, of removing the clotted blood, or, after this has been effected, of preventing a fresh hemorrhage, perhaps quite as copious as the original. While these objections may be valid, it remains to be shown that the patient is ever saved, when the amount of blood is so large as to induce marked symptoms, without its being evacuated. On the other hand, the recoveries recorded in army life by Petit, Roe- mer, and Bliss, and in civil practice by Morand, Ilecker, Bremond, Ricker, Ogle, Cheva- lier, and Macewen, indicate that the dura mater should be opened to afford the patient the only chance of life. While operations for the removal of the effusion on the dura mater or in the arach- noid sac are indicated wdien the lesion is due to gunshot injury, so little is to be ac- complished by interference when the extravasation results from ordinary causes, that the question naturally arises, How is the treatment to be conducted in this class of cases? Obviously, upon the same general principles as in ordinary apoplexy, from which, as has already been seen, compression from traumatic extravasation differs only in the 56 INJURIES AND DISEASES OF THE HEAD. CHAP. i. absence of external injury, as, for example, laceration of the scalp and fracture of the cranial bones. The object is twofold : first, to enable the brain to accommodate itself to the effused blood, and, secondly, to promote the speedy absorption of this fluid. The first indication is fulfilled, after reaction is fully established, by copious general and local de- pletion, by the frequent use of active and rather drastic purgatives, and by the administra- tion of saline and antimonial medicines, along with the use of light diet, cold applications to the head, and perfect quietude of mind and body. By these means, properly employed, the quantity of the blood is materially reduced both in the brain and in the general sys- tem, and, while the danger of inflammation is lessened, the organ is gradually brought to bear with the extraneous substance, no longer resenting its presence. Blood must not, however, be taken heedlessly or causelessly. No intelligent surgeon would bleed a patient before the system has thoroughly reacted. The same rules must govern us here, in the use of the lancet, as in exhaustion of the system from other causes. Premature abstraction of blood, in this form of compression and in apoplexy, has slain its thousands of subjects, or compelled the poor, crippled patient to drag out a miserable existence. Mercury should be freely used at an early stage of the disease, as soon, indeed, as pos- sible after thorough evacuation by the lancet and purgatives. It should be given in the form of calomel, in doses of three grains every six or eight hours, its action being assisted by inunction of the inside of the thighs and arms with blue ointment, or, what is better, mercurial suppositories. The gums must not merely be touched, but maintained in a tender condition for a number of weeks. When the case has become chronic, iodide of potassium takes the place of the mercurial, as there is now less need of hurry. Throughout the treatment, the greatest vigilance must be exercised over the suffering organ, lest, in resenting the encroachment of the coagulum, it should take on inflamma- tion, the slightest approach to which must instantly be met by the resumption of anti- phlogistic measures. Infants occasionally suffer from compression of the brain, from an effusion of blood beneath the dura mater, before the completion of the ossific process, induced by blows upon the head. The little patient lies in a state of insensibility, and is usually affected with convulsions or spasmodic twitches, and, perhaps, some degree of stertor. Consider- able contusion of the scalp generally exists, but there is no fracture of the skull, because the bones are too yielding for such an occurrence, and the fontanelle appears to be elevated somewhat above its proper level. Pressure made with the finger discovers unusual ten- sion, and may aggravate the symptoms, especially the tendency to convulsions. Such a case is to be treated on general principles; with leeches and cold applications to the head, and stimulating injections, followed by a brisk purgative as soon as the power of degluti- tion returns. If these means fail, and the symptoms are very menacing, the scalp should be opened by a crucial incision, and the distended, and, perhaps, purple-looking, mem- brane punctured with the bistoury, care being taken to make the aperture as small as may be consistent with the state of the extravasated blood, and to protect the parts, imme- diately after the evacuation has been effected, with adhesive strips, a compress, and a roller. SECT. IV FRACTURES OF THE SKULL. Fracture of the skull is a frequent occurrence, and is liable, even in comparatively slight cases, to be followed by the worst consequences. It may happen at any portion of the bony case, in a great variety of forms, from the merest fissure in the osseous surface to the most extensive loss of substance. In its character, tiie accident may be simple, com- pound, comminuted, depressed, punctured, or complicated, and fracture in the form of a mere fissure is by no means infrequent. The import of these terms will be fully understood from what has been said respecting them in the chapter on fractures in general. All fractures of the skull are the result of external violence, applied either directly to the part, or through the medium of the spinal column. It is remarkable how slight a blow will sometimes produce this injury. Several circumstances may be supposed to con- tribute to this result, of which the principal are the unusual thinness and brittleness of the cranial bones. It is by no means uncommon to see skulls which are so exceedingly thin as to be translucent, not at one point merely, but nearly through their entire ex- tent. My collection contains several specimens, the walls of which are hardly half a line in thickness at the thickest part; they are, in fact, mere shells, composed of compact tissue, with hardly any trace of diploe. Such skulls are also, for the reason just stated, generally very brittle, although this property is by no means peculiar to them, but is often witnessed in comparatively thick craniums. When unusual thinness and fragility coexist FRACTURES OF THE SKULL. 57 CHAP. I . in a bone, it requires very little force to break it, either at the point struck, or at some opposite one. The fracture will, moreover, be likely to be uncommonly extensive, com- minuted, and depressed. On the other hand, the skull may be so thick and hard as to be almost proof against force, however severe. In one of my specimens, the average thickness of the cranium is at least half an inch, its density is nearly equal to that of ivory, and hardly a trace is to be seen of a suture. To break such a skull, even in a com- paratively slight degree, would require an amount of violence which is rarely inflicted under any circumstances. The older authors, especially the members of the Royal Academy of Surgery of Paris, have a great deal to say about counterfracture, a fracture occurring on one side of the head when the injury is inflicted upon the opposite one ; and in reading their works one cannot fail to be impressed with the conviction that they must have considered it as a very common accident. That this, however, is not the case, modern experience has conclu- sively shown. The accident is most common in the parietal bone, but it may also occur in the temporal and even in the occipital and frontal, the lesion always presenting itself in the form of a fissure, line, on crack, never as a fracture attended with depression. Fracture at the base of the skull is not, strickly speaking, a fracture by contre-coup, but the effect of two forces applied simultaneously at opposite points, as wlfen a person falls from a considerable height and alights upon his head, the skull giving way at its base from the concentration of the injury by the joint agency of the blow and the weight of the body. Fractures of the skull vary much in form and extent. The most frightful accidents of this kind are those in which the fracture involves a number of bones, travelling, perhaps, completely around the skull from the forehead to the occiput; or, as more frequently hap- pens, from vertex to base, literally separating the anterior from the posterior part of the cranium, as in the cases reported by Luke, Chandler, and other surgeons. The subject of fracture of the skull is an exceedingly complex one, and cannot be un- derstood without the most careful and attentive study. The following arrangement will be found to comprise the most important divisions: 1. Simple fracture without depres- sion : 2. Simple fracture with depression : 3. Simple fracture with displacement, and compression of the brain : 4. Compound fracture: o. Fracture of the base of the skull. 6. Punctured fracture: and 7. Fracture of one table alone, either external or internal. Finally, there may be depression of the skull, sometimes, indeed, of a very marked char- acter, without fracture, the cranial bones being bent rather than broken. # 1. Simple Linear Fracture without Depression The term simple, as applied to fracture of the skull, implies that the bone alone is involved, or that, if there be any injury of the soft parts, it does not present itself in the form of an open wound. Some contusion of the scalp must of necessity always exist, however trifling or insignificant the osseous lesion. Such an occurrence constitutes a complication, but it is very different from a wound communicating with the seat of the fracture, and which, when present, renders the fracture compound. The most simple form in which fracture of the skull occurs is that of a crack or fissure, as in fig. 14, similar to what is observed in a broken pot or a pane of glass. It is a mere solution of continuity of the osseous tissue, compar- able, in many respects, to a simple incised wound. It is unattended with depression or the separation of any piece of bone. The fissure may involve the substance of the bone, or it may run along the course of the sutures, its extent varying from a few lines to several inches. It may be caused by direct violence, or, as occasionally happens, by contre-coup. Such a fracture, provided there is no seri- ous lesion of the soft parts of the cranium, or of the brain, requires none but the most simple treatment. Rest for a short time in bed, an occasional purgative, rigid abstinence, and the avoidance of mental excitement, constitute the principal means of cure. The brain, of course, is carefully watched ; for the shock produced by the accident, causing more or less functional disturbance, may be followed by serious inflammation, and that, too, when, perhaps, it is least expected. Operative interference is not thought of, there being no depression of bone, and no extravasated blood to remove. The fissure gradually closes up by bony matter, without encroachment upon the inner table of the skull, and, Fig. 14. Simple Fracture of the Skull. 58 INJURIES AND DISEASES OF THE HEAD. CHAP. I. consequently, without injury to its contents. In these cases, the older surgeons used to trephine, sometimes taking away large portions of the skull, and thus seriously compli- cating an injury which, at the present day, is often recovered from under the mildest means. 2. Simple Fracture with Depression of Bone This form of fracture is not at all uncommon ; the integument is more or less contused, and the patient is usually severely stunned by the blow or fall by which he lias been hurt. The bone is found to be depressed, as in fig. 15, or driven beyond the surrounding level, but not sufficiently far to be produc- tive of compression. If the injury has been very violent, the bone may be comminuted, and some of the pieces may be partially de- tached, pressing, perhaps, against the dura mater. The great danger from such an ac- cident, after reaction has taken place, is inflammation of the cranial contents, and, re- motely, nervous irritation, followed by epi- lepsy, if not epilepsy and fatuity. The ques- tion then arises, how shall it be treated ? Upon this subject, surgeons have been much divided in opinion, some favoring, others con- demning, operative interference; favoring, because of the dreaded primary and secondary effects ; condemning, because a simple frac- ture is thus converted into a compound one. Avoiding both these extremes, as calculated, if fully carried out, to be followed by mis- chievous consequences, the judicious prac- titioner will be governed, in the choice of his remedies, by the circumstances of each indi- vidual case. When the fracture is of small extent, free from comminution, and without much depression, the only rational plan is not to attempt elevation, but to treat the patient upon general principles, using depletion by the lancet, leeches, and other means, with a view of preventing inflammation and other evil consequences. If, on the other hand, the fcone is forced down considerably, so as to impinge very decidedly upon the brain, or if it be comminuted or jagged at the edges, the sooner it is raised or removed the better; since, if it he allowed to remain, it cannot fail to become a source of trouble, either by exciting inflammation, or by causing serious secondary effects. I am fully, indeed painfully, sensible of the responsibility which I incur in giving this advice; but I feel satisfied, after mature consideration, aided by the light of experience, that it is the best, if not the only proper, course to be pursued under the circumstances. A man labor- ing under such an affection is never free from danger; he may get well, or be well to all appearance, and yet be only partially cured, subject, at any moment, to have his mind and life imperilled by the broken bone. It is like the sword of the tyrant suspended over the head of his subject. 3. Simple Fracture with Depression, and Symptoms of Compression In this variety of fracture, the bone is not only displaced, but sunk so far below its natural level as to produce compression of the brain. The patient lies in a comatose condition, breathing heavily and stertorously, with dilated pupil, and a slow, laboring pulse, the side opposite the seat of injury being paralyzed. The symptoms are unmistakable. The fractured and depressed bone, with, perhaps, sanguineous effusion, is the cause of trouble. The case, although different from the preceding, has yet much in common with it, the cerebral com- pression constituting the main feature in the dissimilarity. Here, too, the treatment is not settled, some contending for delay, others for immediate action ; the former, hoping, by depletion and other means, for cerebral accommodation and prevention of inflamma- tion ; the latter trusting, by operative measures, to prevent both present and future evil. In such a condition the immediate safety of the patient is unquestionably best secured by the avoidance of the trephine, provided the symptoms of compression yield within a rea- sonable time, as two or three days, under the use of the lancet and other suitable remedies ; at any rate, this is the plan of treatment now fully approved by the general experience of surgeons, both in civil and military life. On the other hand, it must be remembered that so long as the bone is depressed, serious secondary accidents are liable to occur, as inflam- mation of the brain and its envelops, epilepsy, insanity, and other nervous affections, as distressing to the patient as they are embarrassing to the practitioner; in a word, acci- Fig. 15. Fracture with Depression. on A p. i. FRACTURES OF THE SKULL. 59 dents which render life wholly undesirable. Not a few cases of such accidents have fallen under my observation; and, on the other hand, I have met with numerous instances in which enormous depressions had existed for many years unproductive of any appreciable mischief. 4. Compound Fracture A fracture of the skull is said to be compound when the injury of the bone is associated with a wound in the scalp, communicating with a fissure or an opening in the bone. Such a fracture may be comminuted or depressed, or both comminuted and depressed, and attended with or without compression of the brain. The scalp is fre- quently much contused and ecehymosed, and a good deal of swelling generally arises soon after the occurrence of the injury. The symptoms may be those merely of shock, perhaps severe and protracted, or concussion and compression may coexist, commencing simulta- neously, and running on, step by step, until reaction ensues, or until the case terminates in sinking. Hemorrhage, occasionally quite copious and protracted, may attend the acci- dent, adding thus to the exhaustion of the already enfeebled frame. The danger of a compound, or a compound, comminuted fracture of the skull is three- fold, from shock, from inflammation, and from fungus of the brain. When the violence inflicted upon the bone and the soft parts has been unusually severe, death may occur without reaction, or after a feeble and unsuccessful attempt at restoration ; or, the first symptoms having passed off, life may be assailed by inflammation ; or, this danger being happily surmounted, the patient may perish from fungus of the brain. When the frac- ture is very extensive, and is accompanied with great laceration of the dura mater, death may occur from sheer loss of cerebral substance, as in a case under my observation in 18f>2. The patient, a little girl, nearly three years of age, had received a blow from a brick, which literally mashed the top of the cranium, causing extensive laceration of the dura mater, through which the disorganized brain escaped in immense quantity despite the efforts to prevent it. In another case, also fatal, the loss of cerebral substance was still more extensive. The treatment in compound fracture, as pursued at the present day, is to refrain from instrumental interference, provided there are no serious complications, as persistent symp- toms of compression or threatened inflammation, spasm, or convulsions; circumstances which loudly call for the use of the trephine. In compound fracture, attended with de- pression and comminution of bone, the invariable rule is to operate, whether there be symptoms of compression, or not. The great object in such a case is to remove any loose or partially detached fragments, which, if left, would inevitably cause serious, if not fatal, mischief. The operation is performed at once, while the parts are still fresh from the first effects of the injury, and, consequently, prior to the supervention of inflam- mation. Elevation and retention of the depressed fragments are effected whenever prac- ticable, but all loose pieces are removed, as well as such as are nearly detached, lest they should become a source of irritation, either present or future, by acting as foreign bodies. In the compound, comminuted fracture, I have, on several occasions, been compelled to take away an extraordinary quantity of bone, fully equal in size to that of the palm of the hand, and yet recovery followed in almost every instance. The danger of such a pro- cedure is probably not so great as is generally imagined, provided there is no lesion of the brain and its envelops. When these structures are wounded, the case assumes at once a grave character, as there is then risk not only of convulsions and of violent inflammation, but also of loss of cerebral substance and of the ultimate formation of fungus ; three circum- stances which cannot be too much dreaded. If, in such a case, the detached bone be found to be perfectly smooth, it should by all means be retained, as a means of affording tem- porary support to the injured organ, and of counteracting the tendency of the cerebral pulp to protrude during each pulsation of the heart; otherwise it should be promptly removed, sheet lead or some other appliance being employed as a substitute. Support, in some form or other, is indispensably necessary in such a condition. The offending bone having been raised, or removed, the edges of the wound are gently approximated by suture and plaster, the whole being supported by a compress and roller, with an eye to thorough drainage. The head, previously well shaved, is maintained in an elevated position, and kept constantly wet with cold water, or, what is better, a blad- der partially filled with pounded ice, or some refrigerant lotion. If the patient is young and plethoric, and there has been no serious hemorrhage, blood is taken freely from the arm, or by leeches from the temple, the bowels are thoroughly moved by drastic purga- tives, and the heart’s action is equalized with antimonial and saline preparations, aided by the moderate use of opiates and aconite or veratrum viride. Light and noise are ex- INJURIES AND DISEASES OF THE HEAD. CHAP i. eluded from the apartment, and the diet is of the mildest and simplest character, consist- ing of panada, thin gruel, rice, or arrowroot, along with acidulated drinks. 5. Fracture of the Base of the Skull Fracture of the base of the skull may be per- fectly simple; mild symptoms characterizing the affection, and mild remedies sufficing for its relief. But it is far otherwise when the fissure is extensive, owing to the lesion sustained by the brain and its envelops, the former being often severely concussed, and the latter freely detached, large quantities of blood being at the same time frequently extravasated at the site of injury, either in the arachnoid sac or beneath the dura mater. The accident is usually caused by falls upon the vertex, or by the head being crushed laterally, as by the passage of the wheel of a carriage, or by the head being jammed in between two hard and resisting bodies, as a post and a railway car. A fall upon the buttocks, knees, or feet may also produce this fracture, but such an occurrence must be extremely rare, and will only be likely to happen when the cranial bones are uncom- monly thin and brittle. In most of the cases of this fracture that have come under my observation, the injury was occasioned by the person pitching, head foremost, from a second story window or a high scaffolding down upon the pavement, tlie weight of the body being received upon the vertex. In a remarkable instance of this kind, which was treated in 1846 by Professor T. G. Richardson, and which I had an opportunity of seeing soon after the accident, the fracture extended in a circle around the occipital, sphenoid, temporal, and frontal bones, separating them completely from the rest of the skull. The man had been pushed down a high flight of stairs, and in the fall had struck his head violently against the floor. lie was immediately picked up in a state of insensibility, in which he continued, without any successful attempt at reaction, until he died, about forty-eight hours afterwards. Dissection showed not only the frightful extent of fracture here indicated, but an immense coagulum at the base of the skull. The adjoining cut, fig. 83, affords an excellent illustration of the form of fracture now described. It will be observed that the occipital, temporal, and sphenoid bones are most extensively fissured, the injury having been occa- sioned by a fall upon the vertex. Chassaignac and Hewett have each related an in- stance in which a direct fracture of the base of the skull occurred by the forcible projection of the con- dyle of the lower jaw against the glenoid cavity of the temporal bone. In the case of the French sur- geon, the bone pressed upon the middle lobe of the brain, in which there was a large abscess, causing death between five and six months after the receipt of the injury. It is, then, not so much on account of the fracture, as of the great mischief inflicted upon the soft parts, the brain in particular, that this injury is so justly dreaded by the intelligent surgeon. The moment he sees his patient, he is fully impressed with the criti- cal nature of his condition. The symptoms are always of the worst possible description, being inva- riably a combination of those of concussion and com- pression, the latter coining on early, and usually con- tinuing, with little or no mitigation, until the close of life. The countenance is deadly pale, the pulse is feeble and hardly perceptible, the respiration is nearly extinct, the pupils are widely dilated, and there is not the slightest sign of sensibility of any kind. Blood often issues from the ears, nose, and mouth, from some of the vessels in these parts having given way, from the severity of the blow or fall inflicting the injury. Occasionally the bleeding from the ears is very copious, especially in fracture of the petrous portion of the temporal bone, and sometimes even when there is merely a rupture of the membrane of the tympanum. Now and then the blood proceeds from the interior of the skull through a crack in the cranium communicating with the nose, the mouth, and the orbit, the fluid, in the latter case, sometimes discoloring the conjunctiva and perhaps even the lids. There is also occa- sionally, as was first shown by Dolbeau, ecehymosis of the posterior wall of the pharynx, extending from the occipital bone to the upper cervical vertebra?, but difficult to be seen, as it is generally concealed by the palate. In fracture of the petrous portion of Fig. 16. fracture of the Base of the Skull. CHAP. i. FRACTURES OF THE SKULL. 61 the temporal hone fatal hemorrhage sometimes arises from rupture of the lateral sinus of the dura mater or tlie internal carotid artery, the blood in each event filling the middle ear and descending through the Eustachian tube into the lungs and stomach. Fracture in this situation attended with laceration of the drum of the ear is sometimes followed by an escape of air. When the ethmoid and temporal bones are severely crushed, large fissures may be formed at the base of the admitting of the discharge of a considerable quantity of brain through the ear and nose, along with more or less blood and cephalo-spinal fluid. An escape of serum from the ears is occasionally observed, and great stress is justly laid upon it on account of its diagnostic value. This singular occurrence, already indi- cated by Berengario and Van der Wiel, and indistinctly shadowed forth in the writings of O’Halloran, Dease, and others, was first correctly interpreted by Laugier and Robert, in a memoir published upon the subject in 1846. The discharge generally begins within a short time after the accident, and after having continued, often quite profusely, for several days, gradually vanishes. It seldom proceeds from both ears, even in the more severe grades of fracture, and is not necessarily accompanied or followed by deafness. The escape, which is commoidy continuous, is sometimes accelerated by a prolonged or forced expiration. The fluid, at first red from the admixture of blood, soon assumes a clear, limpid appearance, and usually so remains until it finally ceases. The quantity varies in different cases and in different circumstances. As many as three, four, and even five ounces may be lost in the twenty-four hours, the fluid dropping upon and saturating the patient’s pillow. In the remarkable case published, in 17*27, by Van der Wiel, the discharge, consequent upon a severe fracture of the base of the skull, was truly enorm- ous, and continued almost uninterruptedly for five days. The fluid, always strongly saline in its taste, from the presence of chloride of sodium, is, in its pure state, of a clear, watery aspect and consistence, and is entirely destitute of coagulability, exhibiting merely a trace of albumen, and differing, therefore, essentially from ordinary serum. Chatin, in analyzing it, found its composition to be identical with that of the cephalo- spinal liquid ; and Bernard ascertained the additional fact that both fluids contain a small quantity of sugar. The various notions that were formerly entertained respecting the source of this dis- charge have all given way to the theory which ascribes its origin to the cephalo-spinal liquid, the evacuation of which, by the ear, is due to a fissure, generally a transverse one, in the petrous portion of the temporal bone accompanied by a rent in the cul-de-sac in the arachnoid membrane formed around the auditory nerve in the auditory canal, the tympanum being, of course, ruptured as a necessary concomitant. This view of the case is fully corroborated by the similarity in the physical and chemical properties of the two fluids, and by the fact that the serous investment of the brain has been repeatedly found to be torn completely across, opposite the outlet at which the escape has been observed to take place. The discharge, usually most abundant in young, vigorous subjects, is equally common at all periods of life. When the fracture in the temporal bone is longitudinal, the accident is less grave, and the discharge is generally composed of blood instead of serum. An escape of cerebro-spinal fluid may accompany almost any fracture of the skull, apart from that of the petrous portion of the temporal bone, when there is a laceration of the arachnoid membrane. The occurrence has been noticed in fracture at the vertex, but is most common in lesions of the occipital region. In a case reported by Mr. Henry Gray, of London, the fluid evidently proceeded from the inflamed membrane of the middle ear, as there was no fracture of the temporal bone ; and in another, ob- served by Mr. Holmes, of St. George’s Hospital, the discharge was due to a fracture of the lower jaw, one of the fragments of which had perforated the wall of the auditory passage. Facial paralysis on the side of the fracture is an occasional symptom, caused either by direct injury of the portio dura, or by inflammation of its substance and of the parts around, interfering with the transmission of nerve-fluid. In the former case the paralysis is generally immediate, whereas in the latter it seldom manifests itself under several days. It may occur without any escape of cerebro-spinal fluid, and is always a symptom ot great diagnostic value. Paralysis of the face, not unfrequently coexists with paralysis of the uvula and palate, evidently due to injury sustained by the filaments of the spheno-palatine ganglion that are distributed to these structures. This coincidence is so much the more valuable, diagnostically considered, because it only occurs when the injury which gives rise to it is 62 INJURIES AND DISEASES OF THE HEAD CIIAP. 1. seated wi thin the cranium, close to the petrous portion ot the temporal bone. \\ hen there is paralysis of the face alone, without paralysis of the palate and uvula, it may be assumed that the lesion is external, or in the peripheral brandies of the facial nerve. The diagnosis of fracture at the base of the skull is generally not difficult. The history of the case, the coexistence of violent concussion and compression, the profound coma and insensibility, the absence of fracture at the more accessible portions of the cranium, and the obstinate persistence of the symptoms, are, in most sufficiently declarative of the nature of the accident. The inferences derived from these sources will be materially strengthened, if there be at the same time a discharge of blood from the ears, profuse and continued, as it will be likely to be when there is fracture of the petrous portion of the temporal bone. A flow of serosity from these passages is an infrequent, but, diagnostic- ally considered, a most valuable occurrence, as it always affords indubitable evidence of the lesion in question. The same is true of the discharge of cerebral matter from the nose and ears, and of the existence of facial paralysis. Bleeding from the nose and mouth and discoloration of the conjunctiva and eyelids may proceed from other causes, and are, therefore, of no diagnostic value. Fractures of the base of the skull, if at all severe, are seldom followed by recovery. I have myself, out of at least a dozen instances of this kind, witnessed only one in which the patient was saved ; and this result is, if I mistake not, in full accord with the gen- eral verdict of the profession. In the milder grades, on the contrary, recovery is not uncommon ; and occasionally even an apparently desperate case is safely bridged over. Thus, in an instance reported by the late Professor Armsby, of Albany, there was, in ad lition to arterial and venous hemorrhage, an escape of cerebral substance from the right ear, and yet the man made a complete recovery. That injury in the more severe or ex- tensive forms of fractures of the base of the cranium should usually end in this manner s not surprising, when we reflect upon its violent and complicated character, and upon the fact that, under any circumstances, hardly anything is to be effected by treatment, which is obliged to be altogether expectant. Operative interference is, of course, wholly out of tlie question. The only thing, indeed, to be done, is, if possible, to establish reaction, and afterwards to employ means for averting inflammation. In most of the cases that have come under my observation, the patient never recovered from the unconscious and exhausted condition consequent upon the immediate effects of the injury, death having usually occurred before the end of the third day. A patient, after recovery from fracture of the base of the skull, occasionally becomes affected with pneumatocele at the posterior part of the head, evidently due to an escape of air from the middle ear through a crevice in the petrous portion of the temporal bone. The tumor is usually small, of an irregularly spherical shape, soft, elastic, painless, reso- nant, and effaceable by pressure. The treatment, as stated in the section on lesions of the cranial hones, is best conducted by systematic compression. 6. Punctured Fracture A punctured fracture is a small, circumscribed opening in the skull, attended with depression of both tables, the inner, however, being always more displaced, as well as more badly broken, than the outer. It derives its name from its size, which is often quite in- significant, and from the circumstance that it is inva- riably produced by a narrow weapon, as a poker, bayonet, ball, or dirk. It is sometimes caused by a fall upon a nail, a sharp stone, or the top of an iron railing; and I have seen several cases where it was produced by a blow with a hammer, hatchet, or brick, the angle striking the bone. From the manner in which the injury is inflicted, there is always necessarily severe contusion of the scalp, if not laceration of its entire thickness, constituting, in the latter case, a compound fracture. The annexed drawing, fig. 17, from a preparation in my collection, affords an excellent idea of the nature of this variety of fracture. The case was neglected or mis- managed, and the man died in three weeks from abscess of the anterior lobe of the brain, caused by the pressure of the depressed bone. Punctured fracture is not often attended with compression ; for although the inner table of the cranium may be considerably depressed, there are few cases in which it causes such an amount of pressure as to produce this effect. Sometimes a sharp spicule of bone dips down into the membranes of the brain, and even into its substance, sadly complicating Fig. 17. Punctured Fracture of the Skull. FRACTURES OF THE SKULL. chap, i. the case. The accident is always easily recognized by inspection and digital exploration, aided, if necessary, by the probe, the latter often affording important information relative to the nature and extent of the depression. However simple, a punctured fracture of the skull is always a most serious lesion, from which, unless it is properly treated, few persons ever make a happy escape. The great danger is inflammation of the brain and its membranes, frequently coming on within a few days after the accident, and sure to terminate fatally, if the case has been neglected or mismanaged. If the patient should be so fortunate as to escape with his life, he can scarcely fail to suffer afterwards from cerebral irritation, especially epi- lepsy and mental imbecility. In view of these occurrences, practitioners have long been agreed that the proper treatment is trephining, performed at the earliest possible moment, and without the slightest regard whatever to the character of the head symptoms; or, in other words, as to whether there is compression or not. It is sometimes very difficult to.persuade a patient, when there is merely a little hole in his cranium, without pain, headache, or any other symptom of consequence, to submit to what he may regard as so serious an operation as that of trephining. A case forcibly illustrative of this fact came under my observation, many years ago, in a man who lost his life from this cause. The fracture, inflicted with a brick, was situated at the middle of the left parietal bone. He was stunned for a few minutes by the blow, but, on recover- ing, immediately mounted his horse, and rode to my house, a distance of nearly two miles. Upon his arrival, he was in every respect comfortable, except that he complained of a little soreness of the scalp. Discovering the nature of the fracture, I pointed out to him very fully its dangers, and begged him to submit without delay to an operation. This, however, he peremptorily declined, and I accordingly dismissed him, having previously enjoined absolute rest, a purgative, light diet, and constant elevation of the head, with cold water-dressing. Two days afterwards, when I was sent for, I found him very feverish, with a tendency to delirium. Again an operation was urged, and again declined. He grew gradually worse, and on the seventh day, when he was in a comatose condition, I was permitted to use the trephine. No relief followed the operation, and he died in thirty- six hours thereafter. Pus and lymph were found at the seat of the injury, along with slight softening of the brain, and the lateral ventricles contained several ounces of serum. 'VVho can doubt that this man lost his life by his obstinacy and folly? If he had been immediately trephined, he would probably have made a speedy and perfect recovery. 7. Fracture of only one of the Tables Fracture of the external table alone of the skull is extremely uncommon, and can happen only in the adult, or in persons whose cranial bones have a distinct diploe. Moreover, its occurrence implies unusual brittleness of the outer table, and inordinate firmness of the inner. The fracture is generally of small extent, and the depression inconsiderable. The most common cause is a blow from a narrow, blunt-pointed body. Besides being momentarily stunned, the patient suffers no particular inconvenience, save what results from the scalp lesion. The diagnosis of such a fracture must necessarily be obscure, and, unless great care be taken, it might easily be confounded with an ordinary punctured fracture. Mistake will best be avoided, in case of wound, by the careful use of a fine probe, carried around the edge of the de- pressed bone, by the pressure of the finger, and by filling the artificial hollow with water. If the probe enter any side crevices, the finger cause motion, or the water disappear, there will be reason to conclude that the fracture involves both tables of the bone, and that it is of a punctured nature. The injury requires no particular treatment, apart from that which may be necessary on account of the lesion of the scalp and brain. The external table of the skull is sometimes broken by force applied to the internal surface of the bone, as when a bullet, discharged through the mouth, traverses the brain, and strikes the cranium without penetrating its substance. In a case of this kind, related by Mr. Teevan, of London, there was no fracture at the spot struck by the missile, but a fissured fracture existed at the corresponding point in the external table. It would seem, as remarked by the narrator of this case, hitherto unique in the annals of surgery, that, whether the inside or the outside of the skull be struck, fracture of the distal table only, without injury to the proximal one, can be produced in either event, in obedience to a well-known physical law that the solution of continuity begins in the line of extension, which is the distal side, and not in that of compression, which is the proximate one. Fracture of the internal table alone, fig. 18, is, if possible, still more uncommon than fracture of the outer one, and, as the accident is chiefly, if not exclusively, caused by gun- shot injury, it necessarily falls to be considered under that head. However induced, the lesion is seldom discovered until after death, and then, perhaps, only accidentally, as it does not give rise to any marked, much less characteristic, symptoms. When it is suspected to INJURIES AND DISEASES OF THE HEAD CHAP. I, exist, and especially when there is concomitant com- pression, the proper remedy would be the trephine, tor the same reason that this operation is performed in punctured fracture. 8. Depression without Fracture Depression of the cranial bones without fracture can take place only in very young subjects, before the completion of the ossific process. It is a bending rather than a fracture of the osseous fibres, and is confined chiefly, if not entirely, to the frontal, parietal, and occipital bones. It is usually produced by a fall from a considerable height, in which the child alights upon the top of the skull, which is sometimes flattened in a most grotesque manner, and in a most extraordinary degree. I have seen only three instances of this occurrence, one of which made a great impression upon me at the time, on account of its extent, the patient being a child two years and a few months old, who, in falling down a long flight of stairs, struck its head violently against the floor. It was picked up in a state of insensibility, and, for a few minutes, was supposed to be dead. Signs of reanimation, however, soon appeared, and in a few hours the reaction was perfect. The anterior and upper portion of the skull was completely flattened, the frontal and parietal bones being pressed out in such a manner as to give the head a most singularly deformed appearance. The child lay for the better part of a day in a comatose condition, with frequent spasmodic twitches, but no decided convulsions; both pupils were dilated, but not altogether insensible to light; and the pulse, after the subsidence of the shock consequent upon the fall, was slow and labored. Under mild treatment, these symptoms gradually disappeared as the depressed bones re- gained their natural level, as they did in less than a week from the time of the accident. In another case, the depression was much less, and the effect proportionately milder. In the American Journal of the Medical Sciences for August, 1840, a very extraordinary instance of this accident is related by one of my former pupils, Dr. Burt, of the Navy. A child, three years old, fell out of a second-story window, head foremost, upon the pave- ment below, a distance of sixteen feet, knocking the skull as flat as a board, the frontal bone projecting two inches over the eyebrows. For an hour the child had symptoms of violent concussion, when slight convulsions came on, followed by vomiting, which afforded great relief. The treatment consisted of cold applications to the head and of gentle cathartics. No fracture could be detected. The bone speedily began to resume its natural position, and in a short time the skull had regained its former shape. Depression of the skull unaccompanied by fracture occasionally exists without any serious symptoms. Thus, in a case reported by Green, the patient experienced no par- ticular inconvenience, although the hollow in the bone was sufficiently deep to receive the bowl of a dessertspoon. In cases similar to those now mentioned, the treatment resolves itself into the adoption of the most gentle measures, as leeches and cold applications to the head, purgatives, and stimulating enemata. If the patient is very plethoric, blood may be taken from the arm, but this will generally be unnecessary. The bone gradually resumes its natural position, by its own resilient powers and the pulsatory movements of the brain. All interference with the trephine is, of course, avoided. If the child be very young, an attempt may be made to raise the bone by suction with a cupping-glass, as recommended by Pare and Hildanus, and practised successfully, in 1849, by Dr. W. L. Moultrie, of Charleston. The depression, in this case, occupied the parietal bone, and was large enough to contain with ease the bowl of a common table- spoon. The instrument having been properly adjusted and exhausted of air, traction was made upon it, with the effect of rapid and complete restoration of the entire surface to its natural level. The child, which was five months old, recovered without any untoward symptom. A case of a similar nature, in a child two years of age, has been reported by Dr. Nicolls, in the Dublin Medical Press for September, 1853. The depression, a deep, narrow one about three inches in length, was promptly raised by a cupping-glass placed upon an embankment of common glazier’s putty, in order to afford it a proper purchase. 9. Fracture of the Frontal Sinuses.—This accident may happen from any of the causes that give rise to fracture of the skidl generally, as blows, falls, pointed weapons, or gun- shot injury; and in their character they may be simple, compound, or comminuted, with or without depression. Children are not subject to such lesions, as these cavities are Fig. 18. Fracture of the Inner Table of the Skull. CHAP. I. FRACTURES OF THE SKULL. 65 absent in early life, or only very slightly developed. One of the great peculiarities of fracture in this situation is an escape of air, particularly noticeable in blowing the nose, when it often passes out with a distinct whizzing noise. When the bone is depressed, and there is no external opening, the air collects in the connective tissue beneath the skin, form- ing a characteristic, crackling swelling, which occasionally occupies a considerable portion of the neighboring structures, as the forehead, eyebrow, eyelid, and even the root of the nose. The reason why it never extends over the entire scalp is the extraordinary density and firmness of the connective substance in this situation. The occurrence of emphysema in fracture of the frontal sinuses is readily accounted for by the communication which naturally exists between this cavity and the nose. The treatment of fracture in this region of the skull presents nothing peculiar. De- pressed bone, in view of the deformity which it must inevitably cause if left to itself, should always be promptly elevated, even when there is no wound in the skin, as it never resumes its natural position spontaneously, and no possible harm can arise from the use of the knife, the brain being entirely out of the way. The emphysema usually in a short time disappears of its own accord, or under the usual remedies. Any fistulous openings that may remain after such injuries, are to be managed upon ordinary principles, a plastic operation being occasionally required to effect their permanent obliteration. In a case of compound fracture of the frontal sinus, which I attended along with Dr. Ronalds, in a child eight years old, the outer table of the bone was broken at several points, and knocked considerably below the natural level. A wound, one inch long, existed on the left eyebrow. In attempting to raise the depressed bone, which I suc- ceeded in doing with a delicate and slightly curved awl, the boy had a violent convulsion, but from this he soon recovered, and he had no bad symptoms afterwards. 10. Fracture of the Walls of the Orbit Gunshot injuries of the orbit will be spoken of under another head ; here I shall limit myself to a brief consideration of ordinary and punctured fractures, more especially the latter, which are so very liable to be followed by fatal results. Fracture of the walls of the orbit is occasionally caused by contre-coup, the primary impression having been made upon the vertex, forehead, or occiput. However induced, the existence of the lesion is generally denoted by extravasation of blood be- neath the conjunctiva, and, if some little time has elapsed since the occurrence of the accident, by swelling of the eyelids and circumorbital pain and tenderness on pressure. The precise extent of the injury must, of course, be a matter of conjecture. Such a frac- ture is not, as a rule, in itself at all dangerous. It is otherwise when the injury is inflicted directly upon the wall of the orbit and the ethmoid or sphenoid bone with a sharp-pointed instrument, as a knife, dirk, gimlet, piece, of wire, a stick of wood, or a pair of scissors, as in a remarkable case recorded by Sir Astley Cooper. Owing to the great thinness of the orbital plates, very little force is required to perforate the bone and to wound the brain and its membranes. The opening of entrance of such a wound is not always easily detected, especially when the vulnerating body has passed under the upper, or above the lower, lid. Generally, however, its passage is indicated by the presence of extravasated blood, by more or less discoloration, and by a slit or fissure in the conjunctiva or in one of the lids. The treatment consists in the prompt removal of the foreign body, if still present, in arresting hemorrhage, which, however, seldom requires special attention, and in using every effort to prevent cephalo-meningitis, the great danger after such an occurrence. Such lesions should never be regarded with indifference ; if inflammation come on through neglect, or a want of proper management, death will be almost certain to destroy the patient within the first six or eight days from the receipt of the injury. A wound of the nostril, made with a sharp instrument, and penetrating the ethmoid bone, may, unless properly treated, cause death by inflammation of the brain and its membranes. Several such cases are to be found in works on juridical medicine. 11. Separation of the Sutures This accident is uncommon. It may exist as an inde- pendent lesion, or, as is more frequently the case, in association with more or less exten- sive fracture of the adjacent bones. Sometimes, indeed, nearly all the pieces of the cranium are broken and even comminuted, as when the injury is caused by a cannon ball, by a fall from a great height, by the kick of a horse, or by great and continuous compres- sion, as when the head is forced in between two hard and resisting bodies. The sutures most liable to suffer in this manner are the sagittal and coronal. However induced, the symptoms are usually of a blended character, denotive both of concussion and compres- sion. Very frequently there is copious hemorrhage from the ears, with extensive ecchy- mosis of the scalp and conjunctiva. The prognosis is unfavorable. Death may occur almost instantaneously, or, at all events, within a few hours after the accident, with little, 66 INJURIES AND DISEASES OF THE HEAD. CHAP. i. if iiny, effort at reaction. When the patient lives for several days, the post-mortem inspection invariably reveals all the usual evidences of inflammation of the brain and its membranes. The treatment does not differ from that of ordinary injuries of the skull. The first object is to promote reaction, and the second to prevent inflammation, the danger of which is generally very imminent in all cases where the patient survives the primary effects of the accident. Restoration of the displaced hones is not always practicable, and the attempts to accomplish it must be conducted in the most cautious manner, the chief agent being manual and digital pressure, conjoined with the bandage. 12. Apparent Depression The practitioner is sometimes sorely puzzled to determine whether what he sees and feels upon the skull is really a depression of the bone, or merely a deceptive appearance. Of this occurrence I have seen several well-marked instances, and, as it is by no means uncommon, it is very important that we should be acquainted with its true character, lest we he tempted to use the trephine in cases which will either yield to very slight treatment, or where, from the injury done to the brain, treatment of every description is hopeless. The manner in which it is produced is easily understood. A man receives a blow or fall upon the head, severely contusing the scalp, and, perhaps, inflicting serious injury upon the cranial contents. Upon examination, a tumor is found, having a depressed centre and elevated edges, its size, perhaps, equalling the palm of a small hand. The depression, indicating the spot upon which the violence was concen- trated, is due solely to the condensation of the tissues of the part ; while the tumor itself is caused by the blood that is extravasated at the time of the accident, and which now distends the cells of the adjacent structures. The following cases will serve to illustrate the nature of this occurrence. An elderly man, picked up in a state of coma from a fall received a short time pre- viously from a second-story window upon the pavement below, had a very large tumor upon the right side of the head, over the parietal protuberance, the edges of which were remarkably prominent and well defined, while the central cavity felt precisely as if it had been caused by a fracture with depression of the bone. A careful examination, however, satisfied me that the appearance was altogether deceptive, and the death of the man, nine hours afterwards, confirmed the accuracy of the diagnosis. The parietal bone was per- fectly sound, but one of the most extensive fractures that I have ever witnessed existed at the base of the skull, along with an immense effusion of blood. A boy, sixteen years of age, in riding rapidly around a race course, was pitched, head foremost, off his horse upon the ground, the animal being at the time under full speed, lie was picked up in a state of utter insensibility, and a large tumor was discovered just above the left eyebrow, with a well-marked central depression. Although convinced that the bone beneath was sound, I was induced to cut through the part, but found no fracture. The lad never rallied, and died in a few days after the receipt of the injury. An ex- tensive fracture existed at the base of the skull. A boy, eleven years old, a patient of Dr. O’Reilly and myself, was thrown off his horse, striking his head violently against a fence. On the right side of the head, just in front of the temple, was a severe contusion, feeling very soft, and readily permitting the finger to sink down into it at the centre, thus imparting the sensation of a badly depressed frac- ture. The lad had been somewhat stunned, but soon regained his consciousness. Being in doubt whether the appearance was real or not, I made a small incision across the swelling, down to the bone, but found no fracture. Recovery occurred without an unpleasant symptom. To the above cases I might add several others, but, as they are sufficiently typical of the occurrence in question, this is unnecessary. What increases the embarrassment in such a condition is the fact that the deceptive appearance of the scalp is often associated with symptoms of compression of the brain, inducing the idea that the cerebral affection might be caused by depression of the skull. Ao harm can result in such cases from an exploratory incision. If" fracture exists, it is all important it should be revealed, and this can be determined only by means of the knife. Doubt may sometimes be thrown upon the diagnosis by malformation of the skull. A man, thirty-two years of age, came under my observation, on account of a wound upon the posterior part of the head, received a week previously by being struck with a piece of iron. lie was stunned by the blow, and for several days was hardly able to walk across the room. The wound, which was about two inches and a half in length, extended down to the bone, and was situated over a ridge just behind the lambdoidal suture. On passing my finger around the wound, I found, immediately in front of it, a broad, deep hollow, FRACTURES OF THE SKULL. 67 CHAP. I . reaching forwards towards the sagittal suture, and looking very much like a depression from a fracture. Upon inquiry, however, I ascertained it had always existed there, as a result of malformation. The patient, on his entrance, had violent headache, along with considerable fever, for which he was bled and purged, and from the effects of which he soon recovered. Ilad he labored under compression of the brain, the deceptive appear- ance caused by this state of the hone might have induced an incautious surgeon to apply the trephine. It is hardly probable that any surgeon, at the present day, would mistake a suture of the skull for a fracture. Such an error is said to have been committed by Hippocrates, who actually applied the trephine for the relief of his patient. An accident like this could only be excused in a case where symptoms of compression are superadded to the depressed appearance of a bone from malformation, the suture running across its surface, and the scalp being more or less contused from the injury. 13. Intrauterine Fractures Fractures of the foetal skull during intrauterine life may arise under two very opposite circumstances; first, from violence inflicted by a fall or blow upon the abdomen of the mother, and, secondly, from injury sustained during the passage of the child’s head in parturition. That the former occurrence is possible is shown by the fact that various bones of the skeleton have been known to be broken by violence applied to the foetus through the abdomen of the mother. I am myself cognizant of two cases of fracture of the clavicle that took place in this way, and many examples of a similar nature have been recorded by different observers. It requires no argument, there- fore, to prove the possibility of such an accident; what may happen to one bone may, under like circumstances, happen to another. The second mode in which fracture is produced is by far the more common of the two, and, what is remarkable, the accident may take place independently of any distortion of the pelvis or the application of instruments. In some of the recorded cases, in fact, the labor was neither severe nor tedious. In general, however, the occurrence will be most likely to happen when the pelvis is unnaturally narrow, or when there is a disproportion in its size and in that of the skull, or where, in consequence of the violence of the uterine contractions, the head is jammed firmly into the pelvis. Under such circumstances, it is easy to conceive of the possibility of such an accident. Indeed, it is only surprising when we reflect upon such cases that they are not of much greater frequency. Sometimes the accident has happened without any assignable cause ; and occasionally it is justly attribu- table to the interposition of one of the arms between the head of the child and the bony wall of the pelvis. The fracture is seldom extensive. In general, it presents itself in the form of one or more fissures, from six to eighteen lines in length, without any concomitant displacement. Sometimes there is marked depression, and a case has occasionally been witnessed in which a spicule of bone could be distinctly felt under the integument. The occurrence is nearly always, if not ipvariably, associated with a bloody tumor of the scalp, caused by the rupture of the vessels of the part in consequence of the excessive pressure exerted upon the head in parturition. Owing to this circumstance, it is generally impossible to distinguish the existence of the lesion, unless it is accompanied by displacement or unusual mobility of the fragments, an occurrence of great rarity. In a case of intrauterine frac- ture observed by Flugel, the expulsion of the head was preceded by “a loud crack,” and the dissection disclosed the existence of two fractures, one of which was an inch and a third in length. The pains were rapid and forcible, and the labor terminated in seven hours without any aid, the case being one of face presentation. The intrauterine fracture generally involves the parietal bone, or the parietal and frontal. The occipital rarely suffers, and there are very few cases in which the temporal bone is implicated. The subjects of these lesions are usually still-born, or, if they survive their birth, they perish within a short time after from the injury indicted upon the brain and its membranes, or from the immediate effects of extravasation of blood. These fractures were formerly ascribed to violence wilfully indicted by the mother for the purpose of destroying her offspring. The error of this opinion, however, was gradu- ally corrected by obstetric practitioners ; and it is needless to say how important is the distinction, especially in a medico-legal point of view. Fractures of this kind, caused by injury transmitted through the abdomen of the mother, have occasionally been found in an advanced stage of repair. In a case recorded by Professor Montgomery, of Dublin, a depression, capable of containing an almond in its shell, existed in the'left temporal bone, but disappeared spontaneously within a few months after birth. The treatment of these cases consists in the administration of minute doses of calomel, 68 INJURIES AND DISEASES OF THE HEAD. CHAP. i. as the third or fourth of a grain, three times daily, and in the application of a solution of chloride of ammonium, in the proportion of one drachm of the salt to the pint of water, with the addition of two ounces of vinegar. If marked displacement exists, the fragments, as a preliminary step, are carefully moulded into shape by gentle pressure. SECT. Y GUNSHOT INJURIES OF THE HEAD. Gunshot injuries of the head constitute an important class of lesions, often difficult of diagnosis, and liable, even when comparatively slight, to be followed by the most serious consequences. They may be limited exclusively to the scalp, merely grazing, bruising, or dividing its substance ; or they may involve the cranial bones : or, finally, they may embrace all these structures, along with the brain and its envelops. The frequency of these injuries, as compared with gunshot wounds of other portions of the body, may be stated to be about 8 per cent., or 1 in every 12, the computation being based upon 151,394 cases collected by Dr. S. W. Gross, in 11,939 of which the head was affected. Of this number 72.8 per cent, were confined to the scalp, of which only 3.5 per cent, were fatal, while in 27.2 per cent, the skull and its contents were involved, of which not less than 66.8 per cent, perished. The number of cases of gunshot injuries of the head, reported during our late war, was 4350, of which 923 were attended with perforating, penetrating, and depressed fractures. Of 4243 cases, of which the result is known, 2514 died, and 1729 recovered. In 328 of the cases the lesion was, apparently, limited to contusions, and of these 55 terminated fatally, the cause of death in most of them having been due, as Dr. Otis very justly sup- poses, to some undetected affection of the skull, brain, meninges, or other structures, as concussion, compression, inflammation, necrosis, pyemia, or abscesses of the lungs and liver, consequent upon phlebitis of the diploe. 1. Gunshot Injuries of the Sculp These lesions derive their chief importance from their proximity to the brain and their consequent liability to give rise to enceplmlo-men- ingitis. Erysipelas is also a common occurrence, and occasionally they are followed by jaundice, with or w’ithout abscess of the liver. When the missile penetrates the peri- cranium, or contuses the skull, the accident may cause suppuration and slight exfoliation of the outer table of the bones. The prognosis after such injuries should, therefore, always be very guarded, the more so wdien it is recollected that they are not unfrequently accompanied with serious mischief to the brain and its envelops. The modern military surgeon meets no longer with any of those curious cases of the circuitous route pursued by balls in gunshot injuries of the scalp, so much spoken of by European writers in the early part of the present century, during the reign of the round missile. The conical bullet performs its work much more neatly, rarely glancing, or deviating from the straight line. The treatment of these lesions is similar to that of gunshot injuries in general. If the ball has lodged, immediate extraction is effected, any foreign matter that may have entered along with it being removed at the same time. Such wounds, which cannot be watched with too much solicitude, often require dilatation and counteropening, to afford vent to effused fluids. 2. Gunshot Injuries of the Skull These injuries may be divided into three classes : 1st, contusions and fractures of the bones without depression ; 2dly, fractures with depres- sion ; 3dly, fractures with penetration of the brain and its envelops. a. Contusions and Fractures without Depression Grave injury is often inflicted upon the skull by the blow of a ball or shell, the osseous tissues being violently bruised and shaken, but not broken. Such a lesion is generally fraught with danger from the fact that it is nearly always attended with serious disorder of the brain, as concussion, contusion, or laceration, eventuating, if the case is at all severe, or improperly managed, in destructive inflammation. The danger here, however, is not merely in the first instance; the patient may happily survive the primary effects of the accident, but perish from the secondary, death happening, perhaps, weeks, if not months, after the receipt of the blow'. Even under the most favorable circumstances, recovery will be tedious and troublesome, if for no other reason than the fact that abscesses under the scalp will be apt to be repeated, with more or less extensive exfoliation of the contused bones. Contusions of the skull are often attended with copious extravasation of blood, especially when there has be6n a rupture of the middle meningeal artery. In such an event, there will necessarily be evidence of compression of the brain, sometimes speedily terminating in death. 69 CHAP. I. Sometimes a ball or shell, in traversing the skull, scoops out a portion of its substance, leaving thus a pretty deep furrow, groove, or gutter, perhaps several inches in length ; or the missile strikes the bone, and breaks it, not unlikely at several points, causing a fissured, stellated, or even a comminuted fi'acture, without depression. Occasionally, although rarely, a shell carries away bodily a considerable portion of the skull-cap, along with the corresponding portion of scalp. The danger of all such injuries is too apparent to require comment. When the diploe has been extensively exposed, the patient will run great risk of perishing from pyemia and erysipelas, owing to the liability of the pus to find its way into the blood, and to lead to the development of emboli and metastatic abscesses in the lungs, liver, and other structures. The treatment must be strictly antiphlogistic, blood being taken freely by leeches, or even by the lancet, if the patient is at all plethoric, and the danger from cerebral involve- ment imminent; the bowels are thoroughly moved by drastic cathartics ; the heart’s action is controlled by antimonial and saline preparations, with the addition of a suitable quantity of tincture of aconite ; and the head, shaved and elevated, is kept constantly covered with pounded ice, or some refrigerant lotion. If the case is obstinate, mercury is employed, in doses of two to three grains thrice a day, with a view to rapid and decided ptyalism. Heroic treatment like this, is, of course, inapplicable when, from any cause, the patient is anemic or much exhausted. Under such circumstances, opium and proper nourish- ment take the place of the lancet and other depletive measures. j3. Fractures with Depression Gunshot fractures of the skull with depression of the bone are among the most common and fatal injuries on the field of battle. The bone may be broken without a wound in the scalp, the latter being, perhaps, merely somewhat contused as when the blow is inflicted by a shell or a partially spent round shot; but, in general, there is also an opening in the soft parts, the case thus constituting one of com- pound fracture. The bone, moreover, may be comminuted, or shattered into numerous fragments. The skull is sometimes frightfully broken, and yet the scalp remains literally intact, as in a case referred to by Dr. Macleod, in which, at the battle of the Alma, a round shot, passing in ricochet, struck the scale from an officer’s shoulder, and merely grazed his head as it ascended. The result was instant death; the skull having been so completely mashed that the fragments rattled under the scalp like so many marbles in a bag. The amount of depression in this mode of fracture is variable, depending upon the size and force of the missile and the brittleness and thickness of the skull. Occasionally it is extremely slight, but examples occur in which it is of frightful extent, involving the greater portion of the posterior vault of the skull, the vertex, or the frontal bone, as represented in fig. 19. In rare cases the fracture is limited to the outer or inner table; probably more frequently to the latter than the former. The possibility of a fracture of the inner table was at one time universally rejected, but that it may take place has been satisfactorily shown by military surgeons, ancient as well as modern. Among the former may be mentioned Pare, Tulpius, Ravaton, Delamotte, and Borelius, and among the latter S. Cooper and Huguier. The lesion manifests itself in various forms. Thus it may occur as a mere crack or fissure, as in a case met with in the Crimean war, in which the ball denuded the bone but left no trace of fracture. The man died on the thirteenth day from the pressure of a large clot of blood and extensive inflammation, when a fissure, confined to the inner table, was found running in the line of the track of the projectile. Dr. Demme observed four cases in the Italian campaign in 1859, in which the inner table was broken without any fracture of the outer one. In one of these cases a piece two inches square had become completely detached. During our late war twenty cases of a similar kind occurred, the specimens of ten being now in the Army Medical Museum at Washington. One of the most remarkable of these is repre- sented in fig. 20. The case of Ravaton is so circumstantially detailed that it deserves to be reproduced here, on account of its great practical interest. When the man was first seen by this great surgeon, six weeks had already elapsed since the receipt of the injury. The bone, on being exposed by an incision, was found to be of a blackish color, but without GUNSHOT INJURIES OF THE HEAD. Fig. 19. Extensive Shell Fracture of the Skull. 70 INJURIES AND DISEASES OF THE HEAD. any appearance of fracture; the pericranium was detached, hard, and thickened, and the inner table was not only extensively broken but depressed to the depth of nearly three-quarters of an inch, the osseous pouch formed by its separation being filled with clotted blood and serosity. Death occurred some hours after the operation. The vessels of the membranes of the brain were deeply congested, and the whole of the longitudinal sinus was in a state of suppuration. The principal symptoms, setting in suddenly within less than forty- eight hours prior to the operation, were profound coma, con- vulsions, frequent pulse, and copious sweats. The existence of such a fracture must always necessarily be involved in great uncertainty, especially when, as in the instance of llavaton, there is simply a contused state of the scalp without any immediate brain symptoms. Even when the bone is exposed, and exhibits every appearance of being dead, it affords no positive evidence that the inner table is broken and depressed, inasmuch as such a condition is invaria- bly present when a portion of the cranium has perished from injury to the periosteum, the detachment of the dura mater, or the formation of an abscess within the skull. Punctured gunshot fractures are not uncommon, the missile forcing in the outer table, in a concentrated form, against the internal, which, in conse- quence, is more or less extensively broken and depressed, if not completely detached. The danger of such an accident, of which the annexed sketches, figs. 21 and 22, copied CHAP. I. Fig. 20. Fracture with Complete De- tachment of the Inner Table of the Frontal Bone. Fig. 21. pier. 22. External View of Punctured Fracture of Frontal Bone. Internal View of Same Specimen, the Bone being Exten- sively Splintered and Slightly Depressed. from the Surgeon General’s Report, are graphic illustrations, is always imminent, inas- much as it is sure, if prompt relief he not afforded, to cause destructive inflammation. There are certain rules which, in the treatment of fractures of the skull with depres- sion, are applicable to all cases of the injury, whatever may be its extent. These are, first, to remove foreign matter, so as to place the parts in the best condition for satisfac- tory reunion, and, secondly, to guard against the supervention of undue inflammation. The disposition of the missile varies. It seldom lodges, but rebounds, and is lost. When it is arrested, it will generally be found to be much flattened, very irregular, and either imbedded in the bone, or intercepted in a crevice of the fracture. Sometimes it is cut in two, one portion being lost, while the other either lies under the scalp or has entered the brain. However this may be, it must, if found, be promptly extracted, along with any fragments of bone that may be very loose, or completely detached. In regard to the depressed bone itself, it should undoubtedly be elevated, if this can be done without in- flicting serious injury upon the brain and its envelops. To leave it in its unnatural posi- tion would be productive only of future mischief. In making this remark, I certainly do not wish to be understood as advocating interference in every case of depressed fracture. When the accident is very slight, and, especially, when it is unaccompanied by a wound of the scalp, the best plan is to let the parts alone, the surgeon restricting himself to the employment of such means as may tend to favor rapid and permanent cerebral accommo- dation. But there are cases in which the propriety of trephining is so self-evident as not to admit of the slightest hesitation. Such cases fall under the same rules as similar in- juries in civil practice. If the depressed bone, perhaps terribly shattered, and, to a con- siderable extent, even thrust into the brain, is not promptly x’emoved, it must either cause CHAP. I. GUNSHOT INJURIES OF THE HEAD. 71 fatal inflammation, or, if recovery should occur, eventually lead to epilepsy and other distressing affections, rendering life hardly worth the possession. There seems to be a growing disposition on the part of practitioners to eschew the use of the trephine nearly, if not entirely, in depressed fractures of the skull. Thus, Dr. Stro- meyer, surgeon-in-chief in the Schleswig-Holstein war, pointedly condemns the operation in every case, on the ground that, independently of the mischief inflicted upon the tissues during its performance, the admission of air to the contused portion of the brain and its membranes greatly augments the danger of inflammation. Of 41 cases of gunshot fractures of the skull with depression, reported by him, 7 died, and 34 recovered. Among the latter was one which had been trephined, and this was the only instance of the kind throughout the war which gave a favorable issue. Observations made in the Crimean war strongly corroborate the views of Dr. Stro- meyer. The English surgeons applied the saw successfully only in four cases, and in those not on account of rifle-ball wounds, during the entire campaign ; and the operation does not seem to have been any more favorable in the French army, Dr. Scrive asserting that it was for the most part fatal. Of ten cases trephined by PirogofF only three recovered ; and of a similar number in the hands of other surgeons, the issue was equally unpropitious. During our late war the trephine was employed 220 times, with 124 deaths and 93 recov- eries, the result being unknown in one. Dr. Macleod concludes, from the result of his experience, that interference is only admissible when the bone is very deeply depressed on the brain, and the patient is comatose, with stertorous breathing, a slow pulse, and a dilated pupil. In all other cases in which these phenomena are not very decidedly marked, or where they do not continue for any considerable length of time, trephining should, he thinks, be avoided. The above views, although emanating from men of large experience, should, I think, be received with great caution when applied as rules of practice. Every surgeon knows that there are certain lesions of the skull which must necessarily be fatal under any mode of treatment, however judiciously conducted, and the very fact that the use of the trephine is required, is of itself an evidence that the case will be one of doubtful issue, not so much in consequence of the injury inflicted upon the parts during the operation, or, as Larrey and Stromeyer suppose, of the admission of air, but of the intrinsic mischief done to the brain and its membranes by the primary blow. As a proof of the great mortality of such lesions, it may be stated that, in the Crimean war, they invariably ended fatally when- ever they were at all severe. Of 76 cases of depressed fractures unattended with pene- tration or perforation, 55 perished, 12 were invalided, and 9 only were discharged as tit for duty. In the 21 who survived, the amount of depression was very slight, and all these, excepting one, recovered without a bad symptom. Of 86 cases, in which the skull was perforated, not one was saved. That the great mortality after trephining is due to the extent of the primary injury and its effects upon the brain and its membranes, and not to the operation itself has been clearly and satisfactorily shown by Dr. S. W. Gross in a paper published in the American Jour- nal of the Medical Sciences for April, 1867. Thus, of 160 cases of trephining in army practice, 97, or 60.62 per cent., were fatal; wdiile of 573 serious gunshot injuries of the skull treated by expectancy, 426, or 74.34 per cent., perished. Of 126 cases in which fragments of bone or various foreign substances were removed with the elevator, forceps, or Iley’s saw, 56 recovered, and 70, or 55.55 per cent., died. A comparison of these results shows a ratio of recoveries after trephining alone of 39.38 per cent., after the ele- vator, forceps, and saw of 44.45 per cent., after all operative measures combined of 41.61 per cent., and after conservative treatment of only 25.66 per cent. Since the cures after surgical interference and expectancy are in favor of the former by 15.95 per cent., it follows that the mortality from gunshot injuries of the skull must be referred to cerebral disorders and not to the operations practised for their relief. Of 252 cases of trephining, derived from private and hospital practice, European and American, analyzed by Dr. Gross, 133, or 52.77 per cent., perished, the mortality being less than that of army practice by 7.85 per cent. Moreover, it must be remembered that there is a great difference between gunshot lesions of the skull as inflicted with the conical and the round ball, the former making, as a general rule, an incomparably worse wound than the latter. In former times, men injured with the round ball often made excellent recoveries, with hardly any treatment at all, or perhaps even after the most severe exposure and fatigue, evidently because, although the cranium was apparently badly hurt, the brain and its membranes had sus- tained little or no injury. Thus, after the battle of Talavera, ot fourteen men with 72 INJURIES AND DISEASES OF THE HEAD. CHAP. i. wounds in the head, involving the skull, not one died, notwithstanding they were com- pelled to march tor sixteen consecutive days under the influence of a burning sun, with no other treatment than simple water-dressing. In several of these cases both tables of the skull were broken, and in two fracture of the frontal bone coexisted with destruction of the globe of one eye. Now, no one will presume to assert that these men would have fared so well, if they had been wounded with the heavy cylindro-conoidal ball, instead of the old round ball, used in the Peninsular Avar. When the internal table alone is depressed or splintered, trephining affords the only chance of relief, as is exemplified in the celebrated case treated by Mr. Samuel Cooper, in which, at the battle of Waterloo, a large splinter was driven more than an inch into the brain, the patient on its extraction instantly recovering his senses and the power of voluntary motion. The part of the skull to which the instrument was applied did not indicate any depression, and was only selected because the scalp showed that there the injury had been inflicted, the existence of extravasated blood having been suspected instead of a fracture of the inner table of the skull. Finally, in compression of the brain from blood or pus, consequent upon gunshot injuries, the same rules of practice are to be pursued as in ordinary cases. The great difficulty here will be, not in performing the operation, but in knowing when it is necessary. In general, the formation of matter, under such circumstances, does not occur under several weeks. y. Fractures with Penetration of the Brain These injuries are nearly always promptly fatal, the patient dying either on the spot from shock and hemorrhage, or, at all events, within the first eight days, from the effects of inflammation. The danger in these cases is not from the ball alone, although this is generally very great, but also from the presence of pieces of bone, hair, and other extraneous matter which are forced in with it, and which are often much more destructive than the missile itself, contusing, tearing, and pulpifying the cerebral tissues in the most frightful manner. A ball, lodged in the brain, is some- times encysted, and may thus become a comparatively harmless tenant, the functions of the mind and body being performed with their accustomed vigor; in general, however, it acts as an irritant, even when it is thus isolated, exciting inflammation, which is certain to be followed by abscess and death. Bone and other foreign matter are never encysted ; the lymph effused around them is incapable of organization, and the consequence is that they soon produce fatal disturbance. Although gunshot wounds of the skull and brain nearly always prove fatal, yet a remark- able exception occasionally occurs, the patient getting well, as it were, despite the injury, and in defiance of all the laws of prognosis. This was happily exemplified in the case of a youth, aged eighteen, the particulars of which have been kindly communicated to me by Professor May, of Washington. The ball, an ounce one, entered the upper and back part of the skull, making an opening capable of receiving the index finger, and penetrating the brain, as was proved by the fact that some of it had escaped at the wound. Where the ball lodged could not be ascertained. Rapid and complete recovery followed without a solitary untoward symptom. An instance of a parallel character has been furnished me by Dr. William Lough, of Missouri, the patient being a lady eighteen years of age, who recovered so completely that she afterwards married and bore children. The ball, a small round one, entered the left temporal bone, losing itself in the brain, as was proved by the fact that some of its substance exuded at the external opening and that a probe was readily passed to the depth of an inch and a half. A case reported by Dr. W. W. Keen and Dr. William Thomson, in the Philadelphia Photographic Review of Medicine and Surgery for 1871, admirably illustrates how recov- ery may occasionally occur after an injury of this kind, even when apparently of the most desperate character. The wound, inflicted at the battle of Antietam, occupied the posterior and middle part of the skull, the openings of entrance and exit being three inches apart. The cavity left by the latter was two by two and a half inches in diameter, and twelve lines in depth, involving the hemisphere of the brain to a fearful extent. The unconsciousness and paralysis, consequent upon the injury, lasted several months ; and the large fungus which formed during the progress of the cure, was shaved off not less than five or six times. Notwithstanding this immense amount of injury, recovery grad- ually ensued, with only slight impairment of sight and memory. When recumbent, the hollow in the head, as I have myself observed, is gradually effaced, and replaced by a rounded protuberance. A similar effect is produced by coughing. The pulsations of the brain are barely perceptible. An instance of gunshot wound of the head, observed by Dr. Benjamin Howard, shows upon what a very trivial circumstance the diagnosis of a case sometimes hinges. The 73 CHAP. i. GUNSHOT INJURIES OF THE HEAD. missile had struck the left temple, and, passing underneath the scalp, entered the frontal bone a little to the right of the middle line, causing a kind of trap-door fracture, with a triangular depression, and an aperture so small as not to admit a common probe. Be- lieving, from the character of the symptoms, and the presence of a single hair in the fissure of the fracture, that the ball, a fragment of which had previously been removed from the scalp, had penetrated the brain, he applied the trephine a fortnight after the accident, and thus succeeded in finding it, although it was buried in the cerebrum at a depth of two inches. The softened and discolored cerebral substance being scraped away, the parts were united in the usual manner, and the case treated upon rigidly antiphlogistic principles, the man, who was nineteen years of age, making an excellent recovery. An officer wounded at the battle of Wagram died many years after, at an advanced age, when the ball was found in the left lobe of the cerebellum. Ilis genital organs retained their vigor for a long time. A similar instance has been recorded by Anel. The ball, after death, was found lying upon the pineal gland. In a case observed by Dr. John E. Gibson, of Nashville, the ball remained in a quiescent state in the anterior lobe of the brain for six years, when it excited fatal inflammation ; and Dr. T. B. Cam- den, of West Virginia, attended a man who survived an injury of this kind thirteen years. A case has been reported in which a ball was imprisoned for forty-one days before it caused death. All the faculties, muscular, organic, and intellectual, remained perfect to the last. A remarkable case of shot wound in a child seven years of age has been re- corded by Dr. J. O. Harris, of Illinois. The shot, sixteen in number, made, as they entered the brain, a solitary, ragged opening in the forehead, nearly one inch in diameter. As the child was comatose, he contented himself with removing some loose splinters, and applying simple dressings. No serious symptoms, however, afterwards arose, and, in three weeks from the time of the accident, the little patient was perfectly well, with the exception of the subsequent discharge of a few pieces of dead bone. Foreign bodies, of considerable weight and bulk, occasionally remain in the substance of the brain for a long time, without provoking serious disease, the patient, perhaps, meanwhile enjoying excellent health, both mental and corporeal. Dr. O’Callaghan at- tended an officer who lived for seven years with the breech of a fowling-piece, weighing three ounces, in the forehead ; and a number of similar examples have been recorded by other observers. But, although a foreign substance, one even of large size, may occasion- ally remain for a considerable length of time as a harmless occupant of the brain, it is sure, sooner or later, to excite severe inflammation, eventuating in destructive softening and suppuration, generally proving fatal in a few days. In a remarkable case recorded by Anel, the man died suddenly while playing cards, after having lived for many years in excellent health. The missile was deeply lodged in the brain surrounded by recently effused blood. In Camden’s case, the man, after having latterly suffered from convul- sions, finally died of abscess of the brain formed around the encysted ball. Dr. S. W. Gross met with a case in a man forty-eight years of age, in whose cerebellum an ounce ball lay in a comparatively harmless state for six months, when he wras seized with signs of suppura- tion, followed suddenly by death a few weeks afterwards. The treatment of these accidents resolves itself into the removal of foreign matter, the elevation of depressed bone, and an effort to sustain the brain in its attempts at repair. The finger is, of course, the best probe, but all officious interference is to be avoided, inas- much as it is far better to let the missile and even detached pieces of bone remain where they are than to search for them at the risk of severe additional injury. The propriety of removing foreign bodies, when it can be accomplished without inflicting much injury upon the brain, is shown by an anylysis of 31G cases, of which 160 recovered, published by Dr. R. M. Wharton, in 1879. In 106 examples of extraction, death followed in 34, or 32.07 per cent.; while in 210 in which the foreign substance was not removed, 122, or 60 per cent., died. Of the entire number, 272 were the result of gunshot injury, of which 62.79 per cent, recovered after extraction, and only 37.63 per cent, recovered when the missile was permitted to remain. In a considerable number of the cases the extraneous substance remained for some time in the brain without causing any symptoms, when sud- denly cerebral symptoms supervened, followed by death. A counteropening with the trephine, with a view of facilitating the extraction of the ball, is hardly to be thought of in any case, although two instances have been recorded, one by Larrey and the other by Charles Bell, in which such a procedure was followed by the most happy result. In the case treated by the French surgeon, the ball, entering the forehead, lodged in the poste- rior part of the brain, whence it was removed through the occiput, the missile falling upon the floor. 74 INJURIES AND DISEASES OF THE HEAD. CHAP, i. The antiphlogistic measures must be strictly gauged by the exigencies of each par- ticular case; depletion must not be carried to excess ; if the shock and loss of blood have been great, stimulants and even anodynes may be required from the start, to support the system and quiet the heart’s action. Fungus, so apt to arise during the progress of the treatment, should be repressed in the usual manner. Gunshot injuries of the base of the skull are, if we may credit the residts of statistics, less deadly than is generally supposed. I)r. John A. Liddell, of New York, in a paper in the American Journal of the Medical Sciences for April, 1881, has given the particu- lars of 137 cases of fractures in this situation, from which it appears that a large propor- tion of them recovered, thus clearly proving that such lesions, although always more or less dangerous, are not necessarily fatal. The fact, however, must not be lost sight of that gunshot and other fractures at the base of the skull are often followed, after recovery from their immediate effects, by serious secondary disorders, which, if they do not imperil life, render life permanently wretched. The most frequent and important of these dis- orders, disorders evidently due to changes in the brain-structure, are epilepsy, headache, vertigo, blindness, deafness, loss of sexual power, incontinence of urine, paralysis of the muscles of the face and limbs, and impairment of the mental faculties. A knowledge of the possibility of such occurrences implies the necessity of a guarded prognosis and un- common vigilance in the subsequent management of the patient. In the cases analyzed by Dr. Liddell there were two of obstinate hemorrhage from the middle meningeal artery, which was effectually controlled by ligation of the common carotid. Gunshot Injuries oj' the Orbital Plate of the Frontal Bone Experience has shown that a ball, entering the orbit, and passing directly backwards and upwards, generally destroys life by the violence which it inflicts upon the brain and its envelops, the patient dying either on the spot from shock and hemorrhage, or within a few days after the acci- dent from inflammation. If, on the contrary, it pursues a downward course, the brain may entirely escape, or suffer merely in a slight degree. The eye is often seriously implicated in gunshot injuries in this situation ; in some in- stances it is totally annihilated, while in others it is so severely wounded as to be destroyed by the resulting inflammation. Occasionally the globe of the organ escapes, but the optic nerve is cut off, the lesion being followed by immediate and permanent blindness. It is well known that the orbital plate may be severely shattered, and yet, if the case be properly treated, the pieces may ultimately perfectly reunite; for such is the abundant supply of vessels and nerves of the soft parts of the face and eye that they impart to this portion of the skeleton a much greater conservative power than is possessed by the osseous system in general. A ball sometimes passes across the skull from one temple to the other, without inflict-- ing any serious injury upon the brain or other soft parts, the patient ultimately making a good recovery. Such an occurrence, however, is much less common now than formerly, during the use of the round ball. After the battle of Waterloo a number of cases of this kind were treated successfully by the British surgeons. Gunshot Fractures of the Mastoid Process—Ordinary injury, as a blow or fall, does not seem to be capable of fracturing this process, but such an effect may readily be produced by the passage of a bullet, and the late war fur- nished a considerable number of such cases. The accident may be quite simple, merely exposing the mastoid cells, as in fig. 23, or it may be com- plicated with serious lesion of the middle ear, eventuating in violent inflammation and in loss of hearing. When the missile is very rough, or when the bone is much shattered, erysipelas is very liable to occur, troublesome abscesses and sinuses form, and a long time generally elapses before a complete cure is accomplished. A very curious case of gunshot fracture of this process, attended with complete separation of the apex from its base, has been reported by Dupuy- tren. The ball entered anteriorly, and, perforat- ing the right concha, issued near the outer border of the splenius. The apex of the bone was drawn downwards and forwards by the sterno-mastoid muscle, the amount of displacement being in- Fig. 23. Gunshot Fracture of the Mastoid Process. CHAP. 1. WOUNDS OF THE BRAIN AND ITS MEMBRANES. 75 creased or diminished as the head was moved to the left or right. In order to counteract this tendency of the muscle, the head was confined, by means of an appropriate apparatus, to the chest in such a manner as to keep the chin permanently inclined towards the left side. The muscle being thus relaxed, the fragment retained its proper position, and gradually united by ossific matter. When the bullet is firmly imbedded in the bone, the best plan is to remove it at once with the trephine. If allowed 1o remain, it would only be productive of mischief. A similar procedure should be adopted when there is imprisoned necrosed bone. SECT. YI SWORD AND ARROW INJURIES OF THE HEAD. Fractures of the skull inflicted with the sword, sabre, or Indian arrow, are generally of a very grave character, usually proving fatal, either from shock, hemorrhage, or inflamma- tion. A sharp arrow, as I am informed by Dr. T. C. Henry, of the Army, will cut a hole into the skull, owing to the great force and velocity with which it is propelled, without apparently any fracture whatever, producing a kind of incised wound, which, however, is very liable to be followed by death. Fig. 24 affords a good illustration of such an in- jury, from a preparation in the Army Medical Museum at Washington. When the head of the missile protrudes very little effort will generally be required for its extraction. A portion of the outer table of the skull, or even of its entire thickness, is sometimes sliced Fig. 24. Fig. 25. Indian Arrow penetrating the Temporal Bone. Sabre Cut of Parietal Bones. off by a sabre, hatchet, or sword, hanging, perhaps, merely by a narrow flap of scalp, as in fig. 25. When this is the case, the parts should immediately he replaced, and secured by suture, in the hope of their speedy reunion. Wounds of this kind, apparently of the most desperate character, are sometimes hap- pily recovered from. A case related by Ambrose Pare admirably illustrates the truth of this remark. “A party,” he says, “ had gone out to attack a church where the peasants of the country had fortified themselves, hoping to get some booty of provisions; but they came back very soundly beaten, and one, especially, a captain-lieutenant of the company of the Duke de Rohan, returned with seven gashes on his head, the least of which penetrated through both tables of the skull, besides four sabre wounds in the arm, and one across the shoulder, which divided one-half of the shoulder-blade. When he was brought to the quarters, his master, the duke, judged him to be so desperately wounded that he abso- lutely proposed, as they were to march by daylight, to dig a ditch for him, and throw him into it, saying that it was as well that the peasants should finish him. But being moved with pity, I told him,” says Pare, “ that the captain might get cured. Many gen- tlemen of the company joined with me in begging that he might be allowed to go along with the baggage, since I was willing to dress and cure him. This was accordingly granted. I dressed him, and put him into a small, well-covered bed, in a cart drawn by one horse. I was at once physician, surgeon, apothecary, and cook to him, and, thank God, I did cure him to the admiration of all the troops, and out of the first booty the men-at-arms gave me a crown apiece, and the archers half a crown each.” 76 INJURIES AND DISEASES OF THE HEAD. CHAP. I. SECT. VII WOUNDS OF THE MAIN AND ITS MEMBRANES. Wounds of the brain and its membranes may be produced in various ways, or by what- ever is capable of causing fracture of the skull. From the character of the weapon by which they are indicted, they may be incised, punctured, lacerated, contused, or gunshot. They may occur without fracture, as when they are the result of contre-coup, but the most severe varieties of the injury are always associated with fracture and wound or laceration of the meninges of the organ. As stated under the head of concussion, this lesion is not unfrequently complicated with laceration of the cerebral substance, exhibiting itself in the form of a rent or fissure, often several inches in length. Such an occurrence is by no means uncommon at the base of the brain from fracture by contre-coup, as it is some- times termed, as when a person falls from a great height and alights upon the top of the head. A severe wound of the brain is occasionally caused by depressed bone, or by a spicule of bone driven down into the substance of the organ. Punctured wounds in the adult are generally confined to the anterior lobes of the brain, and are usually inflicted with narrow, sharp-pointed instruments, such as a fork, pen-knife, stick of wood, dirk, bayonet, and the like, thrust across the orbital plate of the frontal bone. Children, before the completion of ossification, may be injured in a similar manner through any portion of the skull. A case has been communicated to me of a punctured fracture of the skull, by a long nail penetrating deeply into the brain, in a lad six years old. The child, in fall- ing from a considerable height, struck the top of his head against the nail, which was thus driven nearly two inches into the left hemisphere. In another case, vyhich I saw along with Dr. Rogers, a child four years old fell, head foremost, upon the point of an iron fence rail, receiving a frightful wound of the brain, and literally impaling himself. The cranial bones were extensively comminuted, and a large quantity of brain escaped during the removal of the loose fragments. Convulsions soon followed, and recurred, with more or less frequency and violence, up to the time of death, eighteen hours after the accident. A badly punctured wound is sometimes inflicted upon the skull of a child by the spur of an infuriated cock. The brain has been known to be traversed from one extremity to the other by a ball, bayonet, dirk, sword, or other weapon. Occasionally, again, the vulner- ating body is retained in the organ. Thus, a ball, the but-end of a pistol, pieces of iron, fragments of bone, and various other substances, have been found within the skull, in con- tact with the surface of the brain, or lodged more or less deeply in the cerebral substance. What is remarkable, in such cases, is that the extraneous matter does not always speedily cause death. Instances, as stated in a previous page, are upon record of balls having become encysted in the brain, and afterwards remaining comparatively harmless. The usual tendency, however, of such bodies is to excite fatal inflammation. But the most formidable wounds of the brain are generally those which accompany compound fractures of the skull and extensive laceration of the meninges. They are usually of a lacerated and contused nature, are apt to be followed by copious hemorrhage, and are frequently attended with purification and disintegration of the cerebral tissues, which sometimes escape in large quantity. The symptoms and effects of wounds of the brain vary according to the extent of the lesion, and also according to the particular parts implicated. When the lesion is compa- ratively small, and the cerebral substance is not too much mashed or contused, recovery is altogether within the bounds of possibility, and may, under judicious management, take place even readily. The great danger to be apprehended, in all cases, is encephalitis, with the formation of fungus, or protrusion of a portion of the brain. The mind is not necessarily affected, and the patient often recovers without any untoward symptoms. When the accident is more severe, the danger will, of course, be greater; but even here it is wonderful what little disturbance sometimes follows in cases apparently the most des- perate. Occasionally large quantities of cerebral substance are lost, and yet the patient makes a most excellent recovery, his intellect being not only not weakened, but, perhaps, improved by the occurrence. Such cases are, of course, uncommon, and are chiefly in- teresting as serving to show the extraordinary resources of the system in surmounting the effects of some of the most frightful accidents that can possibly befall it. In some of these cases there was even an absence of serious symptoms. Paroisse has given an account of twenty-two French soldiers, who, notwithstanding their vertices had been sliced off by sabre-strokes, along with more or less brain, were so free from suffering that they per- formed a journey of thirty leagues, one-half of the distance on foot, twelve finally recovering. When the wound involves the base of the brain, or the superior portion of the spinal CHAP. i. WOUNDS OF THE BRAIN AND ITS MEMBRANES. 77 cord, life may be instantly destroyed by the stoppage of respiration. The intellectual faculties are also more deeply affected, if not completely annihilated, and ultimate recov- ery is doubtful in any case, however simple. If the patient is so fortunate as to escape with his life, he will afterwards suffer from loss of bodily and mental power; the mind will be permanently crippled, some of the special senses will be weakened, if not abol- ished, and the limbs will be affected with paralysis and contraction, followed sometimes by the most disgusting deformity. Epilepsy is also of frequent occurrence. Wounds of the cerebellum are often followed by priapism and other evidences of inordinate sexual excitement. The prognosis of wounds of the brain and its membranes is too variable to admit of general specification. While in some cases, indeed in a great many, the slightest injury causes death, in others, attended, perhaps, with excessive shock, and the loss of a large quantity of blood and cerebral matter, the most prompt and satisfactory recovery occurs. Thus, in a case treated by my colleague, Professor Ellerslie Wallace, the fracture, inflicted by a circular saw, was four inches and a quarter in length by one-sixth of an inch in width, extending horizontally across the skull, along the coronal suture, wounding the brain, and dividing the longitudinal sinus; and yet the patient, a girl ten years of age, rapidly recovered without one untoward symptom. Another case, equally frightful, fol- lowed by an excellent cure, was reported in 1869, by Dr. A. C. Fulsom. A still more extraordinary instance happened in 1848, in the practice of Dr. J. W. Harlow, of Vermont; a case so unique that, if it were not well attested, its occurrence could hardly have been supposed to be possible. The accident took place while the man, who was twenty-eight years of age, was engaged in blasting rock, by the propulsion of a tamping iron, three feet seven inches in length by one inch and a quarter in diameter, and weighing upwards of thirteen pounds. The iron entered by its narrow extremity, near the angle of the lower jaw, on the left side, passing obliquely upwards behind and below the zygomatic arch, traversing the skull, the anterior lobe of the cerebrum, and the longitudinal sinus, and fracturing, as was supposed, the malar, sphenoid, temporal, and frontal bones, at the latter of which it emerged, just in advance of the coronal suture. Not- withstanding this horrible mutilation, the man made an excellent recovery as it respected his bodily health, but his disposition was so completely changed that he was ever after fitful, irreverent, vascillating, and impatient of restraint. He remained in this condition for twelve years and a half from the time of the accident, when he was seized with violent epileptic convulsions, in one of which he expired. No post-mortem examination was made. Wounds of the meninges are always very grave accidents, often as surely fatal as wounds of the brain itself. Even a mere separation of the dura mater from the inner surface of the skull, independently of any fracture of the bone or extravasation of blood, is usually a most dangerous occurrence. Such a lesion, even when the detachment is comparatively insignificant, is almost invariably followed by subcranial abscess, necrosis of the corre- sponding portion of the bone, and inflammation of the different membranes. The dura mater, which is more immediately concerned in the injury, is softened, thickened, injected, discolored, and incrusted with lymph. When the morbid action runs uncommonly high, sloughing will be apt to arise, followed by fungus of the brain, and a discharge of thin, foul, offensive matter. The membranes of the brain generally suffer more or less severely in comminuted frac- tures, from the ends of some of the fragments being forcibly driven into their substance, if not also into that of the brain. If speedy removal be not effected, they almost invari- ably cause violent inflammation in all these structures, attended with unnatural vascu- larity, deposits of lymph, effusion of serum, and, if the case last sufficiently long, the for- mation of pus. The subarachnoid tissue nearly always participates in the disease, as is shown by the turgid condition of its vessels and the presence of a greenish, sero-plastic material, which is often poured out in large quantity. Such lesions are necessarily always speedily fatal, whatever plan of treatment may be adopted for their relief. The treatment of wounds of the brain and its envelops must be conducted upon the most rigid antiphlogistic principles; great care, however, must be taken not to carry this plan too far, inasmuch as a certain amount of inflammation is absolutely necessary to insure the restoration of the injured structures. If the depletion be pushed to an inordi- nate extent, the system may be so completely exhausted by it as to be unable to furnish the requisite supply of blood and plasma to carry on the work of repair. Besides, it can hardly be doubted that very active measures, tending to add still further to the debility of the patient, can fail to prove prejudicial, by abstracting unduly the nervous influence of the brain, thereby seriously retarding, if not altogether preventing, recovery. On the 78 INJURIES AND DISEASES OF THE HEAD. CHAP. I. other hand, too much forbearance must be equally disadvantageous. Hence, a strictly middle course should be adopted, the practitioner not allowing himself too much free- dom on the one hand, nor exhibiting too much inactivity on the other. Having removed all extraneous substances, and placed the parts, if accessible, as nearly as possible in their natural relations, the patient is carefully watched, any tendency to overaction being at once arrested by the lancet, leeches, and other means. Early recourse is had, in all cases, to active purgation, the best articles for the purpose being calomel and jalap, or infusion of senna and sulphate of magnesium. When the patient has difficulty in swallowing, stimu- lating enemas must take the place of cathartics. Vomiting must, of course, be carefully guarded against, but when there is great dryness of skin, conjoined with an active pulse and excessive restlessness, there is no remedy more likely to promote perspiration, subdue vascular excitement, and tranquillize the system, than a solution of acetate of ammonium and aconite or veratrum viride, in union with morphia and tartar emetic, in the dose each of one eighth to the twelfth of a grain, frequently repeated until the object is effected. I am never afraid to employ either of the latter articles in wounds of the brain, after the system has been properly reduced by bleeding and purgatives, or when these means are rendered unnecessary by previous shock and loss of blood. The head, well shaved, is thoroughly elevated, and kept constantly covered with a bladder partially filled with pounded ice. Starvation is not carried too far, lest it should create irritability in the heart and brain ; at the same time great care is taken that the diet is perfectly simple and non-stimulant. All excitement is avoided, both during the active treatment and lor a long time afterwards. An unaccountable prejudice has generally existed against the exhibition of anodynes in wounds of the brain and its envelops. Early in the disease they are, no doubt, usually injurious, but after due depletion has been practised, or when marked exhaustion has been induced by shock, loss of blood, or other causes, they not only prove eminently useful, but are absolutely indispensable to quiet the system and place the affected structures in a suitable condition for repair. Their effects should, of course, be sedulously watched, and, in most cases, they may be advantageously combined with some diaphoretic, as ipecacu- anha, tartar emetic, or the neutral mixture. Cases occasionally occur in which a portion of brain is lost, and a piece of the broken bone is forced down beyond the surrounding level, so as to occupy its place. If, in such a condition, there are no symptoms of compression, it will be well, as was long ago sug- gested by Sir Astley Cooper, not to disturb the depressed fragment, as the operation would be very liable to be followed by undue inflammation and by the development of fungus, if not also by extravasation of blood, thus greatly lessening the chances of recovery. Any loose splinters that maybe present should, of course, beat once removed, especially if they impinge upon the brain and its envelops. SKCT. VIII FUNGUS OF THE BK AIN. This affection, at one time known as hernia of the brain, consists in a protrusion of cerebral substance through an opening in the skull, accompanied by a laceration of the brain and its envelops. It occasionally follows caries of the cranial bones and disease of the dura mater. One of the worst cases that I have ever seen was produced by syphilitic ulceration of the skull. When it supervenes upon external violence, it generally makes its appear- ance within a few days after the accident, and sometimes, indeed, almost immediately, especially when the cerebral lesion is unusually extensive. Its progress is commonly very rapid, the growth often attaining the size of a hen’s egg in less than a week. Pressure has a tendency to restrain it, and to limit its bulk. The form of the tumor bears a considerable resemblance to that of a mushroom, the expanded portion overhanging the skull, while the narrow, projecting through the abnormal opening, is connected with the brain below. Its surface is rough, incrusted with grayish, dirty colored lymph, and bathed with fetid, ichorous matter; in some cases it is studded with fungous granulations. The appear- Fig. 26. Fungus of the Brain after Fracture. C II A F. I . INJURIES OF THE CEREBRAL NERVES. 79 ances ot‘ cerebral fungus are well illustrated in fig. 2fi, from one of my patients. The frac- ture was situated at the outer and inferior portion of the frontal bone. If a section be made of the fungus, it will be found to be composed of a mixture of cerebral substance and plastic matter, sometimes the one, sometimes the other, predomi- nating. When the growth is recent and rapid, it is not unusual for it to contain small masses of clotted blood, similar to apoplectic depots of the brain. Its structure is usually very vascular, and it, therefore, often bleeds quite freely when cut, or even when roughly handled. Destitute of sensibility, it is elastic and compressible, moving synchronously with the pulsations of the brain. That this tumor is not composed entirely, or even in great measure, of cerebral tissue, is proved by the circumstance that, after death, the loss of brain does not at all correspond with the volume of the morbid growth and the repeated retrenchments to which it was subjected during life. If this were the case, we should often find the greater portion of one entire lobe destroyed, or, at all events, an immense cavern in the affected hemisphere ; but such, except in a few rare instances, is not the fact. The cerebral tissues around the tumor are always softened, discolored, and more or less infiltrated with serosity. It is impossible to confound this morbid growth with any other, its history, the rapidity of its development, and the peculiarity of its shape, being always sufficient to mark its character. The symptoms which accompany it are variable. The discharge is usually thin and ichorous, very profuse, and excessively fetid. Frequent bleeding occurs. The mind is sometimes affected from the very first ; at other times it is perfectly clear and calm for days and weeks together. In general, however, there is considerable cerebral disturbance, as indicated by the delirium and by the incoherent answers of the patient ; the countenance has a peculiarly vacant expression ; the skin is dry and harsh ; the pulse, seldom normal, is either too rapid, or, as more commonly happens, too slow ; the secre- tions are deranged ; the bowels are constipated ; and the sleep is interrupted by frequent starts and twitches. As the disease nears its close, coma and convulsions set in, and the patient dies, gradually exhausted, from nervous irritation. Recovery is an extremely rare occurrence in any case, however simple. In the treatment of this affection, in its earlier stages, before the tumor has made much progress at extrusion, well conducted, systematic compression constitutes the most im- portant feature. The object is to restrain the growth, and to circumscribe its limits. The pressure is made with a piece of compressed sponge, and a roller, changed as often as may be necessary to insure firmness and cleanliness. As the mass recedes, the sponge gradually sinks into the osseous opening, until it is reduced to the level of the brain. To prevent relapse, the pressure is steadily maintained, now, of course, more gently, up to the very point of cicatrization. When, through neglect or mismanagement, the protru- sion is unusually large, the redundant portion should be excised, or destroyed with the Vienna paste, or, what is preferable, the actual cautery, the parts being afterwards well protected. Offensive discharge is neutralized with chlorinated sodium, or permanganate of potassium. The patient’s strength is supported with tonics and a mild but nutritious diet. The head is maintained in an elevated position, and all excitement carefully avoided. Sometimes the fungous mass, becoming strangulated by the edge of the orifice in the skull, loses its vitality, and drops off; rarely, however, with any permanent advantage. SECT. IX INJURIES OF THE CEREBRAL NERVES. Fractures of the skull are not unfrequently attended by serious lesion of the cerebral nerves, which, in their passage through the different openings at the base of the cranium, are liable to be contused, lacerated, and even completely cut asunder by the sharp edges of the osseous fragments, or by the vulnerating body, as in gunshot and other injuries. The nerves most prone to suffer in this manner are the auditory and facial, as they lie in the internal auditory meatus. Sometimes the mischief is induced by the compression experienced by some of these cords from displaced bone or extravasated blood, whether external to them or within their neurilemma. Occasionally, again, the injury is mani- festly dependent upon mere concussion of the nerve-pulp. The symptoms attendant upon these lesions vary according to the nature of the affected nerve, as to whether it is one of motion, sensation, or respiration. When a nerve of mo- tion suffers, there must necessarily be paralysis of the parts supplied by it, the depriva- tion of function being either partial or complete, according to the extent of the injury. In fracture of the base of the skull, palsy of one side of the face is a frequent phenomenon, noticed from the earliest periods of the profession. Paralysis of the upper eyelid, teehni- 80 INJURIES AND DISEASES OF THE HEAD. CHAP. I. cally called ptosis, may be caused by injury of the third pair of nerves, more generally by pressure from extravasated blood than by contusion or laceration, both of which are very uncommon here. In some of the recorded cases of this affection, the ptosis was associated with dilatation of the corresponding pupil and paralysis of other parts of the body. The fourth pair of nerves, owing to its protected situation, enjoys a remarkable immunity from injury in fracture of the base of the cranium. When the fifth pair is wounded or compressed, the most important symptom is loss of sensibility of the face, accompanied, in severe cases, by a similar condition of the tongue and nose. When the sixth cerebral nerve is compressed or lacerated, convergent strabimus is liable to follow, from paralysis of the external straight muscle of the eye. Loss of hearing, sight, and smell ensues upon injury, respectively, of the auditory, optic, and olfactory nerves. It is worthy of note that facial paralysis may exist without deafness, and conversely. Injury of the pneumogastric, glosso-pharyngeal, hypoglossal, and spinal accessory nerves is at- tended with dyspmca, aphonia, dysphagia, and torpor of the stomach. Loss of smell may be caused by direct injury, as in fracture of the frontal and ethmoid bones, or indirectly, as when the injury has been inflicted upon the occiput or top of the head. In a paper by Dr. Ogle, on Anosmia, in the Medico-Chirurgical Transactions of London for 1870, two cases are reported in which this effect was produced by a blow upon the occiput, followed, as was supposed, by rupture of the olfactory nerves as they pass from the bulb through the holes in the ethmoid bone. A blow not violent enough to inflict serious mischief upon the anterior lobe of the cerebrum may, nevertheless, be sufficient to lacerate these nerves, owing to their excessive softness and delicacy. Anos- mia is sometimes associated with loss of taste, and the concurrence of anosmia and apha- sia is by no means uncommon. Some of these affections subside spontaneously or under the influence of appropriate medication ; others are incurable. When there is reason to believe that the cause of the trouble is compression from extravasation of blood, a mild course of mercury with iodide of potassium, and steady but gentle purgation, might be useful; but, under opposite cir- cumstances, the case is generally hopeless. SECT. X INTERCURRENT EFFECTS. Various affections are liable to arise after injuries of the head, more or less seriously complicating the original accident. Of these affections the most common are erysipelas, pyemia, pneumonia, hectic irritation, and profuse suppuration. Tetanus is a very rare occurrence. More or less traumatic fever, of course, generally attends, but of this no particular account need here be given. 1. Erysipelas, as an effect of injuries of the head, is exceedingly common, especially in camps and hospitals, in persons of dilapidated health and intemperate habits. It gene- rally comes on within the first three or four days of the accident, for the most part upon the scalp and face, but sometimes also upon the trunk and the extremities, and constitutes one of the most serious complications to which a patient, in this condition, is liable. It may follow the most insignificant as well as the most violent injury, as the merest scratch or puncture of the scalp, and is especially dangerous when it breaks out upon the head, from the proximity of the affected structures to the meninges of the brain. It often spreads with great rapidity, and terminates fatally in a very short time. Its advent is usually announced by rigors and high fever, speedily followed by delirium and a typhoid condition of the system. The treatment is by leeches, blisters to the scalp, and other antiphlogistic remedies. Anodyne and other supporting measures, as quinine, iron, and milk punch, will be required when there is excessive prostration. 2. Among the more common of the intercurrent effects of these injuries is pyemia, with abscesses and purulent effusions in different parts of the body, connected either very re- motely or not at all with the head. The organs which are most liable to suffer in this manner are the lungs and the liver. Collections of pus also sometimes occur within and around the larger joints, and in the connective tissue beneath the skin and among the muscles. Abscesses of the internal organs, especially of the lungs and the liver, may coexist with suppurative inflammation of the brain and its meninges, or they may occur entirely independently of it, as a result simply of inflammation of the intracranial contents, the scalp, the pericranium, or the osseous tissue. Pyemic abscesses are particularly liable to form in the lungs during the progress of in- juries of the head. The connection between injuries of the brain and abscesses of the liver has long been noticed. Many examples illustrative of the fact are to be found in 81 CHAP. i. INTERCURRENT EFFECTS. the writings of the older surgeons, more especially among the contributors to the Memoirs of the Royal Academy of Surgery of Paris. It was supposed, until a comparatively recent period, that the liver was more liable to suffer in this manner than the lungs ; but experi- ence has proved that this is not the case, the latter of these organs occupying a very de- cided precedence, as it respects the development of pyemic abscesses after all injuries, of whatever character. Thus, of eighteen examples of cerebral injuries observed by Mr. Prescott Hewett, abscesses were found in the lungs in thirteen cases, and in only three in the liver. The spleen and the kidneys rarely suffer. Marchetti met with an instance of pyemic abscess in the heart, after an injury of the skull. These secondary abscesses may follow upon the slightest as well as upon the most severe lesions of the head. A mere contusion of the scalp, so insignificant as hardly, at first, to attract any attention, has sometimes led to suppurative inflammation of the lungs, liver, and other internal organs. Concussion of the brain, the result of a slight blow, has been known to give rise to it. By far the most frequent cause of all, however, is in- flammation of the diploic structure of the skull, whether occasioned by an extension of disease from the scalp, or by direct injury inflicted upon the spongy texture itself, as when it has been more or less severely contused, or exposed by a gunshot fracture, the ball plowing through the outer table. The veins of the diploe, which are both large and numerous, readily take on inflammation in this condition, soon terminating in the forma- tion of thrombi, which, becoming disintegrated and being carried into the circulation, are arrested in the parenchyma of the organs, and thus lay, by the irritation they excite, the foundation of embolic abscesses. The period which intervenes between the primary injury and the supervention of these abscesses is frequently very short, not, perhaps, exceeding five or six days. On the other hand, a number of weeks may elapse. Ilennen has recorded a remarkable case of a woman in whose liver pus was found within less than two days of the receipt of a blow upon the head. The symptoms declarative of these secondary occurrences are usually of a very insidi- ous character, the most important being rigors, or creeping, chilly sensations, alternating with flushes of heat, high constitutional excitement, excessive restlessness, anil great pros- tration, rapidly followed by delirium and death. The diagnosis of this form of abscess in the lungs is very equivocal. The respiration is more or less embarrassed, as in ordinary pneumonia, but, as the abscesses are small, the pulmonary tissues admit air so freely as not to cause any material alteration in the res- piratory murmur, and in the sounds of the chest. In metastatic abscesses of the liver a jaundiced appearance of the skin and pain in the right hypochondriac region, along with bilious vomiting, have occasionally been noticed. Abscesses of the spleen and kidneys cannot be distinguished from other acute diseases of these organs. Purulent collections in and around the joints and in the connective tissue under the skin and among the muscles, are characterized by the ordinary phenomena. The prognosis is most unfavorable. In the more simple forms of pyemia, marked merely by chilly sensations and slight febrile movements, recovery is, I think, possible; but when abscesses form in the lungs and liver, or even in one of these organs, death is inevitable. These metastatic abscesses are usually very small ; but, on the other hand, often very numerous, especially in the more protracted cases, the great majority of them being situ- ated either upon the surface of the affected organ, or immediately beneath its lining mem- brane. The matter is of a whitish or yellowish hue, and generally of a thin, cream-like consistence, often interspersed with flakes of lymph. The surrounding tissues are soft- ened and abnormally red, and the veins are commonly occupied by fibrinous concretions. In the lungs these abscesses are sometimes accompanied by sero-purulent effusions in the pleural cavities, and in the liver, very generally, by suppurative portal phlebitis. The treatment of pyemia with its attendant abscesses must be of a supporting charac- ter, consisting of quinine, iron, carbonate of ammonium, brandy, and a good supply of fresh air, with a sufficiency of anodyne medicines to allay pain and induce sleep. External abscesses are opened in the usual manner. 3. Inflammation of the lungs, as an intercurrent disease in injuries of the head, is most common in elderly, dilapidated, and intemperate subjects, long confined in the same pos- ture, or the subjects of cold prior to the occurrence of the accident. Such cases should always be well watched, lest the inflammation make destructive progress before its true nature is detected. The treatment is conducted upon ordinary medical principles, cup- ping, vesication, and general supporting measures forming the more important remedies. • 82 INJURIES AND DISEASES OF THE HEAD. CHAP. I. 4. Hectic irritation is a common occurrence after head-injuries, more especially in com- pound fractures, involving the brain and its membranes, and attended with profuse dis- charge of pus. The symptoms characterizing this condition bear so close a resemblance to those attendant upon pyemia as to defy accuracy of diagnosis. The treatment must be largely of a supporting nature. 5. Tetanus is an occasional consequence of injury of the head, but much less fre- quently than is generally supposed. In the tables of Mr. Curling, embracing 128 cases of traumatic tetanus, the wounds in 11 were either on the scalp or on the face. The treat- ment calls for nothing of a peculiar character. ,6. The tendency to relapse, after injuries of the head, has long been familiar to sur- geons, and cannot be too strongly insisted upon. “ Slow as the brain is in some cases,” says Ilennen, “ to take on diseased action, it is amazingly irritable in others.” Hence, the patient cannot be too sedulously watched, or subjected to too rigid hygienic regula- tions, even after the most insignificant lesion, whether of the scalp, the cranial bones, or the brain and its membranes. Every symptom, however trivial, should not oidy be re- garded with suspicion, but most rigorously scrutinized, with a view, if possible, of deter- mining its pathological import. SECT. XI CAUSES OF DEATH. The causes of death in injuries of the head vary with many circumstances. Among the more common are shock, extravasation of blood, inflammation of the affected struc- tures, different kinds of fractures, erysipelas, pyemia, and tetanus. 1. More or less shock attends every case, however slight, of injury of the brain. When very severe, death may follow instantaneously, or, at furthest, within the first few hours, without, in many instances, the slightest attempt at reaction, the patient lying in a pale and unconscious condition from the moment of the accident up to that of dissolution. Or, reaction having occurred, the vital powers may again flag, and death ensue before the inflammatory stage is reached. 2. Extravasation of blood, causing compression of the brain, is a very frequent cause of death. When the quantity of blood is very small and the case does not present any serious complications, the brain may gradually accommodate itself to the adventitious mat- ter, eventuating in complete recovery ; but when the reverse is the case, the accident nearly always proves fatal, either during the first few days, or after the establishment of inflammation. 3. Encephalitis, especially if accompanied by inflammatory deposits, is almost invaria- bly fatal, the patient dying in a state of coma, preceded by paralysis and convulsions. 4. Fractures of the skull are always dangerous,.often not so much on their own account as on account of the injury that is inflicted upon the brain and its membranes. Punc- tured, compound and gunshot fractures, and fractures at the base of the skull, are a fre- quent cause of death, however judiciously treated, the patient dying either of shock, of hemorrhage, or of inflammation. 5. Death in injuries of the head frequently results from erysipelas and pyemia, the slightest causes occasionally provoking their attack. Congestion of the lungs is always a dangerous complication, especially in persons of advanced age, or even in the young, if compelled to remain for a long time in the supine posture. Tetanus is occasionally a cause of death, but much less frequently than is commonly imagined. G. The mortality after injuries of the scalp, skull, brain, and meninges is greater, other things being equal, in hospital than in civil practice, especially when, as in time of war, many wounded are crowded together in the same wards, without proper ventilation. 7. Operations performed for the relief of traumatic lesions of the head, as has been shown elsewhere, seldom prove fatal from any injury that is inflicted by them, but simply, or mainly, because of the serious character of the injury for w hich they are generally undertaken. Although this statement has many exceptions, yet, as a rule, it is believed to be perfectly true. SECT. XII SECONDARY AFFECTIONS. Injuries of the skull and brain, and, indeed, even of the scalp itself, are liable to be followed by certain affections w hich, as they come on at a variable period after the occur- rence of the original lesion, may be denominated secondary. These affections have refer- ence more particularly to the condition of the mental faculties, the special senses, the CHAP. i. SECONDARY AFFECTIONS. 83 muscular powers, and tlie functions of certain organs. They supervene upon the slightest accidents hardly less frequently than upon the more severe, and exhibit themselves in a great variety of forms, the precise nature of which it is often difficult, if not impossible, to comprehend or to interpret. That this should be the case is not surprising when it is remembered how little is really known respecting the functions of the various component structures of the brain. These secondary effects are sometimes observable at a very early period after the infliction of the injury, whereas at other times they do not appear until long after. Among the more common of the mental conditions is loss of memory. This often exists in a very remarkable degree, either by itself or in association with other affections. In the great majority of cases it refers only to recent events ; but occasionally it involves every circumstance in the history of the individual’s life, past and present. Sometimes he talks with all the garrulity of old age of the occurrences of his childhood, miscalls objects, or is unable to connect his words, or to pronounce certain letters. Instances have come under my observation in which the patient could not recollect his own name, the country of his nativity, or his present residence. Every student of surgery is familiar with the case recorded by Sir Astley Cooper, of a Welshman who, in consequence of a blow upon the head, completely lost his knowledge of the English language, which he had spoken fluently before the accident. One of the most distressing of the remote effects of injuries of the head is mental alien- ation. Of 500 cases of insanity analyzed by Schlager, the disease in 49 was directly traceable to the effects of concussion of the brain, the affection in 19 supervening within the first twelve months, and the others at a later period. The prognosis in such cases is always unfavorable. The most common morbid appearances observed in those who die after such occurrences are, bony deposits upon the surface of the skull, adhesions between the dura mater and the brain, subarachnoid infiltration, effusions into the ventricles, and local atrophy of the cerebral tissues. Occasionally the mind is merely weakened, or slightly crippled in some of its functions. A complete change of the moral feelings is sometimes noticed. Thus a person, instead of being gentle and quiet in his demeanor, as previously to the accident, may be morose, captious, or quarrelsome. Sometimes the effect shows itself in disturbed sleep, in frightful dreams, in excessive irritability of temper, or in inaptitude for business, the mind becom- ing blunted and incapable of the slightest exertion. Children sometimes suffer from chorea. Pain in the head, dizziness, vertigo, noises in the ears, and a haggard expression of the countenance, are among the occasional occurrences. Epilepsy is another, although, happily, an uncommon, sequel. Judging from personal observation, it is most common after fractures of the skull, attended with depression of bone. Special sensation is often greatly impaired, and, sometimes, even completely annihilated. Thus, there may be more or less deafness, impaired vision, contracted or dilated pupil, loss of smell, disordered taste, or diminished feeling in the skin. Or, on the other hand, special sensation may be unnaturally exalted. Of these accidents special mention has already been made in the section on injuries of the nerves. Aphasia is an occasional sequel of injury of the brain, more especially of its anterior lobes. The person, in this condition, is able to talk, but, not recollecting words, he fails to convey his meaning, or to render himself intelligible. Generally, indeed, he employs the same expressions whenever he attempts to speak. The distinction between aphasia, depending upon loss of memory, and the want of ability to articulate or talk, depending upon paralysis of the muscles of the tongue and lips, is readily determined by the fact that, in the latter case, the individual is always able to make himself understood by means of his pen. Occasionally both memory and speech are extinct. These affections, which have been ably investigated by Bateman, Falret, and others, are usually permanent. The effects of compression of the brain from depressed bone upon the bodily and men- tal functions are strikingly illustrated in the remarkable case recorded by Sir Astley Cooper. The subject, a sailor, had remained in a state of unconsciousness upwards of eleven months, in consequence of a fracture of the superior portion of the left parietal bone. When admitted into St. Thomas’s Hospital he was, in great degree, destitute of sensation and voluntary motion. When hungry he was wont to grind his teeth, when thirsty to suck his lips, and when he wished to relieve his bowels and bladder to move about in bed. His pulse was regular, but his fingers were in a constant state of flexion and extension, nearly corresponding in frequency with the heart’s action. During the removal of the depressed bone, he made a noise of complaint, and the motion of his hands ceased. A few hours after the operation he was able to sit up in bed, and put his hand INJURIES AND DISEASES OF THE HEAD. CHAP. I. to the wounded part when asked whether he was in pain. The next day lie could say yes and no, but had still some stupor. He gradually recovered ; and the last thing he remem- bered after the accident was taking a prize in the Mediterranean nearly one year before. Some very curious examples have been recorded in which injuries of the head were followed by great improvement, if not the actual restoration, of some lost function or special sense. Hyslop gives the case of an old lady who, after having been deaf from her infancy, permanently regained her hearing after a severe concussion of the brain. A similar case is mentioned by Liston. An old nurse, whose hearing had long been so obtuse as to compel her to discontinue her occupation, on recovering from a severe injury of the skull attended with concussion, experienced such acute distress in her ears that the slightest noise, even the ticking of the clock in her room, became a source of the greatest annoyance to her. A case of complete restoration to reason after an attack of insanity occurred to Desault. Pope Clement VI. found his memory greatly strengthened after a slight concussion of the brain. “ It is a well-established fact,” says Dr. Forbes Winslow, “ that idiocy, apparently irremediable, connate imbecility, has been cured by a blow upon the head.” The same writer relates the case of a woman who, on awakening from the effects of a slight concussion of the brain, caused by a fall from a third-story window, almost instantly recovered from an attack of acute puerperal mania, attended with exces- sive raving and restlessness. I have known several instances in which the intellect was wonderfully sharpened after the loss of a considerable quantity of cerebral substance. Mabillon, a Catholic priest, in his younger days an idiot, only obtained the full use of his mental faculties after he was trephined, at the age of twenty-six, on account of a fracture of the skull. His memory, it is said, became remarkably acute,and his imagination very lively. Among the more remarkable sequences of injury of the brain, especially of concussion, is an unnatural slowness of the pulse; the occurrence is most common in lesions of the base of the organ, particularly of the medulla oblongata, the bridge of Varolius, and the cerebral crura, and often persists for several months after the disappearance of all the other symptoms. A remarkable feature in this condition of the pulse is the readiness with which, when the patient is excited, it is changed into quickness. Sometimes the secondary effect manifests itself in a disordered condition of the liver, as denoted by the icterode state of the skin. Nausea and vomiting are occasional occur- rences; and at times the chief symptom is constipation of the bowels. When the gastric distress is uncommonly obstinate and protracted, it may be assumed that it is due to direct involvement of the pneumogastric nerves. The assimilative functions are some- times greatly at fault, the patient becoming gradually emaciated, and deprived of strength, notwithstanding a good condition of the appetite. Trouble in the urinary organs is occasionally experienced, consisting in irritability of the bladder, incontinence or retention of urine, and in various alterations in the composi- tion and quantity of the renal secretion, which is sometimes enormously increased, the occurrence usually manifesting itself within a short time of the accident, and generally disappearing in eight or ten days, although cases are met with where it continues lor several months. Traumatic diabetes is nearly always of the saccharine character, the amount of sugar being, however, commonly very small. An albuminous condition of the urine, with or without a diminution of urea, is occasionally noticed, especially after the more severe forms of injuries of the skull and brain. The occurrence of sugar in traumatic diabetes has been variously explained. Claude Bernard supposes that it is due to an increase in the abdominal circulation, in conse- quence of lesion sustained by the medulla oblongata, near the origin of the pneumogastric nerve, by which the excess of sugar in the blood of the liver is sent to the kidneys. Szokalski attributes it to concussion of the floor of the fourth ventricle, the glycogenic centre, if we may credit the results of the experiments of the French physiologist, lley- noso imagines that the phenomenon is caused by defective oxygenation of the blood and the imperfect destruction of the saccharine matter of that fluid. Whether any of these views are correct, remains to be determined. The genital organs sometimes suffer. Violent and uncontrollable sexual excitement, attended with incessant erections, occasionally occurs, generally as a consequence of injury of the back of the head, involving the cerebellum, and coming on soon after the accident. On the other hand, lesions of this kind may be followed by impotence, either with or without atrophy of the testes. Muscular twitches, and paralysis of certain muscles, are occasional occurrences after injuries of the head. They are most common in the muscles of the face and eyes, where they are often productive of great deformity. A whole limb, a hand, ora finger is some- CHAP. I. times paralyzed ; or, instead of being; paralyzed, there may be a want of coordination between certain muscles, thereby interfering with the normal functions of the parts. Lesions of the scalp are liable to be followed by unpleasant secondary effects, among the more common and distressing of which are neuralgia and morbid sensibility in the modular tissues, often difficult to cure, and, in the end, productive of more or less serious disorder of the general health. W hat the pathology of these various secondary affections is cannot generally be deter- mined, as dissection seldom throws any light upon it. They are, probably, however, in the great majority of cases, dependent upon local congestion, irritation, or inflammation of particular parts of the brain, or of the brain and its envelops, upon laceration of the cere- bral substance, upon the presence of extravasated blood, serum, or lymph, or upon injury of the cerebral nerves. Among the more remote effects of injuries of the skull and brain bearing directly upon their pathology, is one recently brought to light by the researches of Virchow. It con- sists in calcification and necrosis of the ganglion-cells, along with their processes, and sometimes also of the fine nerve-fibres in the cortical substance of the periphery of the brain. The change, which is of very frequent occurrence after fractures and fissures of the skull, is evidently due to the commotion experienced by the cerebral tissues at the time of the accident, and is often, if, indeed, not generally, associated with atrophic de- pressions, brownish cicatrices, red softening, or yellowish plates, not always discernible by the naked eye. The diseased ganglion-cells can only be detected with the microscope. The treatment of these various affections must, of course, be in great measure empiri- cal ; but, however this may be, it should always be particularly directed to the head and alimentary canal, consisting mainly of local depletion, quietude of mind and body, the administration of purgatives, an occasional emetic, counterirritation, especially of the pyogenic kind, and a careful regulation of the diet. A gentle course of mercury is some- times beneficial, and in most cases signal advantage will accrue from change of air, tonics, and the cold shower-bath, with dry friction. In the management of traumatic inflammation of the brain and of its envelops, both primary and secondary, special inquiry should be made, from time to time, into the con- dition of the more important viscera, particularly of the kidneys, as any serious intercur- rent lesion on their part may occasion symptoms closely simulating those produced by injury of the head, and thus lead to essential modifications in the diagnosis and treatment of the case. SECT. XIII TREPHINING. The circumstances which require this operation are :—1. Compound fractures with depression of the bone, with or without symptoms of compression. 2. Simple fractures with depression and symptoms of compression after a fair trial of ordinary means. 3. Punctured fractures, no matter what may be the condition of the brain. 4. Extravasa- tion of blood between the skidl and dura mater, or in the arachnoid sac. 5. The exist- ence of pus in the same situations, and in the brain. G. Foreign bodies. 7. Epilepsy, and other secondary effects. A singular case has been re- corded by Velpeau, in which the operation was performed on account of the presence of a lock of hair folded back upon the dura mater, and imprisoned between the edges of the fracture. In performing the operation, the patient is placed upon a narrow dining-table, or lounge, the head and shoulders being properly elevated by pillows, covered with a sheet and a piece of oil-cloth. If he is faint, the less the head is raised the better. The scalp being extensively shaved, the bone is exposed by a suitable incision, of which the semilunar, T-shaped, V-like, or crucial are the most common. Some- times the bone is so much denuded by the accident as to render but little dissection necessary. In no event should any portion of the scalp, however severely lacerated or con- tused, be cut away. The bleeding which follows the use of the knife either ceases spontaneously in a few minutes or is easily arrested by the ligature, although this should always, if possible, be avoided, as it has a tendency to interfere with the adhesive process. The periosteum, upon the in- TREPHINING. 85 Fig. 27. Application of the Trephine. INJURIES AND DISEASES OF THE HEAD. chap, i. tegrity of which the welfare of the bone so essentially depends, is cautiously dealt with, the flaps being, if practicable, drawn towards the sides of the wound, and carefully held there until the operation is completed. If more attention were paid to this subject, there would, I am sure, be much less danger of exfoliation of the bone; an occurrence which often greatly retards the cicatrization of the parts, and leads to much pain and inconveni- ence. All scraping is inadmissible. The crown of the trephine, of which there should be several sizes, is planted upon a sound portion of bone, as in fig. 27, to an extent just sufficient for the accommodation of the centre-pin, which is always protruded at the moment of the application. The instru- ment is then moved by semicircular sweeps from left to right and right to left, until it has formed a groove deep enough to maintain its place, when the pin is permanently retracted, lest, upon reaching the inner table, it pierce the cranial contents. The sawdust is re- moved from time to time from the trephine with a brush, or, what is preferable, a wet sponge, and from the track in the bone with a toothpick. Approach to the diploe, if any be present, is indicated by greater freedom of motion, a more abundant flow of blood, and a less grating sound. The instrument is now turned with more and more caution, and in such a way as to divide the inner table simultaneously at every point. There is no necessity for any hurry; the patient is frequently insensible from the acci- dent, or is rendered so by anaesthesia, and hence the whole proceeding is conducted in the most deliberate manner, the operator constantly bearing in mind that any injury, however slight, which lie may inflict upon the brain and its membranes, may seriously compromise the patient’s safety. The disk of bone often comes away in the saw : when it does not, it is readily raised with the finger, forceps, or elevator. All depressed pieces of bone are next raised, and all loose ones removed. The edges of the osseous orifice are smoothed with a raspatory, blood and other extraneous matter are carefully cleared away, bleeding vessels are tied, and the wound in the scalp is accurately secured by suture and plaster, a small interspace being left for drainage, unless there is the strongest reason to believe, from the appearance of the parts, that they will unite by the first in- tention. Over this dressing is applied a tolerably stout compress, confined by a roller, to support the beating brain, and prevent the occurrence of fungus. The annexed cut, fig. 28, represents the trephine which, from long habit in its use, I prefer to any other. It is a very beautiful instrument, and such is the facility with which it may be worked that, unless the skull is of extraordinary density, the operation may generally be accomplished in a very short time. The other instruments which usually accompany the trephine are a pair of Hey’s saws, fig. 29, or, more properly speaking, the saws of Scultetus, an elevator, fig. 30, a lenticular, fig. 31, and a raspatory. Fig. 28. Fig. 29. Common Fluted Trephine. Fig. 30. Different Forms of Elevators. Different Forms of Saws, TREPHINING. 87 CHAP. I. The old conical trephine, depicted in the works of Pare, Heist u-, and others, was re- introduced to the notice of the profession by Dr. Galt, of Virginia, in 18G0. It consists, Fig. 31. Lenticular. as seen in fig. 32, of a truncated cone, the surface of which is furnished with numerous sharp spiral teeth, which thus greatly facilitate the perforation of the bone, while the instrument, from its peculiar shape, ceases to act the moment the penetration is effected, and so prevents all risk of injury to the brain and its membranes. The saw of Scultetus may often he advantageously employed in removing an overhanging ledge of bone, thereby facilitating the elevation of the depressed frag- ments, so that the use of the trephine may, perhaps, be entirely dispensed with. Sometimes, again, a portion of the margin of the fracture may readily be chipped away with a small chisel and hammer, or a burr attached to the surgical engine. The treatment is particularly applicable to the comminuted form of fracture, attended with exten- sive splintering of the inner table. There are certain points of the skull where, if it be possible to avoid it, the trephine is never applied. These points are the frontal sinus, the anterior inferior angle of the parietal bone, the course of the longitudinal sinus, the occipital protuberance, and the different sutures. The reasons for this injunction are sufficiently obvious. Exposure of the frontal sinus might lead to a fistulous orifice, attended with a constant escape of air and mucus; at the second place indicated is the middle artery of the dura mater, running sometimes in a deep furrow of the bone ; at the top of the skull is the longitudinal sinus ; and in the occipital region there is not only inordinate thickness of bone, but danger of interfering with the lateral sinus. Should an operation at any of these situations become imperative, the greatest caution should be employed in its execution. When the frontal sinus is obliged to be penetrated, two trephines must be used, a large one for the external table, and a smaller one for the internal. The operation being over, the patient is placed in bed with his head and shoulders well elevated, and subjected to the most rigid antiphlogistic regimen. The great danger, of course, is inflammation of the brain and its meninges, and hence the head should be most diligently watched, in order that the earliest moment may be seized to counteract the slightest untoward occurrence. The dressings, which should be strictly antiseptic, are changed from time to time, as they become soiled, or a source of irritation, and great care is taken that the formation of pus beneath the replaced scalp does not become a cause of cerebral oppression. Should this be found to be the case, the dressings must immediately be removed, and, if necessary, a puncture made through the superimposed parts, to afford a proper outlet to the pent-up fluid. The opening left by the trephine is generally closed by fibrous tissue ; sometimes by fibro-eartilage,and occasionally, although very rarely, byathin stratum ofosseous substance. The site of the injury is ever afterwards indicated by a depression in the skull, and for a long time the pulsations of the brain are perceptible through the adventitious structure. As this matter remains weak and thin for years, and, consequently, affords but a very imperfect protection to the brain, the opening should be kept constantly covered with some suitable contrivance, as a piece of leather, silver, or gutta-percha. For want of this precaution, fatal accidents have occasionally occurred. Trephining in civil practice has been followed by different results in the hands of different surgeons. In general, they are anything but flattering. In the hospitals of Paris and Vienna the operation is nearly always fatal ; in London, Dublin, Edinburgh, Glasgow, and other large cities of Great Britain, the mortality, although also very high, is much less; and in the United States, the number of recoveries in proportion to the number of deaths is, as nearly as can be arrived at, as one to four. From the statis- Fig. 32. Conical Screw Trephine. 88 INJURIES AND DISEASES OF THE HEAD. chap. i. tical accounts by Dr. Lente of fractures of the skull in the New York Hospital, it appears that eleven cases out of forty-five that were subjected to this operation were cured. Of 626 cases of trephining for injuries of the head, collected hy Dr. Bluhm, 307 recovered, and 319 died. There is reason to believe that the greatest success of the tre- phine is to be found in private practice. My own experience has furnished ine with a number of excellent recoveries, and many other surgeons have been equally fortunate. In forty-six cases in the hands of Professor Briggs, in which the trephine was employed for the relief of recent fractures, forty-two recovered, and four died. The mortality of the operation will, of course, he materially influenced hy the nature of the case, the charac- ter of the existing complications, the habits of the patient, and various other circum- stances. The operation itself is not free from danger, as is proved hy the fact that it is often fatal when it is performed for the relief of epilepsy and other severe nervous symp- toms, although a distinction, I conceive, should he drawn between such cases and those involving recent injuries. The chief sources of danger are erysipelas, eneephalo-menin- gitis, pyemia, fungus of the brain, profuse suppuration, and hectic irritation. Perforation of the skull for the relief of injuries seems to have been attended with extraordinary success in the hands of some of the older surgeons. Thus, as is stated hy Guthrie, Saviard trephined one person twenty times. Martel and Le Gendre, surgeons to the King of Navarre, in 1686, took away nearly the whole of both parietal hones, and yet the patient made an excellent recovery. Marechal applied the trephine successfully twelve times ; Gooch thirteen times, and Desportes twelve times. In a case related by Schmucker, the operation was performed eleven times in less than one month, and so little, he adds, was the patient incommoded by it that he seldom even went to bed after it. But the most remarkable instance of the kind upon record, one which throws all others into the shade, was that of Philip, Count of Nassau, who, in a fall from his horse, struck his head against the stump of a tree, and fractured his skidl in several places. lie was trephined twenty-seven times by Henry Chadborn,a surgeon of Neomagen, to whom, after his recovery, he gave a certificate as a proof of skill. The most extensive use of the trephine, in modern times, was in a case referred to by Mr. Guthrie, in his work on “ Injuries of the Head,” as having been furnished him by Dr. Evans. The case was one of fracture of the skull, involving the internal table much more extensively than the external. 'Twelve perforations with the trephine were required before the depressed hone could be elevated, and even then the symptoms of compression were not relieved until some extravasated blood was evacuated by incising the dura mater. Complete recovery ensued. How remarkably tolerant the head occasionally is of great loss of hone, is shown in the cases recorded by Vigoroux and Saviard, in the former of which nearly the whole of the frontal bone, and in the latter almost the entire vault of the cranium, was destroyed, without causing death. Age is no bar to the use of the trephine. The operation has often been performed with the most gratifying results in old people as well as in very young children. The latter, however, rarely require such interference, as the skull, even if considerably de- pressed, generally, in a few days, rises to its natural level through its own resilient pow- ers, aided by the pulsative action of the brain. In a remarkable case, observed by Dr. Van Ingen, of Schenectady, a child,-only twelve months old, was successfully trephined on account of a punctured fracture of the skull caused hy a large nail, the disk of bone removed being nearly one inch in diameter. In performing the operation in early child- hood, the utmost caution is required, otherwise, as the skull is very thin, and destitute of diploe, there will he great danger of wounding the membranes of the brain, the more es- pecially as the dura mater always adheres with extraordinary firmness to the inner sur- face of the cranium. Trephining in Epilepsy Trephining is occasionally practised for the relief of epilepsy consequent upon neglected cases of depressed fracture of the skull. The first attempt of this kind was made hy La Motte, in 1705, hut only with partial success. In 1804, Mr. Cline, of London, recalled attention to the operation hy the publication of a successful case; and since then it has repeatedly been performed for this purpose both in Europe and in this country. Dr. Dudley in 1828 published a valuable paper upon the subject in the first volume of the Transylvania Journal of Medicine, in which he detailed the par- ticulars of five cases of epilepsy treated with the trephine, of which three were successful. The results of the practice of other surgeons have not, however, been so flattering. I have myself had occasion to perform the operation four times, with the effect of one cure and three deaths; and I have witnessed it in three other cases, all of which terminated CHAP. I. BANDAGES FOR THE HEAD. 89 fatally. Nearly all the patients perished within the first week from inflammation of the brain and its envelops, evidently induced, not by any direct injury inflicted upon these structures in the operation, but by the disturbance of the cerebral circulation consequent upon the removal of the depressed bone, notwithstanding the most thorough preparation of the system, and the most assiduous attention during the after-treatment. In one of my own cases, that of a man thirty-three years of age, whom I trephined at the College Clinic, in 1857, the cause of death was altogether unique. The depression, which had existed ever since he was eight years old, involved the upper portion of the parietal and frontal bones, being nearly two inches in diameter, by upwards of half an inch in depth at its centre. At the age of twenty-two, epileptic convulsions set in, and continued to recur, with increased severity and frequency, up to the time of the operation. Latterly his speech, memory, and general health had become so much impaired as to render him unfit for business. A large disk of the depressed bone being removed, the case seemed to progress favorably for forty-eight hours, when, stupor and spasms coming on, he gradu- ally lapsed into a state of unconsciousness, and died five days afterwards. The dissection revealed the existence of extensive softening of the cerebral hemisphere at the site of the depression and an enormous effusion of black blood, with an opening in the membranes of the brain large enough to receive the end of the index finger. This opening, noticed at the time of the operation, was produced by the pressure of a small exostosis on the inner surface of the injured bone, permitting a free escape of the cephalo-spinal fluid, both during and after the operation. The pressure upon the brain being thus removed, the diseased vessels at the seat of the softening gave way, thereby causing fatal apoplexy. Dr. Echeverria, in 1878, made an analysis of 145 cases of traumatic epilepsy, subjected to trephining, of which 93 recovered, 28 died, 18 were improved, 5 experienced no re- lief, and 1 was rendered worse. The chief causes of death after the operation were sup- puration and abscess of the brain, hemorrhage, and meningitis. Professor Briggs had, up to 1882, trephined the skull for traumatic epilepsy in 28 cases, with complete recovery in 22, partial relief in 3, and no benefit in one. For insanity caused by injury of the skull, he performed the operation in 2 cases, in l successfully, and in 1 followed by death. Finally, trephining is occasionally required for the removal of necrosed bone, perhaps incarcerated by an overlapping ledge of the cranium. In a case of this kind under my charge, the sequester was not only prevented from escaping, in consequence of the narrow state of the opening in the skull, but the irritation which its pressure exerted upon the brain and its membranes was such as to cause repeated attacks of epilepsy, which promptly and permanently disappeared upon the extrusion of the offending substance. SECT. XIV BANDAGES FOR THE HEAD. For simply retaining dressings, cataplasms, and lotions upon the head, the best con- trivance generally is a light handkerchief, arranged in the form of a nightcap, or a night- Fig. 33. Fig. 34. Recurrent Bandage. cap itself. The handkerchief being folded into a triangle, the centre of the base is applied to the forehead, and the body to the vertex, the tail hanging back over the neck. The side ends, lying upon the cheeks, are then carried backwards over the ears, crossed at the occiput, and tied in front, an inch above the nose, as represented in tig. 33. AY hen Handkerchief Bandage. 90 DISEASES OF SPINAL CORD, VERTEBRAS, AND BACK. CHAP. II. greater nicety is required, as when the object is to make moderate but equable compres sion, a double-headed roller should be used, after the fashion shown in fig. 34. Its application is thus described by Mr. Lonsdale: “The centre of the roller is placed low down on the forehead, and the two heads are carried back and made to cross low down beneath the occiput. One head is brought over the vertex, while the other is carried liorrizontally round to lap its extremity; and this, turned up over the horizontal one, is carried back to the occiput, slightly overlapping the former vertical band. At the occiput, the heads are again crossed, the surgeon shifting his hands for the pur- pose, and a third turn is made on the other side of the vertical band, while a third horizontal round secures it as before. This is continued until the whole head has been uniformly invested.” Fig. 35. Fig. 36. Four-tailed Bandage for the Head, The four-tailed bandage also answers a very useful purpose, especially for retaining dressings. Its application is shown in figs. 35 and 3G. It consists of a piece of soft muslin, linen or calico, of the requisite length, split up nearly to the centre, in such a manner as to form four strips, the anterior of which are carried back and tied under the occiput, while the posterior are fastened under the chin. In some cases the position of the tail is reversed, according as the middle portion of the bandage rests on the forehead, chin, or occiput. CHAPTER II. DISEASES AND INJURIES OF THE SPINAL CORD, VERTEBRAE, AND BACK. The most important surgical affections of the spinal cord are concussion, compression, sprains, inflammation, and wounds. The vertebra; are subject to curvature, tuberculosis, and congenital clefts, attended with protrusion of the arachnoid membrane, and consti- tuting what is called hydrorachitis. Fractures and dislocations of the vertebrae are dis- cussed at sufficient length in the first volume. SEC. I CONCUSSION. Concussion of the cord is produced by accidents similar to those which occasion con- cussion of the brain, as blows or falls upon the back, head, feet, or nates. The severity of the effect is usually in proportion to the directness of the injury ; but the most violent and protracted case of concussion of the spine I have ever seen was caused by a fall, in 91 CHAP. II. CONCUSSION. an elderly gentleman, upon the buttocks, from a height of about ten feet, down upon the floor. Railway casualties are often attended by grave lesions of this kind, not unfre- quently followed by a permanently crippled condition both of mind and body. The affec- tion exists in various degrees, and probably does not always involve the entire cord, being limited to particular tracts of it, or concentrated with special force at particular points. However this may be, the symptoms are commonly very characteristic. The patient feels sick at the stomach, looks excessively pale, and is altogether helpless, his body being more or less paralyzed. A sense of formication, stinging, or prickling, is experienced along the spine and in the extremities; the sphincters are relaxed, and, in the more severe cases, there are apt to be involuntary discharges from the bladder and bowels. Death may occur from the severity of the injury within a short time after its infliction, or, reaction taking place, the effects of the concussion may gradually pass off, the limbs regaining their functions and the sphincters their power of action. In some cases, how- ever, the mind remains bewildered for a number of days, the patient being partially de- lirious, but yet not sufficiently so to prevent him from washing and shaving himself, or even, perhaps, attending to business. Another remarkable symptom, which I have occa- sionally witnessed, after recovery from the more immediate effects of the injury, is exces- sive irritability of the bladder, attended with an almost incessant desire to pass water, which is generally greatly increased in quantity. Concussion of the spine is often followed by extravasation of blood, occurring either at the moment, or within a variable period after the accident. The extravasation will be most likely to happen when the lesion is complicated with fracture of the vertebrae, a par- tial dislocation, or a severe wrench of the ligaments. It may, however, follow upon, apparently, very trivial injuries, simply from rupture of the vessels from the effects of shock. The blood may, as in the brain, lie between the wall of the vertebral canal and dura mater, in the arachnoid sac, upon the surface of the cord underneath the pia mater, or in the substance of the cord, although the latter occurrence is very uncommon. The amount of extravasation varies, of course, in different cases, from a few drops to several drachms or even ounces. When the quantity is considerable, instantaneous paralysis in the parts below the seat of the effusion will be the result, either from its direct pressure influence upon the cord, or, indirectly, upon the roots of the spinal nerves. The paralysis may be complete or partial, and may affect both motion and sensation, or motion may be lost, and sensation be only slightly, if at all, impaired. In intramedullary hemorrhage, the symptoms of motor and sensory impairment predominate; while in extramedullary hemorrhage, the signs are those of motor and sensory irritation. In the worst forms of concussion of the spine, there is not only more or less effusion of blood in the situations here specified, but more or less extensive laceration of the lining membranes of the verte- bral canal, and also, at least in many cases, of the spinal cord and of the roots of some of the spinal nerves. The prognosis, in concussion of the spinal marrow, should be especially guarded, for no surgeon, however skilled in the art of diagnosis, can always tell, with any degree of certainty, the extent of the lesion. In the worst forms of the accident, death may be produced instantaneously, by mere shock ; or, reaction occurring, life may be imperilled by the conjoint agency of concussion and inflammation. Occasionally an apparently slight concussion causes death ; and, on the other hand, the most severe attacks may be recovered from. The restoration may be perfect, or some particular organ may remain in a crippled condition, manifesting itself in impairment, or, it may be, even in complete loss of function, as paralysis, or want of sensibility. Among the more uncommon effects of such lesions, after the patient has recovered from the more immediate effects of the accident, are hyperaesthesia and excessive mental irritability, accompanied by change of temper, and general disorder of the system, rendering the person unfit for active em- ployment. When the case is one of pure concussion, there is very little danger to be apprehended from secondary effects. There may, it is true, be some inflammation interfering with, or retarding, convalescence ; but, with proper care and a little treatment, the disease soon vanishes, and the relief is complete and permanent. But it is far otherwise when there has been effusion of blood, laceration of the cord or of its envelops, or serious injury of the bony structure of the vertebral canal. Few patients ever recover when thus affected. Nature, however, assisted by art, is seldom able to effect repair. The extravasated blood, if not very large, may eventually be absorbed, and function, temporarily arrested by its presence, be gradually restored ; but even such an occurrence is very uncommon, and can hardly be taken into the account in the consideration of the prognosis. Generally the 92 DISEASES OF SPINAL CORD, VERTEBRAS, AND BACK CHAP. II. more fluid parts alone are removed, the solid remaining, becoming organized, and keep- ing up injurious compression, thus interfering with the transmission of the nervous fluid. Various secondary effects are liable to occur after concussion of the spine, as neuralgia of different parts of the body, partial or complete paralysis, muscular twitches, defective speech, atrophy of certain muscles, arrest of development, imperfect sexual power, and a want of control over the sphincter muscles of the anus and bladder. Occasionally the patient is permanently affected with retention or incontinence of urine. The treatment of concussion of the spinal cord must be conducted upon the same gen- eral principles as that of concussion of the brain ; by recumbency and cordials, or mild stimulants, during the stage of depression, and by more than ordinary vigilance during the period of reaction, lest the excitement should transcend the healthy limits and pass into inflammation. If the patient can swallow, brandy and aromatic spirit of ammonia should be given, or, if the power of deglutition be lost, these articles should be freely injected into the bowel; all constriction should promptly be removed; the fan should be actively used; the naked surface should be rapidly struck with the end of a towel wrung out of iced water; and the precordial region, spine, and extremities should be covered with sinapisms. A full dose of chloral, either alone or combined with a quar- ter of a grain of morphia, will generally speedily arrest the irritability of the bladder and the tendency to inordinate renal secretion. The confused condition of the mind may usually very well be left to the operation of time, as little reliance is to be placed upon any mode of medication for its relief. Perhaps the best medicine, if any be given for the purpose, is bromide of potassium, in moderately large and sustained doses. After reaction is fully established, any tendency to undue excitement is promptly checked by the usual antiphlogistic measures; by the lancet, if the patient be strong and vigorous, or, if not, by leeches to the spine, purgatives, aconite, diaphoretics, and a re- stricted diet. Counterirritation by blisters is not neglected, if there is evidence of local- ized inflammation. Dry cupping is often very serviceable, and cases occur in which an ice-bag stretched along the spine is beneficial. Anodynes are given to allay pain, to pro- mote sleep, and to control the heart’s action. The remote effects of concussion of the spine are best combated by sorbefacient remedies and attention to the general health. Iodide of potassium and bichloride of mercury are the most trustworthy internal articles, and ammoniated lotions with veratria the most valuable external ones. In obstinate cases slight but persistent ptyalism will usually be necessary, aided by the application of the hot iron to the seat of the injury, indicated either by the existence of a tender spot of the spine, or by paralysis of the extremities. When the inflammation consequent upon the concussion has completely disappeared, and nothing remains but general debility, whether alone or combined with loss of motor power and sensation, great benefit will accrue from the steady use of nux vomica, iron, and quinine, with exercise in the open air, electricity, shampooing, the cold shower-bath, and the hot and cold douches. SECT, ir SPRAINS. The spine is composed of a series of joints, which, from the peculiar mode of their con- nection, admit of comparatively little motion, except in the cervical and lumbar regions. The ligaments are, for the most part, very short and strong, and the column, as a whole, is still further strengthened by the large muscles and firm aponeuroses which cover them in at the sides behind. Owing to these circumstances, it is impossible for a sprain to occur here without the application of great force, applied either directly to the part itself or indirectly through some neighboring part, as when a person falls from a considerable height and alights upon the buttocks or shoulders. Now and then, a severe sprain of the back is produced by a sudden twist of the body, as when the trunk is forcibly rotated upon its axis, the lower extremities being at the moment implanted in a hole in the ground. The extent of the injury varies. In some cases there is merely a stretching of the ligaments, whereas in others not only some of the structures, but also the muscles and aponeuroses of the back, are more or less contused, and, perhaps, even partially lacerated. In the more severe forms of the accident, as when, for example, a man receives a blow from the caving in of a sand-bank, a portion of the spine may be bent so forcibly forward or to one side as almost to break it. More or less blood is then generally poured out both into the vertebral canal and among the muscles, which, in consequence, often present a very bruised, ecchymosed appearance. Severe, however, as the sprain usually is, the spinal cord commonly escapes serious injury, the principal effect being concussion. The symptoms of this accident are generally well marked, if not positively diagnostic. Not infrequently there is excessive shock attended with partial paralysis of the lower 93 CHAP. II. WOUNDS. extremities. The pain at the seat of the injury is more or less violent, and is always mate- rially augmented by motion, pressure, and change of posture. The patient cannot raise liim- selt up without resting his hands firmly upon his knees, nor can he walk without being sup- ported by assistants. During recumbency his body inclines forward, and he is unable to extend his limbs or turn upon his back. A good deal of swelling occasionally occurs, and, when there has been much extravasation of blood, the skin, after a few days, exhibits a dark, mottled appearance. Sometimes there is bloody urine, from injury inflicted upon the kidneys; and it has been remarked that, if these organs be previously diseased, hema- turia may be produced by a very slight accident. Sprains of the spine, if at all severe, are always serious accidents. Death may be pro- duced by mere shock, as in concussion of the spine, or it may be a consequence of the secondary effects of the injury, such as a deep-seated abscess, inflammation of the cord and its coverings, or organic disease of the kidneys. Lesions of this kind are occasionally followed by stone in the bladder. In the treatment of this class of injuries, the first indication is to relieve shock, and the second to prevent undue inflammation. Recumbency and the use of cordials generally readily fulfil the former; the lancet, leeches, fomentations, and active purgation, the latter. If the patient is plethoric, blood should be freely taken as soon as reaction is established; the parts should be kept constantly covered with cloths wrung out of hot water, medicated with laudanum and acetate of lead; and Dover’s powder, or morphia and tartar emetic, should be administered in full doses, to relieve pain and promote perspiration. If the suffering is excessive, a large blister may be applied, followed by the hypodermic use of morphia. An ice bag often affords great relief. After the severity of the injury is abated, the most suitable topical remedies will be sorbefacient and anodyne liniments, conjoined with occasional dry cupping. When the patient is able to walk, a large opium plaster may advantageously be worn. SECT. III. WOUNDS. Wounds of the spinal cord may be of various kinds, and are extremely apt, even when of small size, to eventuate fatally, from their liability to be followed by inflammation and softening of the proper nerve-substance. Copious hemorrhage sometimes attends them, still further complicating the case by inducing severe, if not irremediable, compression. Very terrible effects are also frequently caused when the accident is accompanied by fracture of the vertebrae, with depression of the bone, which is sometimes driven across the cord in such a manner as to divide it as completely as if it had been cut with a knife. At other times, small fragments of bone are buried in the substance of the cord. Paralysis, partial or complete, temporary or permanent, necessarily attends all lesions of this description. When the injury is very considerable, it may instantly destroy life, especially wdien it is situated above the origin of the phrenic nerves. Gunshot wounds of the vertebra?, with lesion of the spinal cord, are nearly always, if not invariably, fatal. Of 22 cases of this kind in the hlnglish army in the Crimea, not one recovered. Even when the bones alone are injured, the danger is generally very imminent, most of the patients thus affected dying in a short time from inflammation of the cord and its membranes. When men fight behind trenches, terrible wounds, attended with excessive contusion and laceration of the muscles, are apt to be inflicted upon the back by shells, in consequence of the practice which they have, under such circumstances, of lying on the face while waiting for the explosion; such a position being regarded as the most safe. Of 157 severe cases of this description observed by the British surgeons in the Crimea, 20 died, 87 were sent to duty, and 50 were invalided. Dr. Otis has reported 642 cases of gunshot injuries of the vertebrae, in 628 of which the result was known. Of these 349 died, 175 were discharged from the service, and 104 were returned to duty. An excellent illustration of this class of injuries is afforded by a case of gunshot wound of the spinal cord, which I attended along with Dr. Thompson, in a gentleman, twenty- nine years of age, who was shot in the back with a pistol, the ball entering the left shoulder about two inches and a half below its top, and four inches and a half from the middle line. He instantly fell, and for a moment it was thought he was dead. It wras ascertained, however, that he had merely sustained a violent shock; there w’as but little bleeding, and reaction soon followed. Intoxication existing at the time of the accident, it was impossible to make out a satisfactory diagnosis. The hands could be moved, but the lower extremities were completely powerless. The next morning, when the effects of the liquor had passed off-, his body and legs were found to be completely paralyzed, and 94 DISEASES OF SPINAL CORD, VERTEBRAE, AND BACK. CHAP. II. he was deprived of sensation from near the top of the sternum to the soles of the feet. The pulse was remarkably slow; the breathing heavy and laborious. The bowels were torpid, and the bladder had to be relieved with the catheter. The mind was clear and composed. These symptoms continued until he died, at the end of three days and a half. On dissection, it was discovered that the ball, lying loose in the spinal canal, had entered between the last cervical and the first dorsal vertebrae, penetrating and pulpifying the cord, and cutting it in two by projecting across it a fragment from the injured bones. The annexed cut, fiS- 37, from a specimen in the Museum at Washington, affords an illustration of a similar occurrence. Fig. 37. Fig. 38. Dorsal Vertebras Fractured by a Conoidal Ball, which lodged in the Canal. Knife Wound severing the Cord opposite the Fifth Dorsal Vertebra. In another case, of which I have the particulars, but which I did not see, the ball entered near the right axilla, and, passing across the upper lobe of the corresponding lung, between the fourth and fifth ribs, cut the spinal cord in two, except a mere thread, and lodged in the body of the seventh dorsal vertebra. Immediate loss of motion and sensation ensued, and the patient, a man thirty years of age, perished on the eighth day. The subjoined sketch, fig. 38, from a specimen in the Army Museum, at Washington, represents a knife wound, severing the spinal cord opposite the fifth dorsal vertebra. A case, kindly communicated to me by Dr. W. W. Keen, shows how much injury the spine may sustain without a fatal issue. The patient, a soldier, was wounded at the battle of Gettysburg by a ball which, entering the upper lip, lodged in the body of the third cervical vertebra, apparently, comminuting it completely. Altogether about sixteen pieces of bone were at various periods removed or discharged, one of them including the anterior half of the vertebral foramen. At first paralysis of all the extremities existed, but this rapidly subsided after the extraction of the ball, and the man, who subsequently reentered the service, entirely recovered without any deformity of the neck, although nearly the entire body of the vertebra must have been destroyed. In the treatment of wrounds of the spinal cord, the great object should be to moderate inflammation, and to prevent effusion and other ill effects. If foreign matter be present, pressing upon the cord, it should, if possible, be removed, although in attempting to do this there may be great risk of increasing the original mischief. Trephining or resection will not be likely to be of any service, the operation, which has been tried in a number of cases in depressed fracture of the vertebrae, seldom having been productive of the slightest benefit, much less of complete recovery. Thus, of 35 cases, analyzed by Ash- hurst, in which the result was known, 30 died, 3 were relieved, and 2 were not improved. SECT. IV GENERAL EFFECTS OF INJURIES OF THE SPINE. Although fractures and dislocations of the spine have already been treated of under separate heads, it will not be amiss, in view of the great importance of the subject, to reproduce here, in connection with the lesions above described, some of the leading phenomena by which they are characterized. These phenomena necessarily vary a good deal, according to the seat, nature, and gravity of the injury by which they are produced, and, for this reason, it is very important that they should be examined somewhat in detail. Such a course, in fact, is rendered the more necessary on account of the recent advances in our knowledge of the anatomy, physiology, and pathology of the spinal cord. The inquiry, to be of any practical value, must embrace almost every organ of the body. CHAP. II. GENERAL EFFECTS OF INJURIES OF SPINE. 95 1. The mind, in injuries of the spine, is variously affected, depending upon the presence or absence of complications. In the great majority of instances it is perfectly clear and intelligent, from first to last. In two cases, lately under my charge, of paralysis of all the extremities, caused by falls, the patients retained the full possession of their mental faculties up to the time of death, the one dying within the first four days, and the other near the end of the second week. When the lesion is seated high up in the cervical portion of the spine, the mind is more liable to suffer than when the dorsal and lumbar divisions are affected, and this is also the case when the concussion which so generally attends such accidents has extended to the brain. Coma, spasms, and even convulsions, may arise if the patient be seized with spinal, or cerebro-spinal, meningitis. 2. Dyspnoea is generally a distressing symptom, more especially when the lesion is seated in the cervical, or cervico-dorsal, portion of the spine, from injury inflicted upon the cervical and respiratory nerves. When the lesion exists above the fourth bone, death is generally instantaneous, from interruption of the breathing. When the dorsal and lumbar sections of the cord are affected, the embarrassment of respiration is usually due to paralysis of the abdominal muscles, and to the accumulation of gas in the bowels, interfering with the movements of the diaphragm. In the more severe forms of these accidents, the lungs soon become engorged with blood, and stuffed with mucus, speedily followed by asphyxia. When dyspnoea occurs long after the accident, or as a secondary affection, it is to be viewed as an effect of the disorganization of the spinal cord, conse- quent upon inflammation, softening, atrophy, or fatty degeneration. 3. The vascular system, as shown by the state of the heart, is variously affected. Generally the pulse is soft, but abnormally feeble and frequent, seldom, however, above eighty or ninety in the minute. When the dorso-eervical portion of the spine is impli- cated, great slowness of pulse is not uncommon, a condition obviously due to the direct impression made upon the nerves of the heart. The pulse always rises in frequency, and often, also, in force, when the cord becomes inflamed, softened, or disintegrated. When the thoracic ganglia and the sympathetic nerves are involved, as occasionally happens when the lesion is seated in the cervico-dorsal portion of the spine, there will be apt to be, as Bernard and Sehiff have proved, unnatural vascularity of the pericardium, and serous effusion into the cavity of this membrane, but no appreciable lesion in the heart itself. In fatal cases the pulse always increases in frequency on the approach of death. 4. There is no regularity in regard to the nature or amount of involvement of the digestive organs, in injuries of the spine. Dysphagia may be present, when the lesion is seated high up, from paralysis of the oesophagus. Nausea and vomiting are uncommon. The appetite, generally impaired at first, often reinstates itself in a surprising degree during the progress of the case, especially in the milder forms of the accident. Tympa- nites and constipation attend nearly all injuries of the spine seated above the lumbar region. When the lumbar portion is involved, there is always, as a rule, loss of power in the sphincter muscles, with dribbling of urine, and involuntary fecal discharges. 5. The urinary organs never completely escape in any severe traumatic affections of the spine. Among the more common occurrences are, paralysis of the bladder, change in the quality and quantity of the urine, and inflammation of the mucous membrane of the bladder. These affections may be transient or permanent, in the one case lasting only for a few days, weeks, or months; in the latter, during the whole of the patient’s life, whether that be short or long. Paralysis of the bladder may be produced instantly, as when there is a violent shock, laceration, contusion, or compression of the cord, or it may come on gradually, as when it depends upon secondary extravasation of blood. However this may be, there is always, as a consequence of this condition, retention of urine, demanding the use of the catheter. Sometimes, as when the lumbar portion of the spine has been injured along with the dorsal or dorso-cervical, retention coexists with incontinence from paralysis of the sphincter muscle of the bladder. The urine, in paralysis, soon assumes an alkaline character, and, undergoing rapid decomposition, becomes excessively acrid, irritating, fetid, of a dark color, and loaded with thick, ropy mucus, not unfrequently intermixed with pus and phosphate of lime. In rare cases it contains blood, albumen, or even sugar. Renal casts may be present when there is serious involvement of the kidneys. The quantity of urine is occasionally much increased, and cases have come under my observation, apparently of pure concussion, in which there was excessive irritability of the bladder, with frequent micturition. The urine, instead of being alkaline, may be acid, or alkalinity and acidity may alternate with one another. When the fluid is uncommonly acrid, it may provoke not only violent inflammation of the bladder, but even gangrene of the mucous membrane, the sloughs passing away in 96 DISEASES OF SPINAL CORI), VERTEBRAS, AND BACK. CHAP. II small, dark-colored shreds, of an almost insupportably fetid odor. Suppression of the renal secretion is uncommon. 6. Disorder of the genital organs manifests itself chiefly in the form of priapism. The affection, which is most common after injury of the cervical portion of the spine, or of this portion and of the cerebellum, generally supervenes within a short time of the accident, and, in the more severe cases, persists up to the moment of dissolution. The erections are seldom perfect, the penis being rather in a turgescent than in a completely rigid condition, and they are usually, if not invariably, unaccompanied by voluptuous sensa- tions. In chronic paralysis of the lower extremities, consequent upon injury of the spine, the sexual powers are sometimes very vigorous, the person being able not only to cohabit, but to produce offspring, as in the remarkable case reported by the late Dr. Childs, of New York, referred to under the head of fractures of the vertebrae. 7. Motor paralysis is an almost invariable occurrence in injuries of the spine attended with displacement of the vertebra}, or with wound, contusion, laceration, or compression of the cord. Its extent varies according to circumstances. In the great majority of instances, it presents itself in the form of paraplegia; but, when the lesion is seated high up in the spine, it may affect all the extremities, as well as the chest, abdomen, and pelvis. Sometimes it is limited to one limb, or to certain muscles. The sphincter muscles, as stated above, always suffer when the lesion involves the lumbar sec- tion of the spine. Motor paralysis is occasionally associated with muscular spasms, more especially when the lesion depends upon slight compression of the cord. Occurring late in the case, they are sometimes denotive of a return of motor power. In chronic paralysis the muscles become soft, wasted, flabby, and the seat of the fatty trans- formation. 8. Anaesthesia is a very common symptom ; it usually exists by itself, but cases are met with in which it is associated with hypersesthesia. The latter occasionally exists aside from motor paralysis, and is often attended with intense suffering, the more especially when it involves the entire body. When it exists in a very high degree, it is sometimes attended with a cyanosed condition of the skin, and great throbbing of the arteries. Pain is a very common phenomenon ; it is generally referred to the seat of the lesion, and not unfrequently coexists with hyperaasthesia. Considerable diversity obtains in regard to the nature and the degree of the pain. Thus, it may be slight or severe, sharp, scalding, burning, or accompanied with a sense of constriction, pricking, or tingling. These affections are generally most distressing when an important nervous trunk of an extremity is involved, when the burning or pricking feeling sometimes extends to the very ends of the fingers or toes. 9. Certain affections of the eye, as originally pointed out by Brodie, and since by Ogle, Brown-Sequard, llendu, and others, are occasionally met with, chiefly, if not exclusively, in injuries of the cervical portion of the spine, involving the branches of the cervical and great sympathetic nerves, and manifesting themselves in contraction of the pupils, lachrymation, convergent strabismus, paralysis of the upper lid, and unnatural redness of the conjunctiva, accompanied with an increase of temperature of the neck and face, a flushed countenance, and more or less copious perspiration. In fractures and dislocations these phenomena are often directly chargeable to the presence of blood in the substance of the cord, intravertebral pressure, or disorganization of the nerve tissue from softening and inflammatory deposits. 10. A notable increase of vital temperature is not uncommon in these affections, coming on soon after the accident, and often continuing, with various alternations, up to the time of death. It is generally greatest in lesions of the upper portion of the cord, and is, probably, directly due to paralysis of the sympathetic, the great vaso-motor nerve. Varying in degree in different cases and in different conditions, it may be slight on the one hand, or very high on the other, as in the remarkable instance observed by Brodie, in which it amounted to 111° Fahr. It is occasionally associated with a most distressing sense of cold, particularly along the course of the spine and in the legs and feet, the patient feeling as if he would freeze. A persistent elevated temperature is generally de- notive of danger. 11. The nutritive functions are variously affected in these lesions. During the more acute stages, the body often becomes rapidly emaciated, the muscles are softened and attenuated, the fat is absorbed, and the skin is of a pale, sallow, almost icterode com- plexion. Great emaciation is frequently present even when there is no material disorder of the digestive organs, being evidently due to a want of proper assimilative power. The GENERAL EFFECTS OF INJURIES OF SPINE. 97 CHAP. II. joints in the paralyzed limbs gradually stiffen, and in many cases are eventually com- pletely anchylosed, the muscles and even the aponeuroses at the same time becoming per- manently contracted, thus greatly augmenting the deformity and the local suffering. In chronic cases, the patient, instead of being emaciated, often increases in flesh, and, at times, is even remarkably fat. 12. Bedsores are of common occurrence in traumatic lesions of the spine, no matter what portion may be affected. The parts most liable to suffer are the structures over the prominence of the sacrum, the tuberosity of the ischium, and the great trochanter, as it is there that the greatest amount of pressure is experienced in protracted decubitus accompanied with inability of change of posture. The great trouble, in such a condition, is that the patient is generally entirely insensible, and, therefore, unconscious of his dan- ger, until it has completely overtaken him. The first evidence of the local affection is a whitish, sodden condition of the skin, which soon assumes an ash-colored, brownish, or mottled appearance, and finally turns purple or black, the slough, as it drops off, expos- ing a deep, foul cavity, soon followed by a copious, fetid discharge and excessive pain, often sadly aggravated by the contact of the urine and liquid fecal matter. Diagnosis.—The diagnosis of traumatic lesions of the spine is generally very difficult; indeed, often impracticable, however carefully the parts may be examined. Sprains, fractures, dislocations, and wounds nearly always exhibit such striking similarities in regard to their phenomena as usually defy all attempts at a clear and satisfactory dis- tinction. Even the symptoms of concussion not unfrequently closely simulate those that attend these accidents. With respect to the probable degree of injury sustained by the spinal cord, immediate, complete, and permanent paralysis is commonly denotive of the complete division of the cord, or of its compression by depressed bone, extravasated blood, or of both of these causes combined. In pure, uncomplicated concussion there may be loss of power, but it is usually only temporary. When the paralysis is gradual, or does not appear until a short time after the receipt of the injury, the presumption is that it has been caused by effusion of blood. When it does not make its appearance until after the occurrence of spinal meningitis, it may be assumed that it has been occasioned by inflammatory deposits. Paralysis of all the extremities is an evidence that the lesion is situated high up, above the origin of the brachial plexus of nerves; when the inferior alone are involved it implies that the mischief is located below this point. Excessive dyspnoea, flushed countenance, contraction of the pupils and convergent strabismus, are denotive of lesion of the cervical portion of the spine, complicated with disorder of the sympathetic and respiratory nerves. Tympanites, constipation, and retention of urine are always present in serious injury of the dorsal or dorso-lumbar portion of the spine. Incontinence of urine, as a primary afFeclion, always exists in lesion of the lowermost por- tion of the cord. Priapism is generally a prominent phenomenon in injury of the superior portion of the spine, or of this division of the spine and of the brain. Some variety occasionally arises in regard to the side on wdiich the loss of motor power and sensation occurs, depending upon the nature and extent of the injury. In concussion the loss is nearly always symmetrical, although it may not exist in the same degree on each side. In wounds, on the contrary, as well, indeed, as in many cases of compression, whether caused by extravasation of blood or depression of bone, the effect may be unilateral, the paralysis and insensibility existing on one side, which may be either the sound or the injured, and instances are met in which there is loss of motion on one side and loss of sensation on the other. The extent of the loss of motion in these cases may generally be readily determined by the electrical test, which thus affords valu- able diagnostic aid. Professor Ashhurst has ascertained that more than one-half of the reported cases of spinal injury relate to the cervical region, upwards of one-fourth to the dorsal, and about one-tenth to the lumbar. Of 394 cases analyzed by him in 1867, 31 per cent, were dis- locations, 49 per cent, fractures, and 13 per cent, a combination of fractures and disloca- tions. His investigations show that dislocations are most frequent in the cervical region, and fractures in the dorsal. The diagnosis of the secondary lesions of the spine is not always so easily determined as might, at first sight, be supposed. The affections for which they are most liable to be mistaken are cerebral irritation, rheumatism, gout, and hysteria. Cerebral irritation, consequent upon injuries of the head, comeson at a variable period after the primary affections, generally in a stealthy, insidious manner, and usually mani- fests itself in irritability of temper, loss of sleep, cephalalgia, disorder of the digestive organs, partial paralysis, excited pulse, and other indefinite phenomena, difficult, if not 98 DISEASES OF SPINAL CORD, VERTEBRJ5, AND BACK. CHAP. II impossible, to be correctly interpreted. In some cases cerebral coexists with spinal irri- tation, more especially when the injury giving rise to it is seated in the cervical portion of the spine. When the spine alone suffers, the most trustworthy diagnostics are pain at some particular spot, increased by motion and pressure, rigidity of the muscles of the back, tingling sensations in the extremities, impairment of motor power, and the absence of cephalic symptoms. When the cerebral and spinal symptoms are nearly equally balanced, a correct discrimination is usually impracticable. The distinction between rheumatism and secondary traumatic affections of the spine is seldom difficult, the history, alone, of the case often sufficing to establish it. In rheuma- tism, the principal suffering is generally referred to the sacro-lumbar region ; the attack comes on suddenly; the urine, scanty and high-colored, is loaded with lithates; and there is nearly always concomitant pain in other parts of the body, particularly in some of the joints. In gout, the patient complains of diffused pain and tenderness in the spine, along with pain in the limbs and hyperaisthesia; and during the existence of these phenomena gout usually occurs in the toes and fingers. In traumatic lesions of the spine the symp- toms come on gradually, and progressively increase in severity; there is fixed pain with tenderness on pressure, usually corresponding with the seat of the original injury; prick- ling, tingling, or burning sensations are experienced in the extremities; sensibility and motor power are gradully impaired ; and the urine, although, perhaps, more or less acid, is measurably, if not entirely, free from lithates. From hysteria the diagnosis will be sufficiently easy when it is remembered that the attacks in this affection are usually very sudden and more or less emotional, that they are almost peculiar to females, that they generally depend upon disorder of some important function, and, finally, that they are always characterized by distinct intermissions. In spinal disease, on the contrary, the symptoms, coming on slowly and almost imperceptibly, proceed from bad to worse, in a steady, persistent manner, and are gradually succeeded by loss of sensibility and motor power. Prognosis.—Dyspnoea, flushed countenance, increase of temperature, priapism, and cerebral disturbance are unfavorable symptoms. The mortality is greatest in lesions affecting the cervical region, and least in the lumbar. Professor Ashhurst finds that of the 394 cases of spinal injury, above adverted to, the mortality in the former region was 77 per cent., and in the latter 59 per cent. Two-thirds of the fatal cases of injury in the cer- vical region perished within the first week. In the other regions the fatal result generally occurred at a much later period. The causes of death are variable. Many of the cases die from shock, some from congestion of the lungs, if not from actual asphyxia ; some from cerebral complications, and many from the secondary effects, as meningitis, disorder of the digestive apparatus, bedsores, and disease of the urinary bladder. When recovery takes place, the occurrence is generally denoted by a gradual return of sensibility and voluntary motion ; some particular spot of the skin, or some special muscle, perhaps affording the first evidence of the fact. Treatment—The treatment of these lesions having already been discussed in connec- tion with their respective characters, it only remains that 1 should insist here upon a few practical points, designed to promote the comfort of the patient, if not also his recovery. Of these, one of the most important is a good air- or water-bed, with cushions and bolsters of a similar kind. The ordinary bed, even if provided with the best horsehair mattress, will be sure soon to cause sores and to become foul and offensive from the discharges. Special care should be taken to prevent undue pressure of the hips and the sacrum, frequent examinations being made to ascertain their condition, the more especially as the patient, from his insentient condition, is unconscious of what is going on. Unless the greatest vigilance be exercised, frightful bedsores, often more destructive than the primary affec- tion, will be inevitable. The bladder should receive prompt attention, the urine being drawn off regularly three times every twenty-four hours. The instrument, which should always be passed with great gentleness, should never be retained in the organ ; first, because it might prove to be a source of mischief by its pressure upon the lining membrane, and, secondly, because it is very liable to be choked up with mucus, and to become incrusted with sabulous matter. Great care must be taken in regard to the patient’s posture. The respiration being generally much embarrassed, the diaphragm acts with difficulty, and, hence, any sudden change of posture, interfering with the breathing, might be followed by instant death. On no account must the patient be turned upon his abdomen. In no class of affections is attention to cleanliness of more vital importance than in these. From the constant tendency of the urine and fecal matter to run over the thighs CHAP. II. MENINGITIS AND MYELITIS. 99 and nates, it is almost impossible, even with best directed efforts, to prevent the forma- tion of bedsores. If such an occurrence should unfortunately arise, every means calculated to ameliorate suffering should at once be employed, the general principles of management being regulated according to the rules laid down in the chapter on affections of the skin, in the first volume of the work. In addition to the means there suggested, trial may also be made, especially in the earlier stages of these complications, of galvanism, as originally recommended by Crussel, and so successfully practised by Hammond, Wells, and other surgeons. Pain must be relieved by anodynes ; the diet must be light, concentrated, and nutri- tious ; and every effort must be made to prevent meningitis, or, to moderate it, if it have already taken place. After the immediate effects of the injury have passed off, the great point is to promote the absorption of effused fluids by the employment of sorbefacient remedies, as iodide of potassium and bichloride of mercury, or calomel and opium, and frictions with dilute ointment of biniodide of mercury, soap liniment with iodine, and similar preparations. Neuralgic pains are generally most promptly relieved by veratria ointment. When the patient is very nervous, great comfort will accrue from the employ- ment of the bromides, either alone or in union with chloral and oxide of cerium. Strych- nia is of no use in traumatic lesions of the spine ; and electricity seldom affords any mate- rial benefit. Trephining of the spine for the removal of depressed bone is sufficiently discussed in the section on wounds of the spine. SECT. Y MENINGITIS AND MYELITIS. The remark of Pott, that there is no injury of the head, however insignificant, that may not terminate fatally, is still more strikingly applicable to traumatic affections of the spine. How fully impressed the profession generally is in regard to the dangerous char- acter of these lesions may be gathered from what was said upon the subject, many years ago, by one of the most acute observers and sagacious practitioners of the present cen- tury. “ Every injury of the spine,” says Abercrombie, “ should be considered as deserv- ing of minute attention adding, very justly, that the more immediate cause of anxiety in such cases is from inflammation, and from the insidious manner in which disease so often declares itself, perhaps under circumstances in which neither the patient nor his attendant anticipated any ill consequences. Inflammation of the spine presents itself in two varieties of form ; in one as a strictly meningeal affection, and in the other as an affection of the cord, respectively known as meningitis and myelitis. Not unfrequently, however, the two diseases coexist, commencing either simultaneously or nearly so ; or, if the meninges are first involved, the morbid action, especially in cases that last for any length of time, eventually extends to the cord, or con- versely. Meningitis and myelitis may be either acute or chronic, but, as the latter is simply a milder condition of the former, with an abatement, but no material differences in the character, of the symptoms, no special notice of it will here be necessary. The starting point of acute meningitis is generally the pia mater, from which the dis- ease rapidly spreads to the arachnoid membrane, and sometimes even to the dura mater, although the latter often escapes entirely. The attack usually comes on within the first eight-and-forty hours after the accident, being ushered in by a chill, which is soon fol- lowed by high fever, rapid pulse, and other evidences of constitutional involvement. Pain is an early and prominent symptom ; it is felt most keenly at the seat of the inflamma- tion, is increased by motion but not by pressure, and extends along the course of the nerves having their origin in the suffering portion of the cord. The muscles are vari- ously affected ; at first, there are merely spasmodic twitches ; but these are soon succeeded by the most powerful contraction, especially of those of the back, causing great retrac- tion of the head, and an arched, inflexible condition of the spine, not unlike what is witnessed in opisthotonos in the worst forms of tetanus. Sometimes the head is power- fully drawn to one side. The patient is unable to lie upon his back, and his limbs, exqui- sitely painful and partially paralyzed, are strongly flexed, voluntary extension being impossible. The breathing is hurried and embarrassed, the pulse is small but frequent, the eyes are intolerant of light, the countenance has a painful and contracted expression, the bowels are constipated, and the bladder is unable to expel its contents. Hypenesthe- sia is generally present in a distressing degree. When the disease is seated high up in the spine, there is nearly always, as was long ago observed by Ollivier, involvement of the membranes of the brain, thus greatly augmenting the suffering as well as the danger of the case. As the inflammation progresses, delirium, coma, and convulsions, preceded by 100 DISEASES OF SPINAL CORD, VERTEBRAE, AND BACK CHAP. II . complete paralysis of the extremities, especially of the inferior, ensue, death being caused either by asphyxia or exhaustion. The most important symptoms of acute myelitis, at its commencement, are chilly feel- ings, more or less fever, and aching pains in the back and limbs, which rapidly increase in violence. Paralysis soon supervenes, often, indeed, in an almost incredibly short time, due apparently, in the first instance, to pressure of the cord by inflammatory effusions, and afterwards to the joint agency of inflammatory softening and deposits. Pain is always a prominent occurrence, usually most severe at the superior limit of the morbid action, and accompanied by a feeling of constriction, particularly distressing across the chest, as if a cord were drawn tightly around it. The state of the pulse varies; it is usually unnatur- ally frequent at the beginning of the disease, but after softening lias taken place it becomes slow and feeble. Anaesthesia generally exists in a notable degree, but, although this be true, the skin is often the seat of the most excruciating pain. Anomal- ous sensations of cold and heat are not uncommon ; and there are few patients who are not annoyed by a feeling of numbness, formication, stinging, pricking, or tingling in different parts of the body, especially in the hands and fingers, the neck, chest and face, the seat of these unpleasant symptoms being regulated by the seat of the inflammation. The thoracic, abdominal, and pelvic viscera suffer very much as in meningitis. When the cervico-dorsal region is involved, there will be more or less distress in the head, as pain, dizziness, vertigo, noises in the ears, and confusion of ideas with an early tendency to delirium. The diagnosis of these two affections is generally very difficult, if, indeed, not impos- sible. In meningitis there is usually a greater degree of muscular contraction than in myelitis, while in myelitis, on the other hand, there is generally earlier paralysis, with greater frequency of the pulse. The pain on motion at the seat of the inflammation is more severe in the former than in the latter, and the flexion of the extremities is also more distinctly marked. In meningitis it is more common to meet with cerebral com- plications. Delirium often sets in early in the disease, whereas in myelitis the mind often continues clear until the last. Reflex action and muscular contractility remain un- impaired so long as there is no involvement of the cord. In myelitis there is usually a more distressing sense of constriction around the body than in meningitis; the urine is almost invariably alkaline ; priapism is a very frequent occurrence ; and there is a greater tendency to the formation of sloughs, from the pressure of the body, with a marked depres- sion of temperature in the paralyzed limbs. The pain in myelitis is increased by percus- sion, and the application of a sponge wet with hot or cold water. In meningitis the pain is aggravated by motion but not by percussion or pressure. Both these forms of spinal inflammation generally prove fatal, death occurring at a period varying from three to ten days. If a dissection be made, the pia mater will be found to be unnaturally vascular, the ceplialo-spinal fluid greatly increased in quantity and more or less turbid from the intermixture of lymph, or lymph and blood, the arach- noid membrane opaque, and the meningo-rachidian veins distended with blood. Pus is seldom present, even in the more protracted cases. In chronic meningitis the dura mater is sometimes thickened and with great difficulty severed from its connections. When the inflammation is seated on the outside of this membrane, an abscess occasionally forms, the matter, if the patient survive any length of time, eventually discharging itself into the spinal canal, where it soon causes fatal irritation. In acute myelitis the most constant anatomical alterations are, unnatural vascularity and red or yellowish softening of the cord, not unfrequently amounting to actual purification of its substance, either central or peripheral, circumscribed or diffused. The vessels of the pia mater are turgid with blood, and the ceplialo-spinal fluid is cloudy, flocculent, and augmented in quantity. In the chronic forms of these diseases, the arachnoid membrane is generally opaque, not uni- formly but in spots of varying size and shape, some of which are very hard, thickened, and almost of a fibro-cartilaginous character. The cord, instead of being softened, is sclerosed, or one portion may be indurated and another softened. In the treatment of these two affections the main reliance of the surgeon must be upon absolute rest; the application of leeches in large numbers to the seat of the inflammation; and the administration of mercury, in sustained doses, with a view to the speedy produc- tion of gentle but decided ptyalism. Cases occur in which ergot and belladonna are bene- ficial. Pain must be mitigated, and sleep procured, by the free use of morphia. Diapho- retic anodynes, especially in the form of Dover’s powder, must be used if there be deficient action in the skin. Blisters, applied in rapid succession in different portions of the spine, and hydrogogue cathartics, are particularly valuable in spinal meningitis, attended with CHAP. II. DEFORMITIES OF THE SPINE. 101 serous or sero-albuminous effusion, after the disappearance of the more acute symptoms. In myelitis all remedial measures, except such as have a tendency to relieve pain and promote rest, are generally perfectly futile. In chronic spinal meningitis benefit occasionally arises from protracted pyogenic counterirritation, and the use of iodide of potassium in union with bichloride of mercury, five grains of the former with one-eighth of a grain of the latter constituting a reasonable average dose, repeated thrice in the twenty-four hours. The hot and cold douches, the cold shower-bath, electricity, frictions with the flesh brush, and inunctions of veratria ointment sometimes do good. Ergot and strychnia are, now and then, serviceable in imparting tone to the muscles, after the activity of the inflammation has been subdued. Great care must be taken to prevent the formation of bedsores, by the observance of cleanliness and the use of a water bed and other suitable appliances. SECT. VI DEFORMITIES OF THE SPINE. The spine is subject to various deviations, malformations, or deformities, known by the general appellation of curvatures. In order fully to comprehend the nature of these affec- tions, it is necessary to recall to mind tlie fact that the vertebral column, in the normal state, consists of two pyramids, united at their bases, and that it presents, when vihw'ed in profile, four distinct curves, all depending, except the lowermost, which is represented by the sacrum and coccyx, upon the different degrees of thickness of the bodies of the vertebrae and their fibro-cartilages in the different regions. Of these four curves, those of the neck and loins are concave behind, while those of the back and pelvis are convex, the reverse being the case when the column is viewed in front. This alternate arrange- ment of the curves is evidently designed for the more easy support of the superincumbent weight of the head and trunk ; for, if the spine were perfectly straight, the vertical pres- sure would be much augmented, and it would, therefore, require a proportionately greater amount of strength to counterbalance it. A slight degree of lateral deviation generally exists, in most cases even at a compara- tively early age, on a level with the third, fourth, and fifth dorsal vertebrae, with the convexity on the right side, in consonance with a law of development that the growth and power of an organ are in the direct ratio of its exercise. Now, inasmuch as most persons naturally use the right hand more than the left, it follows that the muscles on the right side are larger and more vigorous than those on the opposite, and that, con- sequently, they have a constant tendency to drag the bones in question out of their normal position. The abnormal deviations of the spine may be arranged under the three heads of lateral, posterior, and anterior, their relative frequency being in the order here stated. From this list I purposely exclude that form of curvature caused by tuberculosis, caries, or Pott’s disease of the spine, and generally known as angular curvature. These several deformities may exist singly, as the only departure from the natural standard, or, as not unfrequently happens, they may occur in connection with each other. However this may be, they are all due, as was long ago correctly remarked by Cruveilhier, to the following causes :—“ 1. The wasting of the vertebrae by caries or softening. 2. Want of equilibrium between the strength of the vertebral column and the weight of the body, either alone or when oppressed by burdens. 3. Muscular traction. 4. The frequent repetition of any attitude in which the column is bent.” 1. LATERAL CURVATURE. In lateral curvature, the scoliosis of the older authors, the deviation of the spine is to one side, and is essentially due to irregular muscular contraction, acting upon weakened bones, fibro-cartilages, and ligaments, and dragging them out of their natural position in sucb a manner as to induce more or less deformity. The side most commonly affected is the right, for the reason, probably, that most persons use the right arm much more than the left. Of 569 cases of lateral curvature, treated at the Royal Orthopaedic Hospital, of London, 470 were in this situation. I have myself seldom seen curvature on the left side as a primary disease. The causes which give rise to this irregular action on the part of the muscles, enabling those of one side of the middle line to overpower those of the opposite side, and so estab- lishing a tendency in the spine to deviate from the straight position towards the side of the stronger muscles, are of a diversified character, and possessing, as they do, important therapeutic relations, are deserving of attentive consideration. These causes may be 102 DISEASES OF SPINAL CORD, VERTEBRAE, AND BACK. CHAP. II. conveniently arranged under the following heads :—1. Affections of the muscles, as hyper- trophy, atrophy, inflammation, and spasmodic contraction. 2. Debility, either general or local. 3. Obliquity of the pelvis, from injury, disease, or malformation of the inferior extremities. 4. Altered capacity of one side of the chest, causing increased action of the muscles of the opposite side. 5. Rachitic softening of the bones. G. Defective develop- ment of the vertebrae. Hypertrophy of the muscles, as a cause of spinal curvature, may be induced in a variety of ways; often simply by excessive use of one arm, in the exercise of a particular avoca- tion. Blacksmiths, compositors, tailors, seamstresses, and dragoons are remarkably prone to this form of spinal disease. It is a law of the animal economy that muscles grow and expand in proportion as they are exercised. Hence, if, for example, the muscles of one arm are more developed than those of the other, the necessary result will be a loss of equilibrium, on the principle that the stronger always overpower the weaker, and, there- fore, just in proportion as this preponderance of action exists on one side will the spine, if the muscles so affected are attached to it, be drawn over towards that side. The mus- cles which are most liable to inordinate development from this cause, are the trapezius and rhomboid, which, acting directly upon the spine, completely overpower their fellows of the opposite side, causing thus a marked curvature, the convexity of which corresponds to the hypertrophied limb. An effect similar to the above is sometimes produced when the muscles of one side of the spine become atrophied while those of the opposite side retain their healthy condition. The balance between them being thus destroyed, it is easy for the muscles which possess the preponderance of power so to act upon the vertebral column as to induce more or less lateral displacement. Similar consequences ensue when the muscles become disabled by inflammation, as occasionally happens in rheumatism ; or, by paralysis, as in severe contusions, and in failure of nervous influence ; or, by spasmodic contraction, as in wry-neck, which, when- ever it exists in a high degree, is always accompanied by curvature of the cervical por- tion of the spine, occasionally in a very distressing degree. Debility of the muscles is undoubtedly the most frequent cause of all. It may be gen- eral or local; in the former case, affecting all the muscles, not only of the back, but of the rest of the body ; in the latter, chiefly the spinal muscles. Anything that depresses the vital powers must necessarily weaken the muscular system, and lead to irregularity of action, disqualifying it for the due performance of its functions. Lateral curvature may often readily be traced to the debility occasioned by protracted fever and exhausting discharges. The patient, on recovering from his illness, finds that the muscles of the back are too feeble to sustain the spinal column in the erect posture, and that, consequently, when he begins to walk, it is drawn towards one side, which is always in the direction of the muscles having the preponderating influence. Effects of a like character are produced by the use of unwholesome food, starvation, and inadequate clothing, eventuating in an impoverished and anemic state of the system. Among the more common exciting causes of local debility, considered in its relation to spinal curvature, are, fatigue of the muscles of the back from the protracted maintenance of the erect posture, and arrested growth from tight lacing. The evil effects produced by sitting daily for a number of consecutive hours, without any support for the spine, are well exemplified in young ladies at fashionable boarding-schools, and in young female operatives in crowded factories. The erector muscles of the spine, being continually kept upon the stretch, soon become exhausted, and by the constant repetition of the abuse are ultimately entirely disqualified for their task. If the child happens to be naturally feeble, or if she has become so by disease, the consequences of this practice are frequently most pernicious, the vertebral column being not only distorted laterally, but twisted more or less upon its axis. The effects of tight lacing are known to every surgeon, not merely in their relation to spinal curvature, but in their influence upon the general health. There is not an organ of the body that is not injuriously affected by the corset, or that does not resent the “ vile encroachment.” Circulation, respiration, digestion, and secretion are all brought under its dominion. The muscles of the back are seriously restrained by it. Hence, if the practice be continued for any length of time, they must necessarily become stunted in their growth, and irregular in their action, unfitting them for the healthful discharge of their respective functions, those of the one side being rendered stronger than their fellows of the opposite side, and so dragging the spinal column out of place. Obliquity of the pelvis is invariably followed, if long continued, by lateral distortion of CHAP. II. LATERAL CURVATURE. 103 the spine, particularly in the lumbar region. A good illustration of this coincidence is afforded in diseases and accidents of the hip-joint, in which, in order to throw the weight of the body upon the sound limb, the pelvis of the affected side is elevated, and a curve is formed in the loins, by the constant strain upon the spinal muscles. Affections of the knee-joint and bad habits in walking through which the weight of the body is borne prin- cipally by one limb, give rise to similar results. The effect of an altered state of the chest in producing spinal curvature is well exem- plified in what occurs in empyema and chronic pleurisy, where, in consequence of the compression and obliteration of the bronchial tubes, and the extensive morbid adhesions between the pulmonary and costal pleurae, the ribs sink in and lie almost in contact with each other, thus greatly diminishing the capacity of the thorax of the affected side, while that of the opposite side is proportionately increased. The shoulder cor- responding with the seat of the disease is notably depressed, and its muscles are so much weakened as to permit their fellows on the other side to draw the spine over in that direction. Rachitis is a common cause of lateral curvature of the spine, the bones being so weak as to be incapable of withstanding the action of its several muscles. This disease, which is essentially of an inflammatory nature, and which is almost peculiar to early childhood, is characterized by great deficiency of earthy salts, rendering the osseous tissue so soft and flexible as to be easily cut and bent in almost any direction. The vertebral column, of course, participates in the morbid action, and it is, therefore, easy to perceive how it must be effected by the various muscles which naturally influence and control its move- ments. Some of the very worst examples of curvature that are met with are produced in this manner, the spine being drawn not only sidewards, but backwards. Considerable lateral curvature of the spine is sometimes occasioned by an inequality in the length of the lower extremities, dependent upon disease, injury, or malformation. Finally, lateral curvature may be caused by defective development or malformation of the vertebrae, some of the individual pieces being either too small or too large, or so united as to meet only at particular points instead of at their entire surface, as in the natural state. The consequence of this arrangement is that the muscles of the spine, intent upon regaining their equilibrium, soon act unequally, those of one side overpowering those of the opposite ; not uniformly, but at different heights, so as to induce, perhaps, the very worst form of distortion. The extent of the curvature produced by these different causes is variable. Thus, it may be limited to one particular region, or it may involve one-half, two-thirds, three- Fig. 39. Fig. 40. fourths, or even the entire length of the spine. When the affection is very extensive, the curvature presents itself in the form of an Italic f, compensating curves being formed on Different forms of Lateral Curvature of the Spine 104 DISEASES OF SPINAL CORD, VERTEBRAS, AND BACK. CHAP. II. the opposite sides. In the more common cases of lateral curvature the deformity begins in the upper dorsal vertebrae, on the right side, in an abnormal development of the ser- rate, spinate, trapezius, and rhomboid muscles, which, overpowering their congeners of the opposite side, gradually drag the bones and everything that is connected with them over in the contrary direction, thus forming the first or middle curve of the series. The equilibrium between the muscles being thus destroyed, nature is not slow in her efforts at restoring it; but the only way in which she can accomplish this is by forming compen- sating curves, of which there are generally two, one in the lumbar region, and the other in the cervical, their development usually occurring simultaneously, and, of course, in a direction opposite to the primary. There are instances, however, although they are rare, in which one continuous curve exists on one side, evidently depending upon paralysis of the muscles on the opposite side. A sigmoid curve can never rectify itself, and hence such cases are often irremediable, simply because it is impossible to establish a counter- balancing power in the congenerous muscles. The external characters of lateral curvature of the spine are well displayed in tigs. 39 and 40. Lateral curvature, in its more .aggravated states, is always attended with marked rota- tion of the bodies of the vertebras, through which the spinous processes are directed towards the concavity of the curvature; the vertebral column is diminished in length in a degree proportionate to the lateral deviation, and the chest is materially altered in its figure, the ribs being flattened, elongated, and twisted, and the sternum and costal car- tilages tilted prominently forwards, and depressed towards the pelvis. The scapula on the side corresponding to the convexity of the thoracic curve is unnaturally full and elevated ; its upper border is directed forwards and inwards, while the inferior angle is carried outwards, and hangs off in a very unseemly manner from the side of the chest, in consequence either of the elongation of the latissimus muscle, or on account of the escape of the bone from beneath its surface. A lumbar curve always gives rise to obliquity of the pelvis, and a cer- vical one to obliquity of the head; so that there is occasionally, in reality, a quintuple curve. In the earlier stages of the affection, the curvature is formed chiefly at the expense of the intervertebral cartilages and ligaments; but, as it advances, the bones them- selves become involved in the disorder, some portions of them being absorbed, and others strengthened by the addition of new osseous matter. In old cases the bodies of the vertebrae at the seat of the curvature are usually completely consolidated, and rendered more or less rough by new osseous deposits. In some cases, again, the corresponding ribs are firmly anky- losed, or inseparably united to the sides of the affected vertebras. The annexed drawing, fig. 41, from a preparation in my collection, affords an excellent illustration of the vertebras and ribs in the milder forms of lateral cur- vature. The symptoms of lateral curvature of the spine are subject to considerable diversity, depending mainly upon the extent and duration of the lesion. In gene- ral, they are only such as are denotive of functional disturbance of the thoracic and abdominal viscera. In the milder cases, the patient experiences merely some degree of inconvenience in walking, becoming easily fatigued during exercise, and suffering from occasional palpitation of the heart, with, perhaps, some degree of uneasiness in breathing. Gradually, however, the general health begins to fail; progression, and the maintenance of the semierect posture, become more and more irksome; gastric and intestinal derange- ment supervene; the bowels ai*e apt to be constipated; pains are complained of in the side and back; dysmenorrhoea is often present; and the countenance exhibits a pale, careworn, and chlorotic appearance, indicative of the crowded and compressed condition of the thoracic, abdominal, and pelvic organs. Fig. 41. Lateral Curvature of the Spine. CHAP. XI. LATERAL CURVATURE. 105 Lateral curvature of the spine, to a slight degree, exists, as previously stated, in almost all persons on the right side, owing to the fact that nearly every one naturally uses the right arm much more than the left. Hence, the corresponding muscles are always more developed, and, acting with more vigor than their cogeners, usually draw the upper dorsal vertebrae a little over to the right; hardly, however, to an extent sufficient to deserve the name of disease. Considered as a morbid affection, it is most commonly observed in young girls, from the age of five to fifteen or eighteen, especially in such as are naturally of a feeble constitution, or whose health has become early impaired by want, exposure, and imperfect nutrition. The prognosis of lateral curvature is generally favorable when the affection is recent, or of slight extent, in a person of comparatively healthy constitution. Proper manage- ment will then usually often effect complete restoration, although the treatment will re- quire time and perseverance. Not unt'requently the mere rectification of a bad habit, causing an unnatural strain upon a particular set of muscles, will remove the complaint. When the affection depends upon extensive paralysis of the spinal muscles, organic disease of the vertebra or of their cartilages and ligaments, or serious lesion of the pelvis, hip, or knee, great improvement may be effected, but a complete cure will be difficult, and proba- bly impracticable. The prognosis is also unfavorable in cases of long standing, or where the affected vertebra are soldered together, or bridged over by new osseous matter. Treatment—The treatment of lateral curvature must be governed, in great degree, by the nature of the exciting cause; hence, before any measures are instituted for its relief, the most careful inquiry should always be made with reference to this particular circum- stance. So long as the cause under the influence of which the disease has been developed, is permitted to continue in operation, it will obviously be impossible to make any favor- able progress towards a cure. The mere discontinuance, temporary or permanent, of a particular avocation will often speedily overcome the affection, by enabling the muscles of the two sides of the vertebral column to regain their equilibrium, upon the loss of which the trouble depends. Thus, the lateral curvature which results from hypertrophy of the muscles of the right shoulder and arm of a blacksmith, from a want of proportionate use of the other limb, may even- tually be completely removed, if.early attended to, before there is any structural change in the bones, cartilages, and ligaments, simply by transferring the hammer to the left hand. The steady, daily exercise of the left limb will soon bring out the full strength of its muscles, while those of the right arm, now comparatively quiet and inactive, will gradually be reduced in volume and force, and so in time permit a restoration of the balance of power, and, along with it, a return of the spine to the straight position. Lateral curvature of the spine, contracted by girls at school and by children at factories, from a vicious habit of sitting, standing, or reclining, by which the vertebral muscles lose their equilibrium, can only be successfully cured by a reference to the nature of the exciting cause. The awkward and constrained position must be promptly rectified, and means adopted to improve the general health, when this has been suffering, by gentle exer- cise in the open air, sea-bathing, the cold shower-bath, and a properly regulated diet. Great attention must be paid to the gait in walking, so as to bring into full play the en- feebled and faulty muscles; the spine should be well supported while in the erect posture by a light and well-adjusted appliance; and the child should lie down frequently during the day, in order to afford complete relaxation and rest to the entire system, so conducive to comfort and the restoration of vigor. When the lumbar division of the spinal column is the primary seat, of the deformity, material benefit may be derived from the sloping seat of Harwell, which, by lifting the depressed side of the pelvis, tends to throw the curvature into the opposite direction. This action is well shown in one of his cuts, fig. 42, the deformity, represented by the dotted lines, having been almost rectified by the seat which inclines from the convex to the concave side of the curvature. As soon as the lumbar muscles in the latter situa- tion have become sufficiently strong, the same principle may be carried out by adding a cork sole to the shoe corresponding to the convexity of the curvature. The form of support best adapted to this condition is that of Harwell, fig. 43, in which gentle elastic force is employed in the direction of the radii of the curves. A band passing around the upper part of the thigh supports a pad of thin sole-leather or coutil on the hip, from the two upper angles of which a band of webbing, broadest over the most prominent portion of the curve, is carried around the loins. In front the band is rendered elastic by the insertion of a strong India-rubber ring. In the event of the compensating dorsal curve being well marked, or of the support exhibiting a tendency to slip, a second band 106 DISEASES OF SPINAL CORD, VERTEBRAE, AND BACK. CHAP. II. containing a rubber ring, indicated in the cut by the dotted lines, is passed in front and behind the body to a pad placed opposite the most prominent portion of the dorsal curve, and retained in position by a shoulder strap. Fig. 42. Fig. 43. Barwell’s Sloping Seat. Barwell’s Support for Lumbar Curvature, In primary dorsal scoliosis the best position is that which places the great serrated muscle on the side of the curvature at rest, and at the same time renders its inactive Fig. 44. Fig. 45. Barwell’s Support for Dorsal Curvature, opponent tense. These objects may be accomplished by directing the patient to carry the arm which cor- responds to the deformity habitually in front of the body, so that the hand shall rest on the opposite side of the waist, and the opposite arm behind the waist. In sleeping, the patient should lie on the affected side, with a small cushion under the axilla, the arm resting in front of the chest, with the hand on the opposite shoulder. The sloping seat will be found to be as beneficial in this as in the lumbar form of curvature. Of the exercises calculated to overcome the torsion of the vertebrae, and enforce the serrated muscle into action, the most useful is elastic traction combined with deep inspiration. Strong rubber cords, provided with handles, having been attached to the wall or an up- Apparatus for Self-suspension. 107 CHAP. II. LATERAL CURVATURE. right frame on each side of the sloping seat, the hand on the side of the deformity, car- ried in front of the body, grasps the handle of the opposite cord, while the other hand, carried behind the body, holds the handle of the cord on the side of the concavity of the curvature. While traction is made on the cords, the patient takes several prolonged in- spirations, through which the enfeebled serrated muscle is made to act on the corresponding ribs and rotate the vertebrae in a direction opposite to that of the abnormal twist. Another valuable aid to the treatment is swinging from two horizontal bars or rings, of which the upper, or the one intended for the hand of the concave side of the curve, is placed four inches higher than the lower. Expansion of the chest may also be attained by self- suspension, as originally recommended by Dr. Benjamin Lee, of this city, the hands being kept above the head, that on the side of the deformity being on a lower level than its fellow, as represented in tig. 44. In all of these exercises fatigue is carefully avoided, and the patient should lie for several hours a day in the semisupine posture, with a cushion under the projecting portion of the spine. Shampooing the back, night and morning, for thirty minutes at a time, gentle flagellation with the fringed ends of a wet towel, the alter- nating hot and cold douches, and electricity, are also of signal benefit in imparting tone to the weakened muscles, and cannot be dispensed with. The only support required in the early stage of the deformity is that of Barwell, fig. 45, the construction and objects of which are so apparent that they do not require description. When the affection is manifestly dependent upon debility or want of tone in the general system, tonics will be indicated, and should be of such quality and given in such quantity as may be calculated to improve rapidly the condition of the blood and solids. The various chalybeate preparations, either alone or in union with quinine or tincture of bark, generally produce an excellent effect, and should be administered, steadily and persistently, for several successive months; the dose being occasionally varied, or a new article added, to relieve the monotony of the treatment. When marked emaciation exists, cod-liver oil will come into play, and will often rapidly improve both flesh and strength. The diet should be judiciously regulated ; it should be perfectly plain and simple, but at the same time sufficiently nutritious in the smallest compass, so as not to crowd the stomach and bowels, or to interfere with the movements of the diaphragm and the expansion of the lungs. Fresh milk anti sweet cream should be freely used, together with an allowance of brandy, wine, porter, or ale, suitable to the age and condition of the patient. Frequent ablutions with strong soap and water, or some alkaline solution, followed by dry friction, the occasional employment of the shower-bath, and gentle exercise in the open air, or, when this is impracticable, swinging in a hammock, the body being in a perfectly passive condition, will be valuable adjuvants. Lateral curvature, depending upon obliquity of the pelvis, is not always curable, inas- much as the cause itself does not invariably admit of removal. When this is the case, the weakened spine may be supported by appropriate stays, and by attention to the posi- tion of the body in progression, standing, sitting, and reclining. Similar means must be adopted when the fault lies in the chest, as in retrocession of its walls from empyema and pleuritic adhesions. The treatment of rachitis, considered as a cause of spinal curvature, need not be par- ticularly discussed here, inasmuch as it has received sufficient attention elsewhere, it is essentially an inflammatory affection, associated with, if not directly dependent upon, im- paired nutritive action of the osseous tissue, attended with a deficiency of earthy matter, and consequent softening of the skeleton. The treatment must be alterant and tonic, and the spine must be mechanically supported until the bones have acquired a sufficient degree of solidity to enable them to resist effectually the influence of the muscles of the back. When the affection is caused by inequality in the length of the two limbs, it may in general be readily rectified by inclining the body habitually to the opposite side, and by increasing the thickness of the sole of the shoe by the interposition of a narrow piece of cork. Lateral curvature, dependent upon defective development of the vertebrae, requires early and persistent mechanical treatment, to sustain the weakened spine, and to afford the affected parts an opportunity of being moulded into a more suitable shape for the due performance of their functions. The occurrence, which is, fortunately, very rare, is apt to be overlooked until it is too late to benefit the patient. When the deformity is confirmed and incurable, much comfort may be derived from wear- ing some form of light, airy, and simple mechanical support, of which, probably, the best, is a sole-leather jacket, fitted upon a cast of the extended trunk, and perforated with nume- rous holes, as represented in fig. 46. When there is considerable displacement of the cervical vertebrae, a head-piece may be added. The apparatus may be worn day and night; and, 108 although it may at first prove irksome, such is the comfort derived from its use that the patient will soon be loth to be without it. The patient’s bed should be furnished with a smooth and elastic mattress, in order that the body may not sink into any hollows or depressions, at the same time that it should be sufficiently soft to insure the requisite comfort. The object, however, of this ar- rangement is not to confine the sufferer to her bed beyond the hours which are necessary for a due supply of sleep and repose after exercise. In the antero-posterior diplacement of the spine from caries, rest, and recumbency, absolute and unconditional, are enforced, and scrupulously maintained for many months ; here, on the contrary, rest and recumbency, although highly important, are not trusted to alone, but are carefully conjoined with gentle exercise in the open air, either on foot, in a carriage, or on horse- back, as may be found most convenient or suitable to the patient. The body, in short, must be invigorated, and the faulty muscles set in action by their appropriate stimulus, namely, motion, varied, diversified, and fre- quently repeated. Myotomy, as a remedy for the cure of this affection, is now seldom practised, experi- ence having shown that it is generally entirely useless. The only cases to which it is at all applicable are those in which there is marked contraction of the muscles and aponeu- roses of the spine, when it may occasionally be advantageously performed as an auxiliary to other measures. 2. POSTERIOR CURVATURE. This variety of spinal deviation, fig. 47, sometimes described under the name of excur- vation, gibbosity, or cyphosis—terms all more or less expressive of the nature of the deformity—is met with chiefly in young and elderly subjects, although it may take place at any period of life, as well as in both sexes, and in persons of every grade and occupation. The curvature, generally situated in the upper portion of the dorsal region, varies in degree from the slightest alteration of the natural form of the column to the most hideous de- formity. When it exists in its maximum de- velopment, the body is literally doubled upon itself, the head and neck projecting almost at a right angle with the trunk. Such a degree of distortion, however, is very rare, except in very aged persons, and is very uncommon even in them. Cyphosis of the lumbar and cervical regions is infrequent. Occasionally an instance of general cyphosis is observed, the whole column presenting an arched ap- pearance with marked concavity in front. The causes of cyphosis, especially as it oc- curs in children and young persons, are essen- tially similar to those of scoliosis. What- ever has a tendency to weaken the system, or to act injuriously upon the spine, may be re- garded as establishing a predisposition to the disease. Among the more common and effi- cient of these causes are rapid growth of the body, imperfect assimilation, spanemia, syphilis, rheumatism, scrofula, softening of the osseous tissue, and the waste consequent upon protracted and exhausting maladies. Certain trades and occupations, requiring a stooping posture, belong to the same category. Whenever, from these or from any other agencies, the spine is materially weakened, the weight of the head and the irregular ac- tion of the muscles will readily draw the vertebrae out of their normal relations, and thus occasion a correspondin'! decree of distortion. Hence, posterior curvature is very com- DISEASES OF SPINAL CORD, VERTEBRAE, AND BACK CHAP. II. Fig. 46. Apparatus for Lateral Curvature. Fig. 47. Posterior Curvature of the Spine. CHAP. II. POSTERIOR CURVATURE. 109 nion among tailors, shoemakers, engravers, scriveners, and persons of similar pursuits. The careless manner of leaning over books, and of sitting upon backless benches at school, with the shoulders and arms hanging forwards, is a frequent source of cyphosis. The deformity of the spine so often observed in old age is, apparently, a natural conse- quence of the “ wear and tear” of the body, and is, therefore, hardly to be viewed as a disease. The pathological changes in cyphosis vary, as in all other deviations of the spine, according to the nature of the exciting cause and the duration of the affection. When the disease is fully established, the bodies of the vertebrae, at the seat of the morbid action, will be found to be materially diminished in front, so as to impart to them a wedge-shaped appearance, while behind, where their nutrition is not impaired by the pressure, they retain their normal thickness, and are, sometimes, even partially hypertrophied. The intervening cartilages suffer in a similar manner. The spinous and transverse processes stand unnaturally apart, and the ligaments are more or less elongated. In protracted cases osseous bridges occasionally extend from the anterior surface of one vertebra to that of the other, and, now and then, the affected parts are completely ankylosed. All these changes are, as a rule, comparatively slight in young subjects and in ordinary cases of cyphosis. Changes of a not less important character are observed in the chest and pelvis. When the gibbosity is seated in the dorsal region of the spine, the ribs are not only drawn back by the affected bones with which they are connected, but are rendered more prominent and angular behind, while their bodies, forced almost in contact with each other, gradually assume an elongated, rounded appearance; sometimes they are very much contorted, or twisted upon their axes. The sternum is remarkably prominent, and is either hollow or convex in front, according as it is bent at the sides or at the extremities. The shoulder- blades hang off from the trunk in an awkward, unseemly manner, being greatly depressed anteriorly, and very salient behind, where they almost approach the spine. In cyphosis of the loins, the pelvis is often sadly distorted ; it loses its obliquity in front, and assumes almost a horizontal direction. When the distortion is very low down, the sacro-vertebral angle is sometimes nearly entirely effaced. Finally, the muscles of the back, elongated and inactive, are pale, wasted, flabby, and partially transformed into fatty matter. The symptoms of cyphosis are not doubtful. A careful examination, made while the patient is divested of his clothing, will generally at a glance detect the characteristic deformity. The gibbosity will be more or less marked, according to the nature of the exciting cause and the duration of the case, but is never as abrupt or distinctly defined as in angular curvature dependent upon Pott’s disease. It is, as before stated, usually most conspicuous in the upper part of the back, or in this situation and in the lower cervical region, and seldom involves less than from three to five of the vertebrae. In the more aggravated forms of the affection, the head is sunk down, as it were, between the shoul- ders, which are themselves more or less deformed and displaced ; the arms hang awkwardly along the sides; the chest, elongated in the antero-posterior diameter, and diminished in the transverse, is narrowed in front, and expanded behind; the abdominal muscles are contracted; and the distance between the ensiform cartilage and the pubic symphysis is sensibly lessened. In cyphosis of the neck, the head inclines forwards, and the chin almost approaches the sternum, thus imparting a singular expression to the physiognomy. Long before the changes now described are fully fbrrned, evidence, more or less well marked, usually exists of the mischief that is going on in the spine. The general health is commonly found to be at fault; the patient is weak and unable to bear his accustomed exercise; the countenance is pallid ; digestion is impaired; the bowels are irregular and distended with gas ; the appetite is vitiated ; there are frequent acid eructations ; the urine is high-colored, and often alkaline; the sleep is disturbed and unrefreshing; the extre- mities are habitually cold; and various kinds of pains, with more or less tenderness on pressure, are felt along the course of the spine. Gradually the symptoms grow worse; exercise is either impracticable, or tolerable only at long intervals and in a slight degree; the erect posture is maintained with difficulty; and the patient becomes eventually fright- fully stoop-shouldered. When the disease is fully established, the deformity of the spine and chest existing in the worst degree, the functions of the heart, lungs, and abdominal viscera will be more or less seriously disturbed, from the compression to which they are subjected by the walls of their respective cavities. The prognosis of cyphosis varies with so many circumstances, general and local, as to render precision of statement entirely impracticable. The senile form of the complaint 110 is, of course, irremediable, while that of the earlier periods of life is usually, under proper management, perfectly amenable to treatment, and is often recovered from without any appreciable deformity. The result must, necessarily, in every case, be materially influ- enced by the nature of the exciting cause, by the duration of the complaint, and by the changes that may have taken place in the bony frame-work of the spine, chest, and pelvis. Treatment—In the treatment of this affection, three leading indications must steadily be kept in view : 1st. The removal of the exciting cause; 2 ana 4 u ~37 — FOREIGN BODIES IN THE EYE. Foreign bodies are liable to pass into the eye, and to bury themselves in its structures, where they at once become a source of suffering and imflammation. They are of various kinds, as scales of iron, bits of glass, particles of stone and coal, shot, splinters of wood, and gun-caps. Although every part of the organ may be thus injured, the cornea, from its exposed situation, is most frequently affected, the extraneous substance being either firmly imbedded in its lamellae, lodged immediately beneath its epithelial investment, or forced into the anterior chamber, one end, perhaps, presenting externally. Great care is often necessary to discover its presence, especially when it is very minute, when it is com- posed of metal, or when it lies immediately in front of the pupil, the black background of which has a tendency to obscure it, so as to prevent it from being easily seen. The best way to examine the part is to stand behind the patient, as he sits upon a chair fronting the window, and then, the lids being raised, make him move the eye about in different directions, thus enabling the light to fall upon its surface. In this manner no object, however minute, can possibly escape detection. The removal of foreign bodies from the cornea requires more skill and tact than is generally imagined. When the eye is much inflamed, the substance buried at a con- siderable depth, or the patient is a child, or a very nervous, irritable, or excitable person, Diagram showing Hypermetropia at a, Myopia at ft. FOREIGN BODIES IN THE EYE. 153 it will be well to perform the operation with the aid of anaesthesia, otherwise serious annoyance may he experienced. The upper lid being properly elevated, and the globe securely steadied by the finger, or in the event of amesthesia being employed, by toothed forceps, very much as in the operation for strabismus, a delicate cataract needle, the point of a lancet, or a spud, fig. 86, is insinuated around the foreign body, which is thus lifted out of its bed, without any digging, a process which cannot be too carefully avoided, on account of its liability to be followed by severe inflammation and extensive opacity. A scale of iron that has been retained in the cornea for a few days is liable to become oxidized; hence, it may break under the instrument, and require to be extracted piecemeal. When the foreign body is firmly imbedded in the layers of the cornea, it is best to make an incision over it, to its full length, with a cataract knife, and then to dislodge it with a small needle. When it has perforated the cornea so as to render it impossible to lay hold of it with the forceps, the puncture should be enlarged until this may be safely done. All officious interference, especially rude and extensive probing, is, of course, avoided in these cases, as it might prove worse than the retention of the extraneous substance. Small foreign substances are liable to lodge in the iris, where their presence invariably excites more or less violent inflammation, often speedily followed by the destruc- tion of sight. In the milder forms of these accidents, the extraneous body sometimes becomes encysted, and remains comparatively, if not completely, harmless for a long time, as in a remarkable case related by Dr. Jacobi, in which a piece of iron occasioned no uneasiness for thirty-four years, when excessive pain occurred with sympathetic irritation in the other eye, necessitating the removal of the affected one. The only course to be pursued, after such an injury, is to extract the foreign substance as speedily as possible, removing along with it the bruised and lacerated portion of the iris, the operation being conducted upon the same principle as an ordinary iridectomy. Among the more unfortunate accidents of this kind are lacerated wounds of the eye, made by fragments of gun-caps, which often pass through the iris into the vitreous humor, and cause violent and destructive inflammation, attended by almost insupportable pain, lasting as long as the foreign body remains in the organ. I have seen more than a dozen of such cases, in every one of which the sight was completely annihilated, while the suf- fering was of the most violent character. If probing of the eye is ever justifiable, it is under such circumstances; and 1 am not certain whether the foreign substance should not be extracted at all hazard. By putting the patient under the influence of anaesthesia, the operation may be conducted with comparative safety, and with great probability of success. A number of cases have been recorded in which foreign bodies have been removed from the vitreous humor, with preservation of the eye, and in a few instances, of a useful degree of vision. Probe-pointed magnets have been introduced into practice for the removal of particles of steel or iron from the interior of the organ. Severe injury of the eye is occa- sionally inflicted by small shot; and in time of war it is not uncommon for the organ to be wounded by bullets, pieces of iron, and splinters of wood. Destructive inflammation always follows the lodgment of such bodies, and the rule, therefore, is to get rid of them as speedily as possible. Dr. Gruellich, of Neugersdorf, has related a very curious case in which a rifle-ball re- mained in the eye of a man for twenty years. Its presence kept up constant irritation ; at the end of two years all trace of the cornea had disappeared, and the organ had con- tracted to one-half its original size. The missile, extracted through the sclerotica, was of an irregularly flattened form, and weighed five drachms and a half. The operation was followed by violent inflammation and complete atrophy of the eye. What should be the treatment when a foreign substance, lodged in the interior of the eye, cannot be extracted? When useful vision still remains, and the foreign body is creating no irritation, the case shonld be kept under close observation, and the patient advised to seek aid without delay when trouble arises in the sound eye. When vision is destroyed, and the foreign body is giving rise to destructive inflammation, the eye- ball should at once be extirpated to remove the cause of a probable sympathetic ophthalmia in the sound eye. Although dissection has shown that a foreign body, as, for example, a shot or a piece of iron, may occasionally become encysted, such an event is extremely rare, and does not afford immunity against future attacks of inflammation. As long, in fact, as the extraneous substance remains, it is liable at any time, even after the lapse of CHAP. IV. Fig. 86. Spud. 154 DISEASES AND INJURIES OF THE EYE. CHAP. IV. many years, whether free or adherent, to provoke suffering and disease, and to induce sympathetic inflammation in the sound eye. Gunpowder is often imbedded in the coats of the eye, and I have seen cases in which the grains penetrated the cornea and became fixed in the lens and iris. The worst acci- dents of this kind occur in mining and rock-blasting. Excessive pain and discomfort attend them, increased by the solution of the nitre in the tears, and followed by high inflammation. The treatment consists in picking out the grains of powder, without delay, otherwise the edges of the wound will close over them, and so oppose their removal. Ex- traction is, of course, impracticable when the powder is imbedded in the iris and lens. Frightful injuries are liable to be inflicted upon this organ by hot fluids, as water, steam, pitch, sulphur, lead, solutions of soda and soap, and also by hot iron, hammered upon the anvil, the sparks flying off* and forcibly striking the eye. The effects vary according to the temperature of the substance, and the duration and violence of the contact. In the milder forms there may merely be some discoloration, or discoloration and slight vesica- tion, with more or less pain ; in the more severe, on the contrary, the part is either killed outright, or the tissues are so much injured as to slough from the consequences of the re- sulting inflammation. The indication, in these cases, is to remove any foreign matter that may be present, and then to employ antiphlogistic measures, early and efficiently, in the hope of saving structure and function. Molten lead is apt to collect in the folds of the conjunctiva, where, unless sought for with great care, it may escape detection. Pitch, if firmly adherent to the eye, may be detached with olive oil; iron is best picked out with the point of a lancet or spud. Various chemical irritants, as the alkalies and acids, are capable of producing severe injury by their contact with the eye, causing violent pain, opacity of the cornea, and ex- cessive inflammation, often terminating in sloughing and total blindness. The treatment of such accidents is sufficiently obvious. The first indication is to wash away with the hand or syringe as much as possible of the extraneous matter by the free use of cool or tepid water; and the second to neutralize what remains by the application of some alka- line or acid lotion, according to the nature of the substance with which the mischief has been inflicted. If this substance be an acid, the most efficient remedy will be a weak solution of bicarbonate of potassium or sodium ; an alkali, on the contrary, is most effectually neutralized by an acid, as a wash of vinegar and water, aided, if necessary, by the vapor of hydrochloric acid. The eye, in either event, should be bathed for a long time after the extraneous substance has been dislodged, and then well anointed with olive oil, a full anodyne being used to allay pain, and leeches, if necessary, to moderate inflammation. Nitrate of silver, too freely applied, whether accidentally or designedly, is readily neu- tralized by a weak solution of common salt. Quicklime speedily destroys the structures of the eye, by inflicting a double injury by its chemical action and by the evolution of heat under the influence of the tears and mucus. The foreign matter having been picked away, the organ should be promptly syringed with a weak solution of vinegar and water, and then thoroughly coated with oil. DISPLACEMENT OF THE BALL OF THE EYE. Displacement of the globe of the eye, technically called exophthalmos, may be produced by various causes, of which the most common are different morbid growths in and around the orbit. A mass of fat, an exostosis, or cyst, by filling up the b.ottom of this cavity, may thrust the eye forwards, out of its natural position, and even force it out upon the cheek, completely beyond the lids. Similar effects are sometimes caused by polyps of the nose, by tumors of the maxillary sinus, and by morbid growths at the base of the brain. When the displacement is very great, so that the optic nerve is put much upon the stretch, as well as compressed, dimness of sight, if not total blindness, is apt to ensue. When the dislocation is the result of an accumulation of fat in the orbit, it may affect both organs simultaneously, as in the case of a negro boy, twelve years old, who had a remarkable protrusion of both eyes ever since he was two years old. The balls hung, as it were, from their sockets, projecting nearly half an inch beyond the root of the nose. They preserved their natural direction, but could not be moved about, nor wrere they at all enlarged or hypertrophied. The sight was unimpaired. The upper lids wrere remark- ably full towards the eyebrows, and were one inch and a half in the vertical direction, by two inches and a quarter in the transverse. Notwithstanding this inordinate development, they were insufficient to cover the ball of the eye completely. The lower lid w'as about the natural size. The right cornea had an opaque spot upon it, and the pupil was vertically elongated. 155 cn.\p. iv. WOUNDS AND CONTUSIONS. The orbits did not contain any hard substance or tumor, as the finger could be pushed into them some distance between the brow and the upper part of the ball. The boy had occasionally had neuralgic pains in the eyes, with lachrymation, but in other respects he had been well. The protrusion had been for some time stationary when he died of gastritis. Upon removing the contents of the orbits, the cause of the protrusion proved to be an accumulation of fat behind each ball, within the muscles, upon which the organ rested, as in a cup. The optic nerves were normal, but somewhat longer than usual. The lachrymal glands, forced considerably forward, were of the natural size, color, and structure. The inner wall of the orbit, especially the left, was more prominent than usual, but had no agency in the production of the protrusion. Both eyes were perfectly sound. An abscess, seated deeply within the orbit, may occasion serious displacement of the eye, as in a case related by Professor Arlt, of Vienna, occurring in a child only fifteen days old. The protrusion of the ball was accompanied by great oedema of the lids, and was promptly relieved by the evacuation of a teaspoonful of thick pus. There is great prominence of the eyeballs in the affection known as Basedow’s disease, or exophthalmic goitre, which is observed most frequently in females, and is marked by a too frequent and tumultuous action of the heart, along with an enlargement of the thy- roid gland. Vision is not impaired, and no lesions are to be observed with the ophthal- moscope beyond an engorged condition, with pulsation of the retinal veins. The pathology of the disease is obscure, but it is believed to be one of the medulla oblongata. Iodine, with iodide of potassium, and belladonna, may be given in combination with tonics. The eye is occasionally dislocated from its socket by external violence. I have never met with such a case in the human subject, but once saw a little poodle, which in a fight with a large mastiff, half an hour previously, had the misfortune to suffer from this acci- dent. The eye hung completely out upon the cheek merely by the optic nerve, without any injury to the ball, but with great stretching of the different muscles, two of which were torn nearly entirely across. The displacement had evidently been produced by the canine tooth of the mastiff. The eye was restored without any difficulty, and the animal made a rapid recovery, without the slightest apparent impairment of vision. When the displacement is caused by a morbid growth, the latter may sometimes be re- moved in such a manner as to avoid injury to the eyeball or any of the accessory structures. WOUNDS AND CONTUSIONS. Wounds of the eye of various kinds, as incised, lacerated, contused, and gunshot, are often followed by excessive suffering and loss of vision. In many cases, indeed, the con- tents of the ball escape at the moment of the injury, or at a more or less remote period afterwards, in consequence of the resulting inflammation. In gunshot wounds the whole eye is sometimes completely carried away by the missile, at other times, perhaps, only a small fragment is left, attached, it may be, to the optic nerve, or to some muscle. In the more severe forms of such injuries, foreign matter and splinters of bone are frequently retained, adding thus greatly to the complication of the case. Severe contusion and concussion of the eye may arise from various causes, as blows or falls, or the forcible contact of a cork in opening a bottle. Such accidents often produce more or less serious changes within the eye, without any external wound, as effusions of blood into the two chambers, laceration of the iris, dislocation of the crystalline lens, or separation of the retina. Sometimes, as a secondary effect, cataract forms, or the sight is impaired by inflammatory deposits. The treatment of these injuries involves nothing of a pecidiar character. Foreign matter, if any be present, having been removed, the edges of the wound are carefully adjusted, and the lids confined with bits of isinglass plaster, a light compress and ban- dage, very much as after the operation for cataract. If the wound is attended with loss of substance, cold applications must be used at first, and afterwards, if necessary, light elm poultices, which are often more soothing than anything else. The patient’s head and shoulders are properly elevated, free use is made of anodynes, the bowels are well evacu- ated, the diet is restricted, and light is excluded from the apartment. Venesection and leeching will be of service in the more severe cases in plethoric subjects. The blood which is effused into the chambers of the eye in concussion generally readily disappears spontaneously, or under the influence of mild treatment, as the local use of cold water and gentle purgation. External injury, even of a comparatively light character, is occasion- 156 ally followed by sympathetic inflammation of the sound organ, thus placing its visual functions, perhaps at a quite remote period, in imminent jeopardy. When this is the case, the only proper remedy is enucleation of the affected eyeball DISEASES OF THE CONJUNCTIVA. Inflammation The conjunctiva is the seat of various forms of inflammation, known by the generic term ophthalmia, as the catarrhal, traumatic, pustular, purulent, gonor- rhoeal, and granular. 1. Simple Inflammation—The most simple form of conjunctivitis is that which results from the suppression of the cutaneous perspiration, exposure of the eye to intense light, the lodgment of a foreign body, disorder of the digestive apparatus, or, in short, from any slight and transient cause, whether acting directly upon the eye itself, or indirectly through the general system. The symptoms are abnormal redness of the conjunctiva, pain, lachrymation, and intoler- ance of light, with a slight discharge of mucus, barely suffi- cient, perhaps, to glue the lids gently together in the morning. The vessels, as seen in fig. 87, are small, tortuous, and few in number. There is no tumefaction of the lids, no involve- ment of the cornea, iris, or sclerotica, and no purulent secre- tion ; in a word, the inflammation is of the most simple character, and, unless neglected or badly managed, generally disappears in from two to three days, the eye rapidly regain- ing its natural characters and functions. An inflammation like this, however, may, if mismanaged or neglected, become a most serious affair, and be productive of extensive structural mischief. The discoloration will then be more diffused, the conjunctiva exhibiting a uniform scarlet or bloodshot appearance ; there will be excessive lach- rymation, great increase of pain, severe intolerance of light, a muco-purulent discharge, more or less profuse and glutinous, and involvement of some of the other structures of the eye. The redness of conjuntivitis is peculiar, not only in the milder and more common forms of the disease, but in every other. It is of a scarlet hue, and may occur either in circum- scribed spots, or, as is more generally the case, be diffused over the whole anterior surface of the ball, except the cornea, according to the extent of the inflammation ; very gener- ally it affects also the inner surface of the lids, and it may even be greater there than elsewhere. It is sealed exclusively in the conjunctiva and the connective tissue, and is usually most conspicuous where the membrane is reflected from the lids over the sclerotica. The arrangement of the vessels is also peculiar. They are spread out arborescently, and are perfectly movable, tortuous, and remarkably distinct, hundreds being visible in every direction, where in the natural state there is hardly one. As the disease augments in intensity, the vessels are, as it were, lost, the inflamed surface exhibiting a uniform scarlet appearance. There is a marked difference between the redness of conjunctivitis and that of sclero- titis. In the former, the color of the inflamed surface is scarlet, especially if the disease have made considerable progress ; in the latter, on the contrary, it is pink or lilac, the reddish hue contrasting beautifully with the naturally bluish tint of the fibrous structure; in the one it is superficial and movable, in the other deep and fixed. In conjuntivitis the vessels are large and ramiform, anastomosing with each other in every conceivable direc- tion ; in sclerotitis they are very small, and disposed longitudinally, running from behind forwards in parallel lines toward the cornea, where they form a distinct zone, often extend- ing completely around the eye. The pain in conjunctivitis is seldom severe, except in the more violent forms, when it is often exquisite. In general, there is merely a sense of uneasiness, or a feeling as if there were a particle of foreign substance in the eye. The uneasiness, pain, or aching is steady, but liable to vesperal exacerbations and remissions, and confined mainly to the site of the disease. In sclerotitis, it is severe, deep-seated, paroxysmal, and circumorbital, generally affecting the temple, cheek, and forehead. The lachrymation is often considerable, even in the milder forms of conjunctivitis ; the tears are hot and scalding, and perhaps gush out in a full stream the moment the lids are separated. The How may continue profusely for an indefinite period, but in general it DISEASES AND INJURIES OF THE EYE. CHAP. iv. Fig. 87. Simple Conjunctivitis. DISEASES OF THE CONJUNCTIVA. 157 lasts only a few days, when it sensibly diminishes, and soon after entirely disappears, especially if there be much muco-purulent secretion. The intolerance of light varies ; sometimes it is very insignificant, at other times exces- sive. In general, however, it is an important symptom, for there is hardly a case of ophthalmia where there is not more or less of it. In the strumous variety it is charac- teristic, and is often so intense as to induce the sufferer to bury his face in the bedclothes, or, if he is a child, in his nurse’s lap. Much difference also obtains in regard to the discharge of mucus, pus, or mucopurulent matter. In the more simple cases, there is usually only a slight increase of the natural secretion ; but, if the disease is at all severe, the discharge will be abundant, thick, glutin- ous, and decidedly muco-purulent. Indeed, there are certain varieties of ophthalmia which derive their distinctive features from the char- acter of the secretion of the inflamed surface; as, for example, in purulent and gonorrhoeal conjunctivitis. The Meibomian glands, par- ticipating in the inflammation, also furnish an abundant secretion, of a peculiarly viscid nature, which, mingling with that derived from the mucous membrane, causes the agglu- tination of the edges of the lids, so common and so annoying in the more severe forms of con- junctivitis. Tumefaction of the conjunctiva is present only in some cases, and is dependent, not upon any marked distension of the membrane itself, but upon the infiltration of the subjacent con- nective tissue, known as the ocular fascia, which plays so important a part in all the more violent forms of conjunctivitis. Pos- sessed of great laxity, this texture admits of extraordinary distension with serum, or sero- plastic matter, giving rise to what is called chemosis, fig. 88. When the tumefaction exists in its worst degree, it forms a kind of rim around the cornea, often several lines in depth, causing the front of the ball to have a cup-slmped appearance. Much swelling is also frequently present at the inner canthus, and at the point of reflection of the con- junctiva from the lids over the sclerotica. It is worthy of note that this symptom is entirely absent in sclerotitis and corneitis. It is sometimes an important sign of violent chorioditis. Swelling of the lids is rarely present in simple conjunctivitis, or even in many of the more severe cases, whilst, in purulent and gonorrhoeal ophthalmia, it is a conspicuous and troublesome occurrence, greatly increasing the local suffering, as well as materially inter- fering with the examination and medication of the eye. In this respect, again, conjunc- tivitis differs characteristically from sclerotitis and corneitis, in which the lids are either not swollen at all, or only in a very slight degree. 2. Diphtheritic Inflammation.—Under this appellation are included two forms of ophthalmia, in one of which, known as membranous or diphtheroid ophthalmia, there is a membranous deposit on the surface of the conjunctiva, and in the other, termed diphther- itic conjunctivitis, the stroma of that membrane is thickened by fibrinous exudation. The affection, which may be either sporadic or epidemic, is most common in children under three years of age, is sometimes, if, indeed, not generally, contagious, and is often associated with diphtheritic inflammation in other parts of the body. Both eyes are usually involved. The tumid part is smooth, remarkably firm, and of a pale yellowish, cineritious, or reddish-white hue. The circulation is greatly embarrassed, the superficial vessels are enlarged, and numerous apopletic specks denote mechanical obstruction and rupture. In the more advanced stages of the disease, few vessels are visible; they ex- hibit the appearance rather of broken canals than of ordinary vascular tubes, and, if the part be incised, neither blood nor lymph escapes from the indurated structures. The symptoms are usually very distressing. Photophobia is present in greater or less degree. The heat is very intense, as is shown both by the touch, and by the rapid evaporation of fluid applications. The pain is very great, even at the beginning, and the CHAP. IV. Fig. 88. Chemosis, or Swelling of the Conjunctiva. 158 DISEASES AND INJURIES OF THE EYE. CHAP. IV. conjunctiva is so sensitive as to be intolerant of the slightest manipulation. Considerable larchrymation commonly exists, and the accompanying discharge, seldom copious, is of a yellowish or dirty grayish color. Gradually as the action progresses, the cornea becomes opaque, ulcerated, and finally, if relief he not afforded, gangrenous, from the strangulation of its vessels. Large portions of the ocular conjunctiva are sometimes involved in the slough. The patient is feverish and restless ; the disease rapid and grave. In the worst forms of the affection, the sight and even the eye itself may he destroyed in twenty-four hours from the time of its first appearance. 3. Purulent Inflammation Purulent ophthalmia derives its characteristic features from the nature of the attendant discharge, which is generally profuse, thick, viscid, and irritating; it sets in within a few hours after the attack, and continues steadily until the disease dis- appears. The affection is particularly prevalent in the warmer latitudes, where it is often epidemic, although sporadic cases are constantly met with everywhere. It it most common among the humbler classes, and seems to he caused hv atmospheric vicissitudes; but, as the matter which is so profusely secreted is contagious, the disease is communicated by actual contact or inoculation. The inflammation is exceedingly vehement, and is accompanied by the most atrocious pain, swelling, discharge, and intol- erance of light; the lids, as seen in fig. 89, are enormously distended; the conjunctiva is profoundly chemosed ; and the cornea, buried almost out of* sight, becomes speedily opaque, and finally sloughs, vision being irretrievably destroyed. Of the fright- ful character of this distemper, when it prevails as an epidemic, some conception may be formed when it is stated that the Chelsea and Kilmainham hospitals contained at one time, soon after return of the British troops from Egypt, 2317 soldiers who were totally blind from its effects. The case of the ship Rodeur, a French slaver, affords a good illustration of the manner in which the disease spreads under circumstances favorable to its propagation. Of the blacks, 160 in number, among whom it first broke out fifteen days after their departure from the coast of Africa, 39 of those who survived were totally blind, 12 lost each an eye, and 14 had corneal opacity. Of the crew, consisting of 25 persons, only one escaped, and he was attacked soon after he landed at Gaudaloupe. It is asserted that 30,000 cases of this disease occurred in the Prussian army, from 1813 to 1821 ; and that in 1862, 4798 men were disabled by it at one time. The Belgian army suffered still more extensively. Fig. 89. Acute Purulent Ophthalmia. Fig. 90. Purulent Ophthalmia in the Newly-born Infant. Purulent ophthalmia occasionally occurs in the infant within a few days after birth, in consequence, as has frequently been stated, of inoculation with gonorrhoeal or leucorrhoeal matter derived from the mother during parturition. That such an occurrence is possible is unquestionable, for multiplied observation has fully established the fact; and it is 159 CHAP. IV. generally believed by ophthalmic surgeons that inoculation is the cause of the disease in a large proportion of cases ; but that it is invariably the cause of the disease is not at all probable, since, of the numerous cases that I have seen of it, 1 have never been able to trace a solitary one to the effects of inoculation of any kind, notwithstanding the most minute and circumstantial inquiry into its history. My conviction is, that the disease, as it usually appears, is of atmospheric origin, depending upon the same causes as the purulent ophthalmia of adults, and that it is, therefore, wholly free from specific poison, although, certainly, capable of being communicated by inoculation. It is charac- terized by an abundant discharge of a thick, yellowish pus, great redness of the conjunctiva, and so much swelling of the lids as to render it extremely difficult, if not impossible, to separate them, so as to get a fair view of the cornea, which is often early involved in the disease. These appearances are well seen in fig. 90. The most healthy children, as well as the most puny, are subject to this disease, the former, according to my experience, suffering more frequently than the latter; it generally runs a rapid course, and, unless properly managed, often eventuates in total blindness, especially when, as usually happens, both eyes are affected. 4. Gonorrhoeal Ophthalmia This disease is produced by the contact of gonorrhoeal matter. It is a most virulent form of inflammation, spreading with great rapidity from the conjunctiva to the other structures of the eye, which is frequently completely destroyed in a few days. Its principal phenomena are exces- sive discoloration, and swelling of the conjunctiva and of the lids, as in fig. 91, profuse muco-purulent discharge, of a yellowish and very viscid character, great pain, lachrymation, intolerance of light, and early opacity of the cornea, which may soon die and slough, thus permitting the escape of the humors with the consequent collapse of the eye. Positive inoculation is necessary to the production of this disease ; I have never seen an instance where it showed itself as a secondary affection, and I question the possibility of such an occurrence, not- withstanding the many apparent proofs that have been adduced in its support. The disease usually Jxegins in one eye, but in most cases the other becomes also involved from the accidental contact of the matter. There is something very curious about this dis- ease, which has not yet been satisfactorily eluci- dated. If gonorrlneal ophthalmia is really an entity, why is it that it does not occur more frequently, for there are thousands of persons, ignorant and filthy, who, while laboring under specific urethritis, carry their fingers, besmeared with matter, to the eye, often rubbing and scratching it, and yet do not contract the disease? May we infer from this that it is difficult of propagation, or that it can only be produced in this way in some individuals, and not in others? Authors constantly adduce cases in which this variety of ophthalmia is said to have been induced by the contact of the patient’s urine, employed for bathing the eye, under the popular belief that it is a good and speedy cure for the disease. Now, is this possible? Does not this admixture of the two fluids effectually destroy the specific poison of gonorrhoea? Could the matter of smallpox, chancre, and other diseases withstand the neutralizing influence of so acrid and readily-decomposed a fluid as the urine? These questions afford food for reflection, and should, if possible, be settled before we receive as true all that has been written upon the subject. This is the more necessary, because it is well known that the ordinary, non-specific form of purulent ophthalmia may destroy the eye completely in less than three days after its outbreak. Meantime, the only evidence that the disease is of a gonorrhoeal nature is derived from its history; that is, we cannot be certain that the affection of the eye is specific, unless we know that the patient is laboring under specific urethritis. Such a diagnosis is, to say the least, not very philosophical, for it may well be asked whether it is not possible for a non-specific but destructive inflammation of the eye to take place during the progress of an ordinary gonorrhoea, and yet be entirely inde- pendent of it? As for myself, I can readily conceive of such an occurr£hce, although, DISEASES OF THE CONJUNCTIVA. Fig. 91. State of the Lids in Gonorrhoeal Ophthalmia. DISEASES AND INJURIES OF THE EYE. CHAT. 1 v. granting all that might he said respecting it, it would be very natural to view the two affections in the light of cause and effect. 5. Granular Inflammation.—The lids are occasionally the seat of a villous condition of the conjunctiva, liable to degenerate into little bodies, which, from their resemblance to the structures observed upon a healing ulcer, are denominated granulations, well seen in fig. 92. These bodies, which are nothing but enlarged villi, found in such abundance upon nearly all mucous surfaces, are never present in ordinary conjunctivitis, while they are exceedingly common in certain varieties of that disease, especially such as are attended with purulent discharge, often forming in an almost incredibly short time. They are always most abundant upon the upper lid, where they are frequently extremely large and numerous, giving the mucous surface a rough, mammillated ap- pearance, not unlike that of a strawberry; they are of a deep red color, and usually occur in groups, which are often separated by well-marked fissures. Similar bodies ure generally met with on the lachrymal caruncle, although seldom in large numbers. On the lower lid they are always comparatively small, and more strag- gling than on the upper. In the Southwest, where the granulations are ex- tremely common, I often saw them form in immense numbers, and of extraordinary size, in less than forty- eight hours from the commencement of the disease. In some regions of that country, especially in the Wabash Valley of Indiana, and some parts of Illinois, Kentucky, and Mississippi, the disease is occasionally epidemic. Boatmen on the Ohio, Mississippi, and other rivers are remarkably liable to its attacks. During my residence at Louisville, I treated large numbers of cases of this kind, and the cities of St. Louis, Memphis, New Orleans, and Chicago have always had a full share of them. The malady was much more common in men than in women, and in young and middle-aged subjects than in children and old persons, and it appeared to me to be often of a miasmatic origin. However this may be, it is certainly most frequent in those regions of the Southwest where neuralgia and intermittent fever are most prevalent. Persons who sleep out in the, open air, or who travel much at night, are particularly liable to its attacks. The disease is always attended with a profuse discharge of thick, viscid, yellowish pus, and with the other phenomena of the more violent forms of conjunctivitis. From the friction which the granulations exert upon the ball, the cornea is soon involved, and is often rendered completely unfit for the purposes of vision. As this peculiar state of the lids can only be ascertained by a careful examination of their inner surface, they should always be thoroughly everted whenever there is the slightest purulent discharge. A great number of cases have come under my observation where, from neglect of this precaution, total blindness wras produced. Trachoma, or vesicular granulation, is another form of the disease, characterized by the appearance in the conjunctiva of the round, white vesicles, looking like grains of boiled sago; this is epidemic, and transmitted by contagion. These two forms of granu- lations may coexist. 6. Phylctenular conjunctivitis will be treated of under the head of strumous diseases of the eye. Treatment—The milder forms of conjunctivitis generally yield to very simple treat- ment. Confinement in a dark room for a few days, light diet, an active purge, and tepid, cool, or cold bathing of the eye, with, perhaps, a Dover’s powder at bedtime, constitute the most appropriate remedies. When the inflammation is more violent, or disposed to be somewhat obstinate, the list may be increased by the addition of antimonial and saline medicines, with greater restriction of the diet, and the abstraction of blood from the neighborhood of the affected tissues by leeching or cupping. Depletion by the lancet can be required only when the patient is plethoric and the inflammation intense. One good, thorough bleeding, at the commencement of the disease, while the patient is in the semi- erect posture, may cut short an attack, which might otherwise eventuate in the destruc- tion of the eye, or in great suffering, with more or less impairment of sight. Among remedies in the different forms of conjunctivitis cathartics hold a prominent rank ; unless there is some positive contraindication, they should partake somewhat of a drastic character, so that they may produce both a derivative and purga- Fig. 92. Granular Lid. CHAP. IV. DISEASES OF THE CONJUNCTIVA. 161 tive effect. They should be given early and late in the disease, with proper regard, of course, to the strength of the patient and the state of the intestinal mucous membrane. Among the more appropriate articles are senna and Epsom salt, jalap and cream of tartar, and the compound calomel pill. When decided evidence of gastric disorder exists, the use of the purgative may be preceded by the exhibition of an emetic. Vomiting, how- ever, is only admissible so long as there is no tendency to disorganization of the eye ; for, when this is present, the concussion which it would cause could hardly fail to prove inju- rious. Mercury is rarely given in conjunctivitis, whatever may be its degree or charac- ter, experience having shown that it is destitute of any controlling power. Anodynes must be administered freely, whenever there is much local suffering, or inability to sleep, in every stage of the malady, unless there are strong and decided contraindications ; for besides answering these important purposes, they usually prove of immense benefit in af- fording quietude to the affected organ, an object of such great consequence in the treat- ment of inflammation generally. Elevation of the head and exclusion of the light will, of course, receive due attention. Locally, none but the mildest remedies should be employed. It is a great mistake, and yet one which is constantly committed, to use strong applications to the eye in every form and stage of the inflammation. Often have I seen a simple conjunctivitis, which in a few days might have disappeared spontaneously, converted into a violent, obstinate, and protracted disease by the untimely use of an improper collyrium ! If a collyrium be ad- missible at all, it is only, as a rule, after the morbid action has been, in some degree, sub- jugated by other means, or when it has assumed a subacute character, or become chronic. When the symptoms are urgent and threatening this rule may sometimes be departed from, but even then seldom without regret. In the purulent and gonorrhoeal varieties of the affection, most ophthalmic surgeons urge the employment of strong collyria, at an early stage of the attack, on the ground of their beneficial influence in controlling inflam- mation. I have used them myself in such cases, but seldom without a conviction of their injurious effects. The most valuable articles of this class of remedies are the different preparations of lead and zinc, wine of opium, borax, alum, and nitrate of silver, the latter of which is at once the most potent and the most abused. The lead or zinc may each be used in the form of solution, in the proportion of one, two, or three grains of the salt to the ounce of distilled water, a few drops being poured upon the inflamed surface twice or thrice in the twenty-four hours. If the application smart beyond a few minutes, it must be weakened, or employed less frequently. Lead should never be used when there is ulceration of the cornea, as it may produce a permanent white deposit at the seat of the ulcer. The best preparation of opium is Sydenham’s laudanum—the wine of opium of the shops—diluted with three or four parts of water, or dropped upon the eye in a pure state. The strength of the nitrate of silver should vary from the eighth of a grain to two grains for ordinary cases, while in the more violent it may range from five to sixty. When the solution is very strong it should be applied by means of a camel-hair pencil, the inflamed surface having previously been dried with a soft linen rag. When the lids also suffer, the best plan is to touch them and not the ball, their return to their natural position serving to diffuse the caustic over the whole of the diseased structure. Whatever collyrium be used, its effects must be carefully watched, so that, if it be found to flag, another may take its place. Solid nitrate of silver ought seldom to be used about the eye, and then only for the lid, the surface of which should immediately be washed with a solution of common salt. A useful application is the “ mitigated stick,” composed of one part ol nitrate of silver to two or three parts of nitrate of potassium. In the more severe cases of conjunctivitis, the patient will derive great comfort from poppy fomentations, cloths wrung out of warm water and opium, and the application of medicated steam, directed upon the eye by means of an inverted funnel. Sometimes a light poultice is very soothing, especially if the surface be wet with laudanum, or lauda- num and acetate of lead, but its use should never be long continued. The cause of chronic or frequently recurring conjunctivitis is often found in the strain resulting from some error of refraction, which must be corrected by suitable glasses before any other treat- ment can avail. The treatment of diphtheritic ophthalmia must be prompt and decisive. The constitu- tional remedies must be employed with vigor; the patient must be confined in a dark room, and blood may be taken by leeches from the temples. The most reliable topical means are early and free scarifications of the swollen conjunctiva, followed by the thor- ough application of a strong solution of nitrate of silver, repeated, in the more severe forms 162 DISEASES AND INJURIES OF THE EYE. CHAP. IV. of the disease, at least twiee in the twenty-four hours, the surface being washed immediately after with salt water. The incisions should extend down to the surface of the sclerotica, otherwise it will be difficult, if not impossible, to prevent opacity and sloughing of the cornea. When the lids are very stiff, glossy, and tumid, from serous and plastic depos- its, great benefit will accrue from external punctures and incisions, and also, in many cases, from the use of blisters and tincture of iodine. Many patients will be found to re- quire a supporting treatment. Most surgeons avoid the use of nitrate of silver or other irritating applications in true diphtheritic ophthalmia, and rely entirely upon iced com- presses and solutions of chlorate of potassium or boracic acid. Others prefer hot fomentations. It must be admitted that the prognosis is unfavorable under any form of treatment. In purulent, gonorrhoeal, and other forms of ophthalmia, attended with unusual swell- ing and rapid extension of the morbid action, the most appropriate measures are, free in- cisions of the inner surface of the lids, extensive scarifications of the chemosed conjunc- tiva, and the injection of the eye, every half hour, with a solution of opium and bichlor- ide of mercury, in the proportion of two grains of the former and one-eighth of a grain of the latter to the ounce of tepid water. If the discharge of pus is very profuse, the inner surface of the lids may be pencilled over twice a day with a strong solution of nitrate of silver. The bichloride of mercury is a remedy of great potency in all cases attended w ith copious puriform deposit. The use of the syringe I regard as indispensable, as it is the only means by which wre can remove the irritating matter, and effectually medicate the inflamed surfaces. If the lids are red and much swollen, they should be continuously covered with light compresses wet with iced water. Solutions of borax or alum are sometimes substituted for the bichloride wash. If an ulcer forms in the cornea, atropia should be used, and, in any case, it will relieve pain. In the purulent ophthalmia o ['infancy, I have usually effected excellent and even rapid cures by the injection every few hours of tepid water, or milk and water, followed imme- diately after by a solution of bichloride of mercury, from the eighth to the twelfth of a grain to the ounce of water. Internally, the best remedy, according to my experience, is a minute quantity of Dover’s powder, and calomel, given every eight hours, to act upon the skin, and to allay pain. The bichloride of mercury is, of all the local means that I have ever tried in this affection, the most efficacious in arresting discharge. Very weak solutions of zinc and alum are also beneficial, but altogether inferior to the bichloride. A tw'o-grain solution of nitrate of silver should be applied daily to the everted lids. Hot stoupes are sometimes useful. When the eye is unusually irritable and sensitive to light, the addition of a small quantity of atropia to the collyrium will commonly be highly ad- vantageous. One of the great points in the treatment of this and other forms of purulent ophthalmia, is to get rid of the acrid secretions, which, if allowed to remain, always act as local irritants. Leeches and counterirritation may generally be dispensed with. Ex- cessive tension of the lids may be relieved by incision of the outer canthus. If the child is feeble, a minute quantity of quinine is given three or four times a day, along with a sufficiency of good nourishment from the mother. As the disease improves, exercise in the open air is enjoined. It is often very difficult to obtain a satisfactory view of the condition of the eye in this disease, owing to the excessive tumefaction of the lids. The proper way to accomplish the object is to place the child’s head between the knees, and to draw the lids gently apart with the index fingers. The spasm of the orbicular muscle in crying w ill assist the ever- sion, which should be accomplished if possible. The eye should always be well syringed before the examination, to prevent the matter from obscuring the ball. The first thing in the treatment of granular conjunctivitis that should claim our atten- tion is the state of the general health, often seriously deranged, by the joint agency of disease, confinement and ill-treatment. Purgatives are generally indicated, and often afford much relief; the diet must be carefully regulated, and pain must be relieved, and sleep procured by a full anodyne administered at night, either by itself, with a diapho- retic, or a drachm of the wdne of colchicum, the latter being particularly serviceable when the suffering is of a rheumatic character. Any large or exuberant granulations that may exist should be scarified with a sharp scalpel or scarificator; and when the bleeding, w hich should be encouraged with warm water pressed from a sponge, has ceased, the raw surface should be freely touched with a smooth piece of copper, or the mitigated stick, any redundant salt being washed aw’ay before the upper lid is permitted to resume its natural position. The patient is directed to bathe the eye frequently for the next two days, and to anoint the edges of the lids at night with a little cosmoline or fresh lard. If the granulations are comparatively in- CHAP. IV. DISEASES OF THE CONJUNCTIVA. 163 significant, the use of the knife is dispensed with, and the application of the copper re- peated every third or fourth day, care being taken to limit it to the upper lid, whence it soon diffuses itself over the whole of the inflamed surface. In the intervals of the cau- terization the eye may be bathed, more or less frequently, with cool, tepid, or cold water, simple, mucilaginous, or slightly astringent, as may be most agreeable to the part and system, or favorable to the reduction of the morbid action. Instead of the copper, the mitigated stick, or a solution of nitrate of silver from two to twenty, thirty, or even sixty grains to the ounce of water may sometimes be used, applied very carefully with a camel-hair pencil to the inner surface of the upper lid, previously everted and dried. When the remedy is applied in strong solution, it should be neutral- ized with salt water before the lids are allowed to come in contact with the cornea. The two remedies may occasionally be advantageously alternated. Pencilling the granular sur- face with Goulard’s extract is now and then followed by speedy amendment ; but, on the whole, it is inferior to the copper and nitrate of silver. The great objection to the ordinary solutions of lead is their liability to incrust the cornea, and to produce opacities. When the reproductive tendency of the granulations is very great, I have found marked benefit from frequent scarification of the lid, and the occasional application of two or three leeches to the neighborhood of the outer canthus. I know that the former of these remedies has met with much opposition, but I can attest its beneficial effects from ample experience. A tonic course of treatment will generally be required with a majority of the patients in our larger cities, and in the wards of hospitals, the most important articles being quinine, iron, extract of bark, and cod-liver oil, conjoined with a nutritious diet, exercise in the open air, and attention to the skin. Whatever means be adopted, steady perseverance, both on the part of the patient and the surgeon, will be indispensable to a final and per- manent cure, for there is no disease more liable to relapse than granular conjunctivitis, or to cause serious complications, such as trichiasis, entropion, or pannus. The corneal opacity, so common an attendant upon this disease, unless very great, usually disappears, as the lids regain their normal condition. If it be disposed to linger, daily applications to the edge of the lower lid of a little very dilute ointment of red oxide of mercury may be made; or, what is, perhaps, better, an ointment of yellow oxide of mercury of the strength of one grain to the drachm of vasaline applied directly to the inflamed surface. Finally, in the treatment of conjunctival ophthalmia, every case attended with muco- purulent discharge should be isolated, so far as the use of the bed, towel, and basin is concerned ; for, although every discharge of the kind is not contagious, too much circum- spection cannot be observed in regard to those whose occupation compels them to be con- stantly in contact with the subjects of these maladies. Pterygium Pterygium is a hypertrophy of the conjunctiva, generally vascular, several shades darker than the surrounding surface, and of a triangular shape, the apex corre- sponding to the cornea, and the base to the inner canthus, as shown in fig. 93. It is commonly situated upon the nasal aspect of the eye, but it may occur upon the temporal Fig. 93. Fig. 94. Pterygium. Double Pterygium. side, or even in the perpendicular diameter of the organ. Only one such growth is or- dinarily met with ; in some cases two are observed, as in fig. 94, and instances have been recorded of three, and even four, although they are extremely rare. Sometimes, also, the pterygium, instead of being horizontal or perpendicular, is oblique, and deviates from the triangular form. 164 DISEASES AND INJURIES OF THE EYE. CHAP. IV. The starting-point of a pterygium is generally at a short distance from the cornea, and presents itself as a little elevation, of a vascular, yellowish appearance, which, gradually assuming a membranous form, extends outwardly towards the canthus of the eye, and inwardly towards the cornea, upon which it always encroaches to a greater or less extent, rarely, however, passing beyond the middle line. When it is developed upon the nasal side of the eye, it generally, in its progress, involves the semilunar valve, and hence it has sometimes been supposed, although erroneously, to originate in that structure. The causes of pterygium are generally such as produce chronic inflammation, but in many of the cases that have fallen under my observation it came on spontaneously, without any antecedent or accompanying disease of this kind. It is sometimes due to the irritation produced by a foreign body. Pterygiums vary much in their structure ; some are quite thin, as if they consisted merely of an additional layer of conjunctiva ; others, on the contrary, are very thick, and of a tough, fibrous consistence. Numerous vessels, generally arranged in a straggling manner, and occasionally granules of fat, exist in them ; but, in cases of long standing, they are often very white, and non-vascular. That they consist maiidy in a hypertrophic condition of the conjunctiva is shown by the fact that the morbid growth is inseparably incorporated with that membrane, that it always lies loosely upon the sclerotica, and that it follows the conjunctiva in its reflection over the cornea, where its attachment is always extremely close and firm. The principal inconvenience of a pterygium is from its mechanical interference with the movements of the eye. It seldom produces pain, but the subjects of it are more prone to inflammation, and vision is materially impaired, when the membrane encroaches consider- ably upon the cornea. Local applications are of no service, even in its earlier stages, nor would interference be advisable so long as the eye is comparatively comfortable, and vision unimpaired. Removal, if deemed necessary, is easily effected by seizing the pterygium at its middle with a pair of forceps, drawing it away from the globe, and shaving it off with a narrow scalpel. Some sur- geons prefer the scissors, but I am satisfied that the operation can be performed much more effect- ually, although perhaps not so rapidly, with the knife. Strangulation may be performed by trans- fixing the growth with two needles, armed with a single thread, as seen in fig. 95. When the - needles are separated from the thread by scissors, four ends will be found below and two above the growth. Strangulation vertically is effected by tying the upper and the lower threads, at the apex and base; and horizontally by tightening the upper loop,and tying the two threads which remain below. Tumors I had recently under my care a young lady, sixteen years of age, on account of a dermoid tumor of this membrane. It was about the size of half a section of a mar- rowfat pea, hemispherical in shape, of a dense, firm consistence, smooth and shining upon the surface, and situated at the inner side of the eye, on a line with its horizontal axis. It partially overlapped the cornea, and was studded with four black hairs, which had often occasioned so much inconvenience by their length as to require the use of the scissors. Excision was readily effected with the tenaculum and bistoury, but a number of weeks elapsed before I could thoroughly overcome, by the scissors and escharotics, the tendency to re- production. Such growths, of which examples have been reported by different observers, as Monro, Barron, Graefe, Taliaferro, Wardrop, Mackenzie, W. W. Cooper, Sprague, and Fig. 95. Operation for Pterygium. Fig. 96. Dermoid Tumor. CHAP. IV. DISEASES OF THE SUBMUCOUS CONNECTIVE TISSUE. 165 Wecker, are always congenital, and are usually found to extend more or less over the cornea, to which and to the sclerotica they are intimately connected. In the cases re- corded by Monro and Taliaferro, the hairs were very long, and from ten to a dozen in number. In those of the latter, there was a symmetrical tumor upon each* eye, although only one had hairs upon it The appearances of this growth are well illustrated in the annexed sketch, fig. 96. Warts, or soft papillary growths, are occasionally met with on the conjunctiva. They should be snipped off, and the raw surface lightly touched with chromic acid. Epithelioma is usually met with in connection with the caruncle and semilunar valve, and is described under the head of encanthis. Xeroma—The word xeroma is employed to denote a remarkable dryness of the con- junctiva, chronic in its character, and associated with more or less thickening and indura- tion of the membrane. The best idea that I can give of the diseased structure is that it resembles the eyelid of the land frog. The morbid change is universal, affecting the entire conjunctiva, although it is commonly most distinctly marked in the ocular portion. In two of the three cases that have fallen under my observation, it was also very conspicuous in the epithelial lining of the cornea, which was singularly dry, slightly opaque, and studded with little grayish points, not larger than a clover-seed. Of the origin and nature of xeroma we have no definite information, although it has generally been ascribed to the effects of inflammation. Again, it has been supposed to be caused by deficient lachrymal secretion ; but such a state has been assumed rather than estab- lished by direct observation, and in a number of the reported cases of the disease it has been most satisfactorily demonstrated that the functions of the lachrymal gland were not materially, if at all, impaired. Nor can the affection be justly ascribed to a want of the proper secretion of the conjunctiva, seeing that the suppression of this secre- tion is a consequence, and not a cause, of the morbid change. Xeroma is usually confined to one eye, the sight of which is necessarily more or less diminished, if not wholly destroyed. In the three cases, which I have had occasion to observe, it occurred in old subjects, had been in progress for many years, was attended with nearly total blind- ness, and came on without any assignable cause. A stiff’, dry feeling of the eye, with some impediment of motion, was the chief inconvenience under which the patients labored. Xeroma is an incurable affection. Temporary improvement sometimes follows the use of mildly stimulating unguents; but, beyond this, nothing is to be expected from local applications. In cases of recent standing, it might be justifiable to try the effects of ex- cision of the diseased membrane, removing it in large sections at three or four sittings, at intervals of so many weeks. Such a procedure might, unless the reproductive tendency is very great, be perfectly successful. Encanthis The lachrymal caruncle and the fold of the conjunctiva, called the semi- lunar valve, are liable to hypertrophy, known under the name of encanthis, represented in fig. 97. The enlargement, which occasionally attains a considerable bulk, extends along the inner margin of the lids, impedes the movements of the eye, and keeps up more or less irritation, with discharge. The tumor is often connected with obstruction of the lachrymal passages, and generally has an angry, reddish appearance. The proper remedies are leeching, scarification, and the application of nitrate of silver, with attention to the general health, which is frequently involved in the causation of the disease. In 1866 I removed .from the semilunar valve of the left eye of an elderly lady a fibrous tumor, of sixteen years’ duration. It was about the size of an ordinary pea, of a reddish color, and of a rounded shape, with a rough and slightly granulated surface. It was attached by a narrow, delicate pedicle to the free margin of the valve, and projected at the corner of the eye considerably beyond the line of the lid. Epithelioma sometimes springs from these structures; it is of a livid or purple hue, rough, knotty, or tuberculated on the surface, hard to the touch, and rapid in its growth, often attaining a considerable bulk in a few months. Its tendency is to progress, ulcerate, and finally to destroy life. Early and thorough excision affords the only chance of relief, which, however, is always very uncertain. Diseases of the Submucous Connective Tissue The only affections of the subconjunc- tival connective tissue requiring notice, are, inflammation, hemorrhagic effusions, oedema, fatty and cystic tumors, and the little parasite, called the cellular cysticerce. Fig. 97. Encanthid. 166 DISEASES AND INJURIES OF THE EYE. Episcleritis, or inflammation of the tissue over the sclerotica, occurs in patches, gen- erally near the corneal margin, of a bluish-red color, and slightly raised above the sur- rounding surface. The disease sometimes extends to the cornea or iris as well as to the sclerotica. It is a painful and very obstinate affection. The result of treatment is often unsatisfactory and relapses are common. Its origin is frequently rheumatic, and, perhaps, sometimes gouty or syphilitic. The best local applications are hot stoupes, atropia, weak astringent washes, and calomel dusted on the patch. Internally, iodide of potassium, sali- cin, and quinine have been used, and counterirritation by blisters on the temple, or behind the ear, sometimes affords relief. When the disease depends upon rheumatism, subcuta- neous injections of pilocarpine are worthy of trial. Blood may be effused into the subconjunctival connective tissue by any accident, as a blow, or spontaneously, without any apparent cause. Of the latter variety I have seen a number of instances, chiefly in young persons, otherwise in the most perfect health. Vio- lent, vomiting or coughing is a frequent cause of the effusion. The occurrence is unattended with pain, and the extravasated blood is either limited to one or two small points, or ex- tensively diffused over the anterior part of the eyeball. The resulting redness is altogether different from that of inflammation. Very little is necessary in the way of treatment; in- deed, the fluid usually rapidly disappears of its own accord, but its removal may be promoted by the use of astringent or stimulating lotions. (Edema of the connective tissue beneath the conjunctiva is of two kinds, the passive and active. The first is the result of a slow effusion of serum, in consequence usually of ery- sipelatous inflammation, or of a retarded state of the venous circulation, of which the exciting cause is compression by some tumor, abscess, or other obstruction ; the conjunc- tiva is elevated, of a white, almost shining appearance, soft, inelastic, and perfectly free from pain. The active variety, usually known under the name of chemosis, is a much more serious occurrence ; it has already been described in connection with purulent ophthal- mia, witli which it so often coexists, and of which it forms one of the most dangerous complications, from its tendency to induce gangrene of the cornea. It is always pro- duced by inflammation, and is commonly of a sero-fibrinous character, and not purely serous as in the passive form. It is a serious symptom after operations, particularly for cataract, as it indicates violent choroiditis. When it exists in a high grade, the swelling forms a ring around the cornea, often a few lines deep, in which this membrane is some- times nearly buried. The proper remedy, as before remarked, is free scarification, to afford vent to the effused fluids, followed by the application of a weak solution of nitrate of silver. Nothing short of this will be likely to save the cornea. A little fatty tumor occasionally forms beneath the conjunctiva, from the size of a cur- rant to that of a pea, irregularly rounded, movable, and of a pale yellowish color. It generally receives a few straggling vessels, grows slowly, and is surrounded by a thin layer of condensed connective tissue. Subconjunctival cysts, with serous contents, are sometimes met with, especially at the angles of the lids of children and young adults. They should be removed by a careful dissection, care being taken to remove the entire wall. Melanotic sarcoma, has been observed near the edge of the cornea, or at the semilunar fold or caruncle. The tumor is usually very vascular, and as it lias a tendency to return its extirpation should be thorough. The proper remedy is excision. A species of hydatid, the cellular cysticerce, is occasionally found in this situation ; the containing vesicle is about the size of a pea, and looks like a little bladder filled with water. Under the microscope, the parasite is seen to have its mouth encircled by dis- tinct booklets. The cysticerce, most common in women and in young persons, is some- times developed at a very early age, and has hitherto been met with chiefly in Germany and Austria among pork-eating people. Lichel lias reported twelve cases of it, Von Graefe five, and Fuchs, of Vienna, thirty-one. The only remedy is extirpation. DISEASES AND INJURIES OF TIIE CORNEA. The most common affections of the cornea are wounds, inflammation, abscess, gangrene, ulceration, opacity, change of form, technically termed staphyloma, and fatty degeneration. Foreign bodies are also liable to enter it. 1. Wounds Wounds of the cornea may be the result of accident or design, and are either incised, punctured, lacerated, or gunshot, according to the kind of weapon with which they are inflicted. Incised wounds are generally caused by penknives and similar instruments; punctured wounds, by needles, pins, thorns, and splinters of wood ; lacer- ated wounds, by gun-caps, pieces of glass, particles of iron, and fragments of stone ; and CHAP. IV. CHAP. IV. DISEASES AND INJURIES OF THE CORNEA. 167 gunshot wounds by small shot discharged in hunting birds. Sometimes the cornea is rup- tured by a severe blow or fall upon the eye. However induced, the injury is always attended with an escape of at least the aqueous humor, if not also of the lens and vitreous humor, thus greatly complicating the case, and often permanently injuring vision. An- other accident, also frequently of a very serious nature, is prolapse of the iris, varying in extent, according to the size of the wound, from the smallest pin-head to nearly the whole membrane. Wounds of the cornea, even when of considerable size, may easily be overlooked, espe- cially when there is no separation of their edges, because of the liability of the membrane to preserve its normal appearance. In general, however, the nature of the case is recog- nized by looking at the cornea, as the eye, turned towards the light, is moved about in different directions, the lids being at the time held carefully out of the way. Superficial abrasions, resembling the merest possible scratches of the skin, are now and then found upon the cornea, as the result of external violence; they involve simply the epithelial covering of the membrane, and are distinguished by the exquisite pain which attends them, which is often much greater than when the wound is deep and extensive. The indications in wounds of the cornea are, first, to clear away foreign matter, and to replace the prolapsed iris or other internal structures; and, secondly, to control the movements of the organ, and moderate the resulting inflammation. If a foreign body is imbedded in the cornea, it should be carefully withdrawn with the forceps ; if it has passed beyond, into the interior of the eye, and is accessible, an attempt should be made to seize and dislodge it, lest, if permitted to remain, it should produce not only destructive inflammation, but become a source of suffering, for which it may be necessary at a subsequent period to extirpate the ball. The probe-pointed magnet will often be found very useful in such cases. Replacement of the iris is best effected with a delicate probe, the patient, especially it a child, being under the influence of anaesthesia. The surgeon, availing himself of the temporary calm, restores the prolapsed membrane, and carefully adjusts the edges of the wound, which generally unite by the first intention, leaving little, if any, defect in vision. The influence of atropia or Calabar bean in dilating or contracting the pupil may enable us to remove the iris from the wound and thus prevent the subsequent prolapse. If the iris has become incarcerated in the corneal wound before the case is seen by the surgeon, the protruding portion should be snipped off evenly with the surface of the cornea. If the lens becomes opaque, in consequence of involvement in the lesion, the case is afterwards treated as one of traumatic cataract. The second indication is fulfilled by the closure of both eyes with the bandage, excluding the light from the room, and employing the antiphlogistic regimen. A full anodyne is administered immediately after the accident. The patient must be closely watched, and, if plethoric, blood should be abstracted by the lancet and by leeches, taking care, how- ever, not to carry the depletion too far, lest it should interfere with the reparative process. 2. Inflammation Corneitis, or keratitis, delineated in fig 98, is characterized by a hazy state of the surface, and a zone-like appearance of the vessels at the periphery of the cornea, which is often very vascular for the distance of nearly a line beyond this point. The vessels are greatly engorged, yet so extremely delicate as to render it difficult to distinguish them without the aid of a magnifying glass. The conjunctiva, iris, and sclerotica usually participate in the morbid action, and hence the case is apt to exhibit the characters common to inflammation of these structures. The opacity of the cornea begins at an early period of the disease, and sometimes extends over the whole surface of the membrane, although, in general, it is more distinctly marked at some points than at others. The pain of keratitis is severe, and is seldom limited to the inflamed membrane, but extends to the other struc- tures of the eye, the orbit, temple, cheek, and forehead. Hemicrania is often a marked symptom. The eye is ex- ceedingly intolerant of light, and there is abundant laebrymation, although there is but little secretion of mucus, or discharge of muco-purulent matter. When the inflammation is unusually violent, there may be constitutional involvement, as indicated by fever ; but, in most cases, there is an absence of general derangement. The characteristic phenomena are the opacity of the membrane, and the zonular arrangement of the vessels at its cir- Fig. 98. Corneitis. 168 DISEASES AND INJURIES OF THE EYE. CHAP. IV. cumference. In iritis, the vascular zone does not extend quite so far forward ; hence there is always a narrow ring of comparatively healthy sclerotica between it and the cornea. The causes of corneitis are various, and often difficult of recognition ; in most cases, the disease is induced by external injury, or by a scrofulous taint of the system. The eruptive fevers, as measles, scarlatina, and smallpox, are frequently followed by a bad form of corneitis. In rheumatic and syphilitic sclerotitis, the cornea is very apt to participate in the morbid action. Keratitis may terminate in resolution, the haziness and vascularity of the affected tis- sues gradually disappearing; or it may pass into the chronic state, with opacity; or, finally, it may lead to suppuration, ulceration, or gangrene. In the treatment of corneitis, care must betaken not to carry the antiphlogistic measures too far. Unless the fiction is extremely violent, there will rarely be occasion for the use of the lancet, or of leeches, and nearly all cases will require a tonic treatment. The eye is kept quiet with anodynes, given in full and repeated doses, and by the use of atropia locally. When the disease is of a strumous nature, the best remedy is quinine, along with cod liver oil, steadily persevered in for many weeks. When there is an anemic condition of the system, the quinine may be advantageously combined with some preparation of iron, as the iodide, sulphate, or precipitated carbonate. When the inflammation is plainly of a rheumatic origin, the use of colchicum is indicated, in the same manner as in sclerotitis. The syphilitic form of the disease is treated with mercury and opium, either alone, or in combination with iodide of potassium. Inflammation of the cornea dependent upon mea- sles, scarlet fever, and smallpox, should be treated with mild means, as poppy fomentations, tonics, especially quinine, anodynes, and a suporting diet. When corneitis, however in- duced, becomes chronic, benefit will accrue from change of air, tepid bathing with salt water, tonics, and gentle, but steady, counterirritation. 3. Syphilitic Corneitis In syphilitic iritis, the cornea sometimes participates in the morbid action, but there is a form of inflammation, the result of hereditary syphilitic taint of the system, in which, as was at first satisfactorily explained by Mr. Hutchinson, of London, the disease is, in great degree, limited to this membrane. The subjects of the inflamma- tion are childi’en and young persons from five to eighteen years of age, with coarse, flabby skin, pits and scars on the face and forehead, cicatrices of old fissures at the angles of the mouth, and a peculiar depression of the bridge of the nose. The permanent teeth are of a bad color, remarkably small and stumpy, and vertically notched at their edges. These changes, as seen in fig. 99, are most conspicuous in the upper in- cisors, but are also observable in some of the other teeth, especially the canine. The history of the attack usually shows that the eldest child is the sufferer, and that well-marked symptoms of inherited syphilis existed during infancy, such as sore mouth, cutaneous eruptions, chronic snuffles, and ulcers about the anus. The earliest evidence of this affection is a diffused haziness of the cornea, like that of ground glass. White specks soon appear, not upon the surface, but deep in the substance of the cornea, and gradually increase in opacity. The conjunctiva and sclerotica show originally little, if any, augmented vascularity, but, in time, they become engorged, and a delicate plexus of vessels extends through the cornea, into the inflamed tissues, particu- larly along the upper and central portions of the membrane. The vessels are small, closely set, and deeply situated, not superficially, as in granular disease and other forms of ophthalmia. No tendency to ulceration manifests itself. The affection usually begins in one eye, but ultimately, generally in six or eight weeks, extends to the other. The treatment essentially consists in the exhibition of iodide of potassium or iodide ot ammonium with bichloride of mercury, quinine, bark and iron, an occasional laxative, a generous diet, and gentle exercise in the open air. Ptyalism must be carefully avoided. The opacity is generally very obstinate, and a long course of medication is required for its removal. A slight degree of haziness frequently remains, despite our best directed efforts. 4. Phlyctenular Keratitis is described in the section on strumous diseases of the eye. 5. Abscess Abscess of the cornea is an occasional consequence of acute inflammation, especially of the traumatic and variolous forms; it is also met with, but much less fre- quently, in the strumous variety of the disease. The matter may be situated immedi- Fig. 99. Syphilitic Permanent Teeth. DISEASES AND INJURIES OF THE CORNEA. 169 CHAP. IV. ately beneath the epithelial covering of the cornea, but more commonly it is found in its substance, nearly equidistant from its two surfaces, not in a distinct, circumscribed cavity, as the term abscess would imply, but as an infiltration among the softened and disorgan- ized fibres of the membrane. The matter, which is of a yellowish hue, is not true pus, but a mixture of pus, lymph, and sloughing tissue, and hence it is always remarkably tough and viscid. The suppurative process is generally limited to a particular portion of the cornea, usually the central or inferior, but now and then it is spread over its whole surface. The formation of matter is denoted by a yellowish appearance of the cornea, and by a marked aggravation of all the local symptoms. As the fluid accumulates, the cornea becomes more prominent, and finally yields at the most diseased part, followed by an im- perfect escape of pus. It is not always, however, that the abscess points externally; on the contrary, it frequently bursts, and discharges itself into the aqueous humor. Suppuration of the cornea, unless extremely slight, is one of those untoward circum- stances the effects of which are never entirely removed ; indeed, when the quantity of mat- ter is considerable, the resulting opacity is likely to eventuate in total blindness, lienee, the practitioner should spare no pains to prevent its occuiTence. If the patient is ple- thoric, local depletion may be called for ; but the reverse is likely to be the case ; he may be pale and exhausted from suffering, and then stimulants and tonics, as milk punch, quinine, or bark and iron, with nutritious food and drink, may be proper. Much judgment will, therefore, be required to enable us to save structure and function. Locally, none but the blandest remedies should be employed. The most efficient local treatment is by supporting compresses and hot stoupes. Small cloths wet with water as hot as can be borne without pain, and changed every two or three minutes, should be ap plied to the closed lids for half an hour three or four times a day ; the eye being in the interval gently but firmly supported by a pad of dry absorbent cotton, held in place with a flannel bandage. Atropia is used to keep the eye at rest and relieve pain, and the free administration of anodynes is likely to be needed. If the area of interstitial corneal infiltration continues to spread, the only hope lies in the free incision recommended by Soemisch. The point of a narrow Graefe cataract knife is passed into the anterior cham- ber through the sound corneal tissue on one side of the slough, and brought out on the other side of it, a bold cut being made. The knife should be turned on its axis before the incision is completed, to evacuate the aqueous humor slowly and avoid prolapse of the iris. Useful vision has been preserved by this procedure in a great many apparently des- perate cases. When the abscess bursts both externally and internally, there will be a gradual collapse of the anterior chamber ; the iris will fall forwards against the cornea, and vision will be greatly impaired, if not completely lost. 6. Gangrene Gangrene of the cornea is a frequent occurrence. It is most common in persons of a delicate, feeble constitution, after the operations for cataract, and the more severe forms of ophthalmia, especially those consequent upon smallpox and the contact of specific matter. It is often produced by escharotic substances. Chemosis, a condition previously described, is very liable to produce gangrene of this structure, unless the greatest care is taken in its treatment to prevent the strangulation of the vessels of the cornea. When this event is about to take place, there is a great and rapid increase of opacity, and the membrane soon assumes a sodden, macerated, and corrugated appear- ance. The local symptoms suddenly increase, but as the gangrene spreads the pain usually very sensibly diminishes in intensity. A deposit of pus often precedes the occur- rence of gangrene. When gangrene is threatened, all depletory measures must, as a general rule, be at once abandoned, and the patient put upon tonics, stimulants, and good, nutritious diet. The cornea should be touched every six or eight hours with a weak solution of nitrate of silver, consisting of about two grains to the ounce of water, and the system kept under the full influence of opiates, to quiet the eye and to promote sleep. The hot stoupe is pleasant and sometimes useful. If mercury was previously used, it should immediately be discontinued, as it cannot fail to do serious harm, by still further depressing the system. 7. Ulceration Ulceration of the cornea is a very common result of inflammation, par- ticularly of the traumatic kind. It is a frequent consequence of the lodgment of a foreign body, and a sequel of strumous, variolous, morbillous, and other forms of ophthalmia. The peculiarity of its structure, indeed, renders this membrane very liable to this morbid action ; it bears a very close resemblance to articular cartilage, and the slightest causes sometimes lead to its erosion. Disease of the fifth pair of nerves is a cause of ulceration of 170 DISEASES AND INJURIES OF THE EYE. CHAP. IV. tlie cornea. Tt is probable that the protracted use of unwholesome food may induce the affection by producing an impoverished state of the blood ; a condition of the system ill calculated to resist the effects of inflammation. Once set up, it is often difficult to arrest its progress, and to prevent the formation of disfiguring and injurious cicatrices. The disease may occur at any period of life, and under almost every variety of circumstances as to constitution and health, but is most common in young subjects of a feeble, delicate organization. Ulcers of the cornea assume every possible form and size, so much so, indeed, as to render it very difficult to furnish any accurate description of them. The most common variety, perhaps, is that in which the part has an excavated appearance, as if a solid por- tion of the cornea, comprising several of its layers, had been scooped out. In other cases the ulcer looks like a superficial abrasion, involving merely the epithelial investment of the cornea. Whatever form the ulcer may assume, its edges are generally somewhat everted, and more or less irregular, if not ragged, as may easily be seen by a careful in- spection with the aid of a glass. It is seldom that they are inverted or undermined. In general, the ulcer has a slight hazy appeartince, especially when cicatrization is about to begin, or has already made some progress. Ulcers of the cornea are usually attended with pain, lachrymation, and intolerance of light, and more or less vascularity of the diseased structures. If their progress be not checked, they extend in depth until they cause perforation of the membrane, escape of the aque- ous humor, and prolapse of the iris. They are apt to lead to incurable opacity, as a natu- ral result of the reparative process, especially when the erosion has been deep or extensive. Unless care be exercised, an ulcer of considerable size may exist upon the cornea, and yet entirely escape detection. To conduct the examination in a proper manner, the sur- geon should stand behind the patient, as he sits with his face fronting the window. The eye being now depressed, while the lids are held out of the way, the light will fall upon the cornea, and disclose any breach that may exist upon its surface. Oblique illumination is a still more effective means of examination. The treatment of ulceration of the cornea requires great judgment and alacrity. Under an idea that the disease is generally one of overaction, the plan formerly pursued was to deplete the patient, if not by the lancet, at least by leeching and purgation, to a point be- yond what is proper for the restorative process. The consequence too often was that the disease was aggravated instead of being relieved. Experience has shown me, that in nearly every instance, the affected part will be immensely benefited by an invigorating plan of treatment, consisting of the liberal use of quinine, or quinine and iron, along with a generous diet, and a full anodyne at least once in the twenty-four hours, especially if there be much pain. When the system is plethoric, and when there is an unusual de- gree of vascularity of the cornea and other structures, a few leeches applied occasionally to the temple, and the steady, but moderate, use of the antimonial and saline mixture, with a grain or a grain and a half of quinine to every dose, will go far in putting a speedy stop to the disease. As it respects direct applications, the fewer are made, as a general rule, the better. Atropia is generally applied, but some authors speak highly of eserine, which they think useful on account of its property of diminishing intraocular tension. Under the means just pointed out, the reparative process usually proceeds very kindly and unless the breach is uncommonly large, little opacity may be expected. It is only when there is a disposi- tion in the ulcer to extend, or when it has a foul, unhealthy aspect, that local remedies are called for, and even then they should be as mild and soothing as possible. One of the most eligible is the solution of nitrate of silver, in the proportion of two to ten grains to the ounce of water, applied directly to the sore by means of a very small camel-hair pen- cil, once a day, or every other day, according to the exigencies of each particular case. A very dilute ointment of the yellow oxide of mercury also answers a good purpose, as does also calomel lightly dusted on the ulcer. When the ulcer is of an unhealthy, pha- gedenic, or sloughing character, its surface may be touched with a stronger solution of nitrate of silver, or this article may be applied very gently in substance, shaped to a very minute point. A compress and bandage are often used with advantage. 8. Opacity Opacity of the cornea exists in various forms and degrees, from the smallest visible speck to a patch large enough to cover its entire surface. A hazy appear- ance of the membrane is present in almost all cases of corneitis, however slight. The more marked and concentrated forms of opacity are generally the result of the cicatriza- tion of deep ulcers and badly healed wounds. When the opacity is slight, it is usually designated by the term nebula, literally signifying a cloudy condition of the part; the hard, white, milky, concentrated spot, on the contrary, is known by the name of albugo, OH AP. IV. DISEASES AND INJURIES OF THE CORNEA. 171 represented in fig. 100. The distinction between nebnia and albugo has a real, practical significance; the former often disappearing spontaneously, or under very simple measures, whereas the latter seldom wholly subsides, whatever treatment may be adopted. Nebula, as it usually presents itself, is sit- uated either in the epithelial investment of the cornea, or immediately beneath it, in the superficial layer of this mem- brane, and often occupies a large extent of surface. Albugo, which frequently embraces the entire thickness of the cornea, is generally very hard and dense, white or milky in its ap- pearance, and of a circular, linear, or angular shape, its sur- face being sometimes smooth, at other times rough.# It is es- sentially an analogous tissue, but so imperfect a copy of the original that it can hardly be said to bear any resemblance to it. The cicatrice of an ulcer is called leucoma; and when the iris is involved in the ulcer, the affection constitutes what is known as adherent leucoma. Finally, cases occur in which the cicatricial tissue is partially transformed into fatty matter, fibro-cartilage, or even bone. The slighter forms of corneal opacity often disappear with the inflammation that has produced them, or within a short time afterwards. If the case prove tedious, or do not proceed satisfactorily, measures must be taken to promote the removal of the effused matter, among which the best are a solution of acetate of zinc, nitrate of silver, or sul- phate of sodium, or a very weak ointment of calomel, or of yellow oxide of mercury. I have derived great benefit, under such circumstances, from a little thin molasses poured upon the opaque cornea once a day, and also from washing the eye night and morning with tepid water, rendered gently stimulating with a little common vinegar or salt. Calomel dusted on the spot is a favorite remedy with some surgeons. For albugo in its aggravated forms, surgery holds out little prospect of relief; it is an organized tissue, part and parcel of the cornea, and no remedies, either local or general, can remove it. When the opacity does not affect the entire cornea, useful vision may oc- casionally be procured by constant dilatation of the pupil with atropia, and, when there is a portion of cornea sufficiently transparent, iridectomy may be performed, and an arti- ficial pupil established. 9. Staphyloma A protrusion of the cornea is technically known under the name of staphyloma; it is an occasional effect of inflammation and external injury, and occurs in every intermediate degree, from the slightest aberration of the normal shape to the most hideous deformity. Two principal varieties of the disease are usually recognized, the spherical, fig. 101, and the conical, fig. 102. The immediate cause of staphyloma is a weakened and attenuated condition of the cornea, especially of its central portion, in consequence of which it is incapable of resisting Fig. 100. Opacity of the Coruea; au Example of Albugo. Fig. 101. Fig. 102. Spherical Cornea. Conical Cornea. intraocular pressure. More or less opacity and a certain degree of abnormal vascularity attend the development of the disease, the progress of which is always tardy, several years usually passing by before it attains much bulk. The tumor is commonly of a coni- cal form ; and, as it proceeds, it gradually projects beyond the lids, separating them from each other, and descending towards the cheeks, its length varying from a few lines to up- wards of an inch. That portion which lies beyond the level of the lids is usually very hard, more opaque than the rest, and constantly inflamed from exposure to the light and the contact with irritants. When the disease is fully developed, the anterior chamber is anni- hilated, and the iris is not only lacerated, but closely adherent to the posterior surface of the cornea. Vision is always greatly impaired, and often completely destroyed. The staphy- 172 DISEASES AND INJURIES OF THE EYE. CHAP. iv. Ionia, after having attained a certain height, remains either stationary, or ulceration sets in, followed by perforation of the membrane, and the escape of the aqueous humor. There is a form of this affection which involves both eyes, although rarely in an equal degree, being most common in young subjects, from the age of eighteen to thirty. The tumor is smaller than in the inflammatory variety, and also retains a greater amount of transparency, the opacity being generally limited to the part projecting beyond the lids. The iris preserves its normal position, the pupil moves with its accustomed freedom, and the anterior chamber, instead of being obliterated, as in the ordinary form of the disease, is only enlarged and changed in shape. Vision is more or less impaired, and the coi’nea is remarkable for its glistening, sparkling appearance. In the incipient stage of staphyloma a gently antiphlogistic course is sometimes of ser- vice, if not in permanently arresting the disease, at all events in staying for a time its progress, and in preventing it from attaining any great development. The best remedies will be mild astringents, particularly the different preparations of nitrate of silver, oint- ment of the oxide of mercury, and solutions of zinc and lead, with frequent puncture of the cornea to take off the pressure of the aqueous humor, or the permanent diminution of pressure by iridectomy. In general, however, these means fail, and the surgeon is com- pelled to resort to other measures, especially if the tumor has attained so much bulk as to be constantly irritated by the contact of extraneous matter. The most appropriate remedy in this case is excision of the cone, or of all that portion which projects beyond the edges of the lids. For this purpose, the lids being held carefully out of the way, the apex of the tumor is transfixed with a tenaculum, and the knife—a sharp, narrow bistoury—is rapidly carried from above downwards, cutting off the requisite amount at a single sweep. Care is taken not to remove too much, otherwise the eye may either collapse from the evacuation of its humors, or, at all events, shrink so much as to interfere with the wear- ing of an artificial one. The excision should, however, include the ciliary body, as this may give rise to sympathetic irritation if allowed to remain. If the ball is at all tender or irritable, it is safe to extirpate it. The operation introduced by Critchett for the relief of this disease is performed by passing four or five curved needles, armed with silk, through the tissues of the globe be- hind the base of the staphyloma, in a vertical direction, as in fig. 103, in which the needles are seen in position. A puncture is then made into the sclerotica anterior to the plane of the needles, and with a pair of probe-pointed scis- sors an elliptical piece is re- moved, as indicated by the dot- ted lines. The needles are then in turn drawn through, and the sutures tied so as to approximate the divided edges as closely as possible. This affords a good support for an artificial eye by preserving a large portion of the globe. For the non-infiamma- tory species of comical cornea there is no cure, but a careful iridectomy or iridesis may be done to improve the optical condition of the eye. Concave glasses alone, or com- bined witli a diaphragm perforated with a circular or slit-shaped aperture, may greatly increase the vision. 10. Fatty Degeneration Fatty degeneration of the cornea is rather of pathological than of surgical interest, and, under the name of the senile arch, has been shown to con- sist essentially in a transformation of the horny tissue of the eye into a substance resem- bling fat. The altered part presents itself in the form of a gray ring, at the periphery of the cornea, near its junction with the sclerotica. The fatty transformation is not peculiar to the old, as the term senile would suggest, although they are undoubtedly most subject to it. It has occasionally been witnessed in children, and I have myself seen two cases of it before the age of twenty. It is often associated with fatty degeneration of the heart, arteries, liver, and other organs. Fig. 103. Critchett’s Operation for Staphyloma. 173 CHAP. IV. DISEASES AND INJURIES OF THE SCLEROTICA. DISEASES AND INJURIES OF THE SCLEROTICA. 1. Wounds—Wounds of the sclerotica may be of various kinds, as incised, punctured, and lacerated. They are, in general, easily recognized by their gaping appearance, caused by the retraction of their edges. When the sclerotica alone is divided, the bot- tom of the wound will be formed by the surface of the choroid, and will, consequently, present a black appearance. If this membrane is also divided, there will probably be a sac-like protrusion of the retina; and, should the lesion embrace all the tunics, there will necessarily be an escape of more or less of the vitreous humor. Incised wounds of the sclerotica readily unite by adhesive inflammation, the plasma which fills the gap becoming speedly organized and transformed into an analogous tissue. To promote this occurrence, both eyes should be subjected to the most perfect repose, for at least a week, by confining the lids with strips of isinglass plaster and a compress and bandage, as after the operation for cataract and artificial pupil. The patient must remain in a dark room, be well purged, and live upon light food. A suture is sometimes useful. Laceration of this membrane may be caused by a blow upon the globe, when the rup- ture usually occurs at a point opposite to that to which the violence has been applied, by a sort of contre-coup, or excessive distension of the fibres of the tunic. Hence, its most common site is either the upper or inner part of the sclerotica, where injury is seldom or never inflicted, the nose and superciliary ridge serving to shield it. The rupture may be limited to the sclerotica, or it may involve the other tunics, and be attended with escape of the vitreous humor and of the crystalline lens into the subconjunctival connective tissue. The treatment is the same as in an ordinary incised wound. If the lens is dislocated, it may be removed by a small incision after the wound in the sclerotica has closed. 2. Staphyloma Staphyloma of the sclerotica signifies a tumor formed by the protru- sion of this membrane beyond its natural level. The exciting causes are usually abnor- mal intraocular pressure and local inflammation, which produce atrophy, and, finally, excessive attenuation of the sclerotica, fol- lowed by a separation of its fibres and the protrusion of the other membranes of the eye. The affection is always accompanied by a discolored and disorganized condition of the inner structures of the eye. The size of the tumor varies from that of a currant to that of a hazelnut; it may be rounded or ovoidal in shape, and has usu- ally a bluish, purplish, or blackish appearance, from the presence of the pigmentary matter of the choroid. When the membrane is diseased at several points, there may be a corresponding number of protrusions, occurring either singly or in clusters. The annexed sketch, fig. 104, conveys an excellent idea of the situation, size, and shape of such tumors. The prognosis of this affection is-of the worst character; its very existence affords irrefragable evidence of incurable disease of the other structures of the eye ; and hence treatment is advisable only in so far as it may be designed to relieve deformity. With this object, the removal of the tumor may be attempted by snipping off the most prominent portion, trusting to shrinking for the disappearance of the remainder. 3. Sclerotitis Inflammation of the sclerotica seldom exists as a pure, uncomplicated affection; most commonly it arises during the progress of other ophthalmic diseases, especially corneitis and iritis. As an independent lesion, it may be induced by various causes, of which the principal are exposure to cold, a rheumatic or gouty state of the constitution, and the action of the syphilitic poison. It is most common in middle-aged and elderly subjects, and winter and spring are its favorite periods of attack. The symptoms are well marked. The pain is severe, throbbing, deep-seated, and liable to vesperal exacerbations; it usually extends to the forehead, temples, and upper part of the cheeks, and is aggravated by recumbency, and by the slightest motion of the eye, which feels full and tight, as if it were compressed by the hand. When the pain is less severe, the organ is sore and tender, or the seat of a distressing aching sensation. During the night, the suffering is often so excessive as to deprive the patient entirely of sleep, compelling him to sit up in bed, or walk the floor. In many cases there is hemi- crania, or a dull, heavy, aching pain in the side of the head, with great tenderness on pressure. In some cases, again, the pain is of a neuralgic character, recurring in regular paroxysms once or twice in the twenty-four hours. The eye is intolerant of light, the smallest quantity generally proving a source of extreme suffering ; and there is always an^ Fig. 104. Staphyloma of the Scle- rotic Coat, seen in Profile. 174 DISEASES AND INJURIES OF THE EYE. CHAP. IV. abundant secretion of tears, although usually very little discharge of mucus. Hence the edges of the lids either do not adhere at all, or only in a comparatively slight degree. If the eye be carefully inspected, it will be found that the discoloration is deep-seated, and of a faint bluish, pink, or lilac appearance, the vessels upon which it depends being exceed- ingly delicate, and disposed in parallel lines, converging towards the cornea, where they are very numerous and conspicuous, forming a well marked zone around its periphery, as in fig. 105. The disease, in its earlier stages, is in great degree, if not exclusively, limited to the sclerotica; in a short time, however, it may involve the other structures, especially the con- Fig. 105. Fig. 106. junctiva, cornea, and iris, as is seen in fig. 100. When this is the case, the ball of the eye often ex- hibits a bloodshot appearance; there is more or less haziness of the cornea, with development of vessels ; the pupil is sluggish, or entirely immovable, and the surface of the iris is altered in its color. . The lids are rarely, under any circumstances, materially involved in the morbid action. Much diversity obtains in regard to the state of the constitution; in many cases there is an entire absence of fever, while in others it may be present from the beginning, and constitute one of the most prominent symptoms. The diagnosis of sclerotitis is sufficiently easy, particularly in the early stages of the disease. The history of the case, the character and intensity of the pain, the excessive lachrymation and intolerance of light, and the peculiar nature of the vascularity of the affected membrane, cannot fail to enable the practitioner to distinguish it from other oph- thalmic affections. In conjunctivitis, the discoloration is superficial, and of a scarlet hue; in sclerotitis, it is deep seated, and of a pale pink, bluish, or lilac tint; in the former, the vessels are very large and arranged arboreseently ; in the latter, extremely small, almost hair-like, and disposed in straight, parallel lines, extending from behind forwards towards the cornea. Finally, in conjunctivitis, the vessels are movable; in sclerotitis, on the con- trary, they are fixed. The treatment must be influenced by the nature of the exciting cause, and the actual condition of the system. The milder, non-specific forms of the disease will generally readily yield to active purgatives, light diet, and diaphoretics. In rheumatic sclerotitis, the best remedies are colchicum and morphia, given in full doses in the evening, and in small doses several times during the day. My usual prac- tice is to administer a drachm of the wine of colchicum towards bedtime, with half a grain of morphia, using a hot and slightly stimulating foot-bath immediately after, so as to induce copious perspiration. The next morning, about ten o’clock, half the quantity of these articles is given, or the dose may be still smaller, according to the tolerance of the system. Syphilitic sclerotitis must be treated with calomel and opium, or some other form of mercury, carried to gentle ptyalism ; or with the iodide of potassium, in doses of ten to twenty grains three times a day, combined with an anodyne, especially towards bedtime. Solutions of atropia to the eye and anodyne liniments, embrocations, and unguents, ap- plied freely to the forehead, cheek, and temple, are often of great benefit in sclerotitis, how- ever induced ; the use of medicated steam, directed upon these parts, or hot stupes will also be found very agreeable and soothing. In some cases, it will be necessary to take blood from the neighborhood of the inflamed organ by cups or leeches. As to counterirritation, in all its forms, I am generally averse to it, for the reason that I have usually seen it do harm instead of good. This is especially true when it is applied to the temple, behind the ears, or even to the nape of the neck. It is less objectionable when applied to the arm, Sclerotitis. Scierotitis extending to the Internal Tunics. CHAP. IV. but even then it often fails to be of any material use in removing the morbid action. When sclerotitis becomes chronic, a mild course of alteratives and tonics will be necessary, aided by a properly regulated diet. 4. Tumors Neoplasms of the selerotica are very rare. In a remarkable instance of chondroma in the hands of Professor Chisolm, of Baltimore, the growth commenced at the age of three years, and gradually but slowly increased in volume until the age of twenty-five, when it was extirpated. The patient died on the thirteenth day after the operation from the effects of secondary hemorrhage, for the arrest of which the common carotid artery had been secured on the ninth day. A case of osteoma has been recorded by W atson. DISEASES AND INJURIES OF THE IRIS. The iris is liable to various accidents and diseases, of which the most common are wounds, inflammation, adhesions, and morbid growths. The inflammation which assails it may be idiopathic, although this is exceedingly rare, or it may be caused by a rheuma- tic, syphilitic, or strumous state of the system. 1. Congenital Vices The iris is subject to congenital malformations, of which the most common are absence of the membrane and irregularity of the pupil. The former of these defects, termed irideremia, is necessarily attended with very imperfect vision, the eye, in ordinary light, being constantly disposed to roll about. In the only instance that I have ever seen of it, the child was nearly blind, and the interior of the globe, instead of being of a reddish tint, as usually represented by authors, was remarkably black. In some of these cases the iris is not completely absent, but exists in a rudimentary state, forming a narrow ring at the periphery of the cornea. In a case of malformation which I saw not long ago, the pupil had the appearance of being double. It occurred in a man, twenty-eight years of age, whose sight was perfect although both eyes were in precisely the same condition. The pupil, which readily obeyed the light, was situated nearer the inner than the outer side of the globe, and occu- pied the inferior portion of the iris, extending down to the margin of the cornea. The more common variety is represented in the annexed sketch, fig. 107. The defect is called coloboma of the iris. The fissure is of a triangular shape, the apex extending downwards towards the ciliary margin of the iris. In rare cases, the pupil, although well formed, is not in its usual place. 2. Tumors.—Tumors of various kinds—solid, semisolid, and fluid—are liable to form in the iris either spontaneously or as an effect of external injury, and ultimately, as they increase in size, seriously en- croach upon vision, which is thus sometimes completely destroyed. The cystic tumor, fig. 108, from Mackenzie, is generally the result of wounds, and is believed, by Wecker, and others, to be due to sacculation of the iris, the contents being formed by the aqueous humor. Von Graefe has recorded a case of dermoid cyst; and a somewhat similar instance has been described by White Cooper. A vascular tumor is sometimes developed upon the iris, composed, as the name im- plies, of a congeries of vessels, connected by delicate fibrous tissue. In cases of this kind, described by Wardrop and Mooren, the growth, although small, often bled so profusely as to fill the anterior chamber with blood. When these tumors are harmless, surgical interference is improper; if, on the contrary, they are a source of suffering, or if they encroach seriously upon the cornea, and threaten the destruction of the eye, they should at once be excised. The cystic formation is sometimes relieved by a mere puncture, barely sufficient to evacuate its contents, and provoke obliter- ative inflammation. The cysticerce of the iris is uncommon. In a case re- ported by Teale, of Leeds, the hydatid presented itself as an opaque body, constricted in the middle, and a little larger than a hempseed. Removal was effected by iridectomy, the portion of membrane to which the parasite was adherent being included in the incisions. DISEASES AND INJURIES OF THE IRIS. 175 Fig. 107. Congenital Fissure. Fig. 108. Cystic Tumor of the Iris. 176 DISEASES AND INJURIES OF THE EYE. chap. xv. A few cases of sarcoma of the iris have been recorded, but the disease is very uncom- mon, and is not easily distinguished from the other affections. The growth is of a grayish or drab-colored appearance, interspersed with opaque points, very vascular and of a soft, jelly-like consistence ; as it advances, it closes up the anterior chamber of the eye, and gradually invades the other structures of the organ. Excision of the ball is the only remedy. In syphilitic subjects condylomata sometimes appear upon the anterior surface of the iris, forming minute tubercles of a grayish, whitish, or drab-colored hue, easily distinguish- able with the opthalmoscope. When numerous, they interfere with the movements of the iris; and, if they attain any considerable size, they are sure to come in contact with the cornea, exciting violent, if not destructive, inflammation of the membrane. The syphilitic history of the case and the peculiar appearances of the tubercles are the most reliable di- agnostics. Iodide of potassium in large doses, and bichloride of mercury are the most suitable remedies. 3. Mydriasis and Myosis—The movements of the iris are effected through the con- traction of radiating or circular muscular fibres, the former under the control of the sym- pathetic nerve causing dilatation of the pupil, the latter animated by the third pair of nerves producing its contraction. Mydriasis or dilatation of the pupil ensues upon para- lysis of the third pair, whether induced by a central lesion, or by rheumatic, syphilitic, or other inflammatory disturbance of its trunk. It may ensue also from the power to over- come the antagonistic circular ones. Its treatment must depend upon its cause, or it may require to be general; locally, in chronic cases, a weak solution of sulphate of eserine may be used. To improve vision, if defective, a diaphragm with a small aperture may be em- ployed, and a convex glass, when the power of accommodation is also deficient, as it is in nearly all cases. Myosis signifies a contracted condition of the pupil, which may follow upon paralysis of the radiating fibres consequent upon severe injuries of the cervical portion of the spinal cord, or pressure upon the cervical sympathetic by an aneurism or a morbid growth. Locally, the instillation of solutions of atropia may be employed. 4. Wounds The chief interest which such lesions possess is that they are productive of serious inflammation, the plastic matter that is poured out being very apt to cause morbid adhesions, interfering more or less with vision. Sometimes the iris is torn off from its ciliary attachments by a blow or fall, leading thus to the formation of an artificial pupil; the opening, even if comparatively small, never closes; while, if it is at all large it will seriously encroach upon the natural one, diminish its size, change its form, and cripple its action. Wounds are generally due to accident, and are caused by the pene- tration of the globe by sharp-pointed instruments, such as needles, scissors, or knives, which may also involve the lens, or by fragments of stone, iron, glass, and gun-caps, which are liable to lodge in its substance, and give rise to destructive inflammation. Such foreign bodies require to be extracted as speedily as possible, together with any portion of the iris which has been bruised or lacerated, by means of the ordinary opera- tion of iridectomy. Should the lens become opaque and swollen, or set up irritation by its pressure upon the iris, it should at once be extracted by the linear method, combined with iridectomy. 5. Injiammation Iritis may proceed from a variety of causes, of which the most important are, external injury, exposure, suppression of the cutaneous perspiration, a strumous, gouty, or rheumatic state of the constitution, and the operation of the syphilitic virus. It may be acute or chronic, and occur in both sexes, in every class of persons, and at all periods of life, even in young children. When it attacks the latter as an independent affection, the probability is that it is owing to a syphilitic taint of the system. The disease frequently begins in a very insidious manner, there being often an entire absence of the ordinary phenomena of ophthalmia, such as discoloration of the superficial tunics, or severe local suffering. In general, however, the pain is an early and prominent symptom, or soon becomes so; lachrymation and intolerance of light are also well marked. Unless the inflammation involves the conjunctiva, the disease may go on through its different stages, and even destroy the sight completely, and yet not occasion any con- siderable redness. The discoloration is limited usually to the sclerotica, at the corneal border of which there is always a distinct zone, as in fig. 109, formed by the Aessels of the fibrous coat as they anastomose with those of the iris and choroid. This zone, which is never absent, is at first of a faint rose color, but afterwards, when the inflammation is fully established, of a deep red, cinnamon, or brick hue. At the begin- CHAP. IV. DISEASES AND INJURIES OF THE IRIS. ning of the disease, there is a narrow ring of white between it and the cornea, but, as the morbid action advances, this is gradually lost by an extension of the vascularity. The Fig. 109. Fig. 110. Acute Iritis. vessels which produce the zone have a fine, hair-like appearance, with a radiated arrangement, and are seated beneath the conjunctiva, in the substance of the sclerotica in which they are immovably fixed, as seen in fig. 110. The pain of iritis is usually very severe and distressing, but cases occur where it is absent from first to last, although these are, of course, exceptional. Usually the pain is deep-seated, beginning apparently in the orbit, and rapidly involving the globe ; becoming more and more severe and constant as the disease progresses; subject to violent noc- turnal exacerbations ; and generally, especially in the more confirmed stages of iritis, extending to the surrounding parts, particularly to the temple, eye-brow, and cheek. Sometimes there is the most violent hemicrania, along with photophobia. The iris itself experiences most important alterations. Even at an early stage of the disease, it is already quite sluggish, while somewhat later it becomes insensible to light. Its anterior surface loses its fibrous appearance, and becomes rough and dull; and the pupil, diminished in size, is ultimately almost obliterated, at the same time it is observed to be deformed, and adherent to the capsule of the lens. In addition to these altera- tions, there is an extraordinary change in the color of the iris, contrasting strikingly with that of the healthy membrane. The morbid hue, usually somewhat greenish, is most conspicuous when the iris is blue ; less so, when it is brown or hazel. Finally, the iris is often preternaturally convex, especially towards the circumference ; the pupillary margin is greatly thickened; the aqueous humor is not only augmented in quantity, but rendered more or less turbid ; and masses of lymph are frequently observed in the anterior chamber, either loose, or adherent to the diseased membrane. When the disease is fully developed, the sight is either much impaired, or completely destroyed ; for not only is the pupil greatly contracted, so as to interfere materially with the transmission of light, but there is often opacity of the cornea, or of the lens and its capsule, and also a disorganized state of the retina and choroid. Fever, often of a high grade, attends the earlier stages of iritis. The distinction between the rheumatic and syphilitic forms of iritis, often obscure, will be best understood by the subjoined tabular arrangement:— Iritis, showing the Characteristic Vascularity of the Globe, the Iris being clogged with Lymph, and the Pupil contracted and irregular. Rheumatic Iritis. 1. Usually coexists with rheumatism or gout. 2. Most common in elderly subjects. 3. Often only one eye suffers. 4. There is little or no lymph in the anterior chamber and upon the anterior surface of the iris. 5. The aqueous humor is usually clear, or nearly so. 6. The pain is nearly constant, although liable to exacerbations, especially at night. Syphilitic Iritis. 1. With papular eruptions, sore throat, and other evidences of syphilis. 2. May occur at any age, even in infancy. 3. Generally both eyes are affected ; first one, and soon after the other. 4. The plastic deposits are always prominent, often presenting themselves in the form of little, fleecy, vascular, reddish-looking tubercles, at- tached to the surface of the iris. 5. Generally turbid, often highly so. 6. Very bad at night, but almost, if not en- tirely, absent during the day. The prognosis of iritis is grave, since, if allowed to progress, the disease is certain to damage the deep structures of the eye, more especially in the rheumatic and syphlitic varieties. 178 DISEASES AND INJURIES OF THE EYE. CHAP. iv. The treatment of iritis, when severe, must, in general, be antiphlogistic. Blood may be taken by cupping or leeching from the temples. The bowels should be thoroughly evacuated by cathartics, the heart’s action controlled by sedatives, and pain allayed by the liberal use of anodynes. In the rheumatic form of the disease, colchicum proves a valuable adjuvant to the alkaline salts generally used. Whenever there is plastic exudation, as in the syphilitic form, mercury, carried to the extent of ptyalism, is the main remedy. The medicine should be given in full doses, its effects, however, being carefully watched, lest profuse salivation should arise. The best article is calomel, in doses of one grain every four hours, properly guarded with opium, and continued until the gums become tender, when it must either be withheld or administered in smaller quantities. When the calomel is tardy in its action, it may be assisted by mercurial inunctions ; for, as already hinted, the object is to make as speedy an impression as possible upon the disease, in the hope of arresting the effusion of plastic material, which might plug up the pupil, and cause adhesions between the iris and the capsule of the lens. That it is well calculated to do this, experience has abundantly established, although we cannot explain the precise mode of its operation. Mercury, then, is the great remedy in this disease, the remedy par excellence, and should be given early and freely, until it has effected the object for which it is exhibited, when it may advantageously be followed by the iodide of potassium. The effects of the remedies here mentioned may occasionally be aided by counterirrita- tion behind the ears or to the nape of the neck ; but all direct applications should be dispensed with, except such as are of the most soothing character, as the steam of hot water and opium, fomentations, and light, medicated poultices. The circumorbital pains are often abated by anodyne embrocations, lotions, and unguents. Of the first importance is the early, frequent, and persistent use of atropia, which dilates the pupil, and thus removes the pupillary border of the iris from the convex central part of the lens, where adhesions are so certain otherwise to take place. A solution of four grains to the ounce should be thoroughly employed many times daily, by dropping it freely into the affected eye. Fresh adhesions may thus be stretched or broken, rest for the muscular fibres obtained, intraocular pressure diminished, and closure of the pupil, the main danger to sight, averted. Should the iritis, in spite of all remedies, remain intractable and assume a chronic character, complicated by firm adhesions and increased intraocular tension with great im- pairment of sight, a large iridectomy should at once be made. This will be found to be the best antiphlogistic, and the inflammation hitherto uncontrolled may rapidly subside. I have no experience with the use of turpentine in the treatment of this disease, but have given it in several instances, apparently quite favorable for the appropriate action of the remedy, and have not been able to perceive that it has been of any benefit. In debili- tated persons, in chronic cases, and in the latter stages of the acute attack, tonics may be demanded, as quinine and pyrophosphate of iron, in union with extract of nux vomica. fi. Prolapse Prolapse of the iris may be caused by wound, ulceration, or sloughing of the cornea, and may present itself in two varieties of form, the partial and the com- plete, of which the former is by far the more common. Complete protrusion of the membrane can only occur when there is most extensive injury of the anterior portion of the ball. Partial prolapse is usually produced by ulceration of the cornea, attended with perforation of all its lamellae. The opening thus made is immediately followed by an escape of the aqueous humor, with protrusion of the iris, by which the gap is effectually closed. Plastic matter being effused, the prolapsed portion forms adhesions to the edges of the ulcer, the site of which is afterwards indicated by a black spot with a slight peripheral opacity. From the manner in which the iris is dragged out of its normal position, the pupil, except in the milder varieties of the accident, undergoes important changes in its form, size, and situation, attended with corresponding alterations of sight. When the displacement is considerable, vision may be completely destroyed. The treatment must be regulated by circumstances, as it is impossible to lay down any particular plan for the guidanee of the surgeon. In complete prolapse, depending upon extensive destruction of the cornea, the case is, of course, hopeless ; if, on the other hand, it is caused by wound, the membrane should be immediately restored by means of a probe, and the lids kept well closed with alight bandage, until the parts have become thoroughly united. The success of the treatment will be greatly influenced by the care with which the replacement is effected ; if the patient is a child, quietude should always be insured by the administration of an anaesthetic, as it will hardly be possible to execute the procedure CHAP. IV. IRIDECTOMY AND ARTIFICIAL PUPIL. 179 in a satisfactory manner without this precaution. The after-treatment is conducted upon strictly antiphlogistic principles. When the prolapse is the effect of ulcerative perforation of the cornea, our hands are equally tied as in the complete form of the affection. To push back the iris, under such circumstances, would only lead to worse results; instead of this, therefore, the part is allowed to keep its place, for it is nature’s plug, and is absolutely necessary to close the artificial opening, how- ever much it may impair vision. When the iris is firmly adherent to the edges of the perforation, the protruding portion should be snipped off This variety of prolapse is well illustrated in fig. 111. The protruded part projects beyond the level of the cornea, looking somewhat like the head of a small fly; whence the term myoce- phalon, applied to it by oculists. When the iris protrudes through several apertures, it may give the surface of the cornea a black, tuberculated aspect, and may require retrenchment, in order to prevent injurious friction of the lids. In the treatment of recent prolapse, dependent upon wound of the cornea, free use should be made of belladonna, or atropia, with a view of bringing the iris as speedily as possible under the full influence of the remedy. By dilating the pupil, the membrane is drawn away from the cornea, and is, therefore, less likely to be permanently intercepted by the edges of the wound. When the wound is peripheral, the iris can be better drawn away from it by the use of a mydriatic. 7. Synechia—This is the name given to an abnormal adhesion of the iris to the cornea or capsule of the lens, the term anterior being added to designate the former, and pos- terior to signify the latter. Anterior synechia is caused by wound, ulceration, or slough- ing of the cornea ; posterior, by iritis. The lesion, in whatever form it may present itself, is always attended with impairment of vision, and occasionally with total blindness. Posterior synechia is often complicated with cataract. When the cornea and lens preserve their transparency, and the pupil is not completely obliterated, sight may sometimes be improved through the agency of atropia, and, at other times, by operation, the nature of which must be regulated by the character of the concomitant lesion. 8. Obliteration of the Pupil Obliteration of the pupil may be caused by the presence of plastic matter, filling up its aperture, either as an amorphous substance, or as an ad- ventitious membrane, adherent to its edges. In the latter case, the affection constitutes what was formerly termed a false cataract. The treatment must be regulated by the exigencies of the case: when the obliteration is dependent upon the presence of organized lymph, an effort at its detachment may be made with a very delicate, double-edged cutting-needle, introduced through the cornea; or, when other means are unavailing, an artificial pupil may be formed. IRIDECTOMY AND ARTIFICIAL PLPIL. Iridectomy, or the excision of a portion of the iris, may be performed as an efficient antiphlogistic in some inflammatory conditions of the eye, or may be needed for the purpose merely of making an artificial pupil. Its marked influence in dimin- ishing intraocular pressure recommends it in cases of ulceration of the cornea which threaten extensive perforation, or which, after perforation, are complicated by obstinate fistule, extensive prolapse of the iris, or marked and increasing staphyloma. In the extensive group of glaucomatous diseases, where there is an increase of ocular tension, followed by excavation of the disc and atrophy of the optic nerve, resulting in entire blind- ness, this operation, at an early stage of the disease, affords the only hope of its arrest. It is also a proper procedure in those intractable and recurrent cases of iritis or irido-choroiditis com- plicated by circular synechia, which entirely occlude the com- munication between the anterior and posterior chambers. It is performed, also, in the excision of morbid growths, and in the removal of foreign bodies from the iris. It would be profitless to describe the multitudinous operative procedures which have been proposed, but the one now recom- Fig. 111. Prolapse of the Iris. Fig. 112 Stop Speculum. 180 DISEASES AND INJURIES OF THE EYE. CHAP. IV. mended will avail either for the removal of a large piece of the iris in the conditions above mentioned, or, with slight modifications for the establishment of an artificial pupil for optical reasons only. The instruments requisite are a stop speculum to control the lids, a pair of toothed forceps for fixing the ball, and, when the incision is to be made inwards or upwards, angu- lar, lance-shaped knives; broad needles, fine, curved forceps, blunt hooks, and delicate, curved or straight scissors, as depicted in the subjoined figures. The patient should be placed in a recumbent position with the head slightly elevated. Unless strong reasons exist to the contrary an anaesthetic should always be given, since the slightest inadvertent movement of the patient’s head or eyeball might turn the point of the knife against the crystalline lens, wound its capsule, and cause a traumatic cataract. The lids being fixed with the stop speculum, fig. 112, the surgeon seizes the ball below the cornea, by grasping the conjunctiva and the tendon of the inferior straight muscle with the toothed forceps, delineated in fig. 113. Fig. 113. Toothed Forceps. A keratome, curved or straight, figs. 114 and 115, is then introduced through the sclerotica at a distance of half a line from the border of the cornea, and passed into the anterior chamber at its very periphery. The blade is carefully pressed forward on a plane parallel with that of the iris, until the incision is externally from two to two and a half lines in length. The knife is then slowly removed, to avoid any sudden escape of the aqueous humor. When the anterior chamber is shallow, or the pupil is widely dilated, the danger of wounding the lens may be obviated by making the incision with Graefe’s cataract knife. Fig. 114. Fig. 115. Straight Keratome. Fig. 116. Curved Keratome. Iris Forceps. The fixation forceps should now be given to an assistant, to control the globe, leaving the surgeon free to employ both hands in the next step, which consists in seizing the iris with the delicate curved forceps, fig. 116—introduced, if requisite, through the incision— withdrawing it carefully, and excising it with the scissors, placed close to the globe. The point of election ordinarily is in the upper direction, when the iridectomy is made to antagonize inflammatory changes, and then it should be extensive, including a large seg- ment of the iris. Fig. 117. Fig. 118. Broad Needle. Tyrell’s Hook. When it is desirable to establish an artificial pupil for optical reasons only, the operator must satisfy himself that a portion of the cornea preserves its transparency and normal curvature, and that there is a percipiency of the retina tor light, as tested by the flame ot a candle moved throughout the patient’s field of vision. An incision may be carried through the cornea with the broad needle, fig. 117, and a blunt hook, fig. 118, passed into the anterior chamber, with which the iris is entangled at its pupillary border, withdrawn CHAP. IV. IRIDECTOMY AND ARTIFICIAL PUPIL. 181 sufficiently from the incision, and excised with the scissors, fig. 119. "When practicable, the incisions should be so located as to leave a small peripheric portion of the iris intact. Fig. 119. Iris Scissors. The operation of Passavant, devised for the reestablishment of a pupil partially closed by adhesions, usually of a syphilitic character, may be substituted for iridectomy. An incision being made into the cornea with the needle, fig. 117, the iris is seized with a pair of delicate forceps midway between its periphery and its pupillary margin, and an effort made at traction, which generally results in the laceration of some of the morbid ad- hesions. This procedure may be required to be repeated even a number of times. Fig. 120. Fig. 122, Iridesis. Fig. 121. Artificial Pupil. Wecker’s Scissors Tridesis, introduced by Critchett, may be executed by passing a broad needle through the sclero-corneal junction, and placing around the incision a loop made of very fine silk, as 182 DISEASES AND INJURIES OF THE EYE. CHAP. IV. indicated in fig. 120, through which a delicate blunt hook is carried to the pupillary border of the iris, a portion of which is then withdrawn, and, instead of being excised, is stran- gulated with the silk, the ends of which are seized by an assistant with ciliai forceps and drawn tight. This operation is sometimes followed by iritis, and is now generally abandoned. A simple incision of the fibres of the iris will occasionally furnish a very satisfactory pupil, and it may be effected by means of the broad needle, affording the result depicted in fig. 121. The great danger of wounding the capsule of the lens and causing traumatic cataract must be fully considered. This procedure often gives excellent results in cases of occlusion of the pupil by inflammatory products after the extraction of cataract. Hay’s knife-needle is a convenient instrument for performing the operation. Incision of the iris under the name of iridotomy has recently been strongly advocated by Wecker, who has invented a pair of scissors for making the cut, represented in fig. 122. When the iris, capsule of the lens, and lymph are matted together in a membrane too tough to be cut with the needle or knife, without dangerous dragging upon the ciliary region, this instrument will often be found very efficient. An incision is made in the cornea with a small keratome and the iris is punctured; the scissors are then introduced, one blade passed through the iris and the other in front of it, and a free cut is made across the direction of its fibres. If the wound does not dilate by contraction of the iris, another incision is made forming a Y-shaped opening. By iridodialysis is signified a separation of the iris at its ciliary border, a procedure which affords occasionally a good result in cases of extensive opacity of the cornea, but where a peripheric portion of it remains transparent. A needle may be passed through the cornea, and with a delicate pair of forceps the iris may be grasped near its ciliary border, gently detached, and a sufficient portion withdrawn from the wound, and excised. A knowledge of the methods described will enable the surgeon to make any modifica- tion that may be demanded in any peculiar circumstances. The after-treatment will be essentially the same as that required in operations for cataract. DISEASES OF THE CHAMBERS OF THE EYE. The only affections of the chambers of the eye requiring special notice are, dropsical accumulations, effusions of blood, and the development of hydatids. 1. A morbid accumulation of water, constituting what is called hy dr ophthalmia, may exist simultaneously in both chambers, or be confined to one, more commonly the anterior. Dropsy of the anterior chamber is caused by thinning and distension of the cornea from congenital defect or inflammation. The ball is very hard in the earlier stages of the affec- tion, but, as the dropsy advances, it generally becomes soft, and fluctuates distinctly under pressure. The patient, experiencing a sense of distension, but no pain, is annoyed by deceptive vision, and gradually loses his sight, which is occasionally completely destroyed. In posterior hydropthalmia, there is always, or nearly always, a fluid state of the vitreous humor; the eye is very large, hard, painful, and moved with difficulty ; the sight progressively diminishes ; the iris is pushed forwards into the anterior chamber ; and the patient ultimately becomes completely blind. The prognosis in hydropthalmia is extremely unfavorable, especially in the posterior variety. An attempt may be made at relief by frictions around the eye with mercurial ointment, and the use of minute doses of calomel, with an occasional hydragogue cathartic, counterirritation behind the ears, and repeated evacuation of the fluid by means of a small puncture of the cornea. Rational, however, as this treatment apparently is, I have rarely derived any essential benefit from it. A large iridectomy may check the rapid enlarge- ment, and preserve some vision ; or extirpation of the ball may be required when the lids are insufficient to cover the protrusion. 2. In consequence of external violence, as a blow upon the ball, or spontaneous rupture of some of its vessels, an effusion of blood occasionally takes place into the chambers of the eye. In the female, it has been observed to occur as an effect of amenorrhoea, and in both sexes as a symptom of a scorbutic state of the system, attended with hemorrhage in •other parts of the body. The fluid usually disappears in a short time by absorption ; when the quantity, however, is inordinate, it may prove a source of irritation by its pres- sure upon the iris and cornea, and should then be evacuated by a small puncture through the latter membrane. 3. A species of hydatid, the cellular cysticerce of naturalists, is occasionally met with, CHAP. IV. CATARACT. 183 in the anterior chamber, floating about in the aqueous humor. It has hitherto been observed exclusively in young subjects, mostly under fourteen years of age, without any apparent cause. The parasite is about the sixth of an inch in diameter, and, as seen through the cornea, looks, wrhen fully unfolded, very much like a miniature balloon, as ex- hibited in flg. 123, being semitransparent, and often quite brisk in its movements, retracting and protruding its head and body at pleasure. The consequence of the presence of such a body in the anterior chamber must, necessarily, be more or less impairment of vision, with a tendency to excite inflammation in the inclosing structures. On this account, it should promptly be removed by an incision through the cornea, the patient being under the influence of anaesthesia. The cysticerce is probably more common in Prussia than in any other country. During my visit to Berlin in 18G8, Professor Von Graefe performed his one hundred and twenty-second operation for the removal of such a body from the eye. Professor Bonders, of Utrecht, who, like myself, wras present on the occasion, stated that he had never seen an example of it in Holland. In Great Britain, and in the United States, it is very rare, and its great frequency in Prussia is ascribed to the consumption of raw or uncooked pork by the people of that country. I have met with it twice in the horse. DISEASES AND INJURIES OF TIIE CRYSTALLINE LENS AND ITS CAPSULE. CATARACT. Cataract is an opacity of the crystalline lens, of its capsule, or of both. In the first case it is called lenticular cataract, in the second, capsular, in the last, capsulo-lenticular. These distinctions are of great practical moment, as they exert an important influence upon the operations that are required for their cure. Cataract may be single or double, simple or complicated, traumatic or idiopathic, recent or old, mature or immature, con- genital or acquired. Of these different forms of cataract, the capsulo-lenticular is the most common. When- ever the capsule is at all seriously affected, the lens must also speedily suffer, although the converse of this may not be true, cases occasionally occurring where the lens is completely opaque, and yet the capsule retains its transparency. Traumatic cataract is always of the capsulo-lenticular variety. Cataract is a very common disease, liable to occur at all periods of life, from birth to decrepitude, but the greatest number of cases are met with after the fiftieth year, or be- tween that period and the sixty-fifth. Many cases also occur between the fortieth and fiftieth year. The disease is often congenital, and sometimes occurs in every member of the same family, as in an instance mentioned to me by the late Professor Drake, where as many as six children suffered in this way. Twelve years ago, a man brought to me three of his children, two sons and a daughter, on account of double cataract. Of his other six children, three were affected with strabismus. In another family, four children out of six were the subjects of this disease, two having been affected with it from birth. Dr. Thomas J. Kennedy, of Tennessee, has communicated to me the particulars of a family consisting of six children, of whom three had congenital cataract. Of these, two were idiotic, and the other labored under harelip and cleft palate. Occasionally, again, the affection is hereditary, cases occurring in parents and their offspring for several suc- cessive generations. Males are more frequently affected with cataract than females; but in what ratio has not been determined. The probability is that the number of cases would be nearly, if not quite, alike in both sexes, if both were equally exposed to the exciting causes of the disease ; for it can hardly be supposed that the difference depends upon any other circum- stances. Cataract frequently comes on without any assignable cause, the subjects of it being often in the most perfect health at the time of its appearance, as well as during its subsequent progress. Sometimes it is traceable to the effects of external violence, as a blow upon the eye, or injury upon the head. Wounds of the lens and its capsule, whether incised, punctured, or lacerated, are always followed by cataract. Violent inflammation, Fijj. 123. Cellular Hydatid. 184 DISEASES AND INJURIES OF THE EYE. CHAP. IV. especially when it involves the deeper structures of the eye, frequently leads to this dis- ease, along with some of its worst complications. There are certain circumstances which are generally regarded, although, perhaps, not with sufficient reason, as so many predisposing causes of cataract. Thus, it is said that cooks, blacksmiths, foundrymen, and persons of kindred pursuits, are particularly prone to the disease. It is also supposed that sempstresses, watchmakers, and other artists, whose eyes are so constantly upon the stretch in viewing minute objects, are unusually liable to suffer from cataract. Without wishing to assert that these statements are wholly untrue, I have seen nothing to countenance them. Most of the cases of cataract that have fallen under my observation have occurred among farmers, mechanics, physicians, lawyers, and divines, who never injured themselves in this way, nor, so far as could be ascertained, in any other. Besides the disease often occurs in infants and young children, at an age when such exposure is impossible. I have never seen cataract in a watchmaker, in a foundryman, or even in a literary man who sat up late at night by the flame of his lamp or gasburner. I believe, therefore, that many of what are considered as predisposing causes of cataract exert no such influence, or only in a very remote degree. There is no question that the condition of the general system often exerts a powerful influence upon the production of cataract. I have repeatedly noticed the disease in per- sons of broken-down constitution, and many cases have been published in which it was evidently caused by diabetes. Cataract generally occurs in a very slow and gradual manner, several months usually elapsing before it exhibits its characteristic maturity. Occasionally, however, it is de- veloped with great rapidity. The disease may begin simultaneously in both eyes, but usu- ally one organ suffers for a time, and then the other becomes affected in a similar manner. There are cases, however, and they are by no means uncommon, in which the cataract is limited to one eye, the other escaping altogether, even if the patient survive the occur- rence a long while. It is sometimes supposed that, when one eye is cataractous, the other will, sooner or later, become cataractous also, in consequence of their sympathetic con- nection ; such an explanation, however, is obviously altogether insufficient, and we shall probably be much nearer the truth if we ascribe the secondary affection to the same cause as the primary. Morbid Anatomy Cataract varies much in its color, form, and consistence ; so much, indeed, is this the case, that hardly any two instances of the disease are precisely alike. The most common color of cataract is whitish, with various intermediate shades of grayish, yellowish, greenish, or brownish. The whitish appearance may be dull and lus- treless, or of a shining, glistening, or pearly character, like the interior of certain shells, or the surface of a silver coin. A yellowish, cineritious, amber, or pale buff tint is some- times observed, but not frequently. A greenish, olive, or bluish-gray hue. is also rare, and is generally indicative of a complicated state of disease. A brownish cataract is very uncommon ; and, as to the black variety of the affection, so much insisted upon by Beer and some other German authoi’s, I have never seen an example of it, although its occa- sional existence is undeniable. The gold-leaf cataract, as it has been termed, also very infrequent, is characterized by its brilliant metallic aspect, caused by the presence of crys- tals of cholesterine. The color of cataract is rarely uniform throughout the entire extent of the diseased structure; on the contrary, it is generally a shade or two darker at the centre than at the circumference. Cases occur in which the lens has a radiated, spoke-like, or stellar dis- position, caused simply by the lines which produce this appearance being of a darker color than the intervening substance. The capsular cataract is often a few shades lighter than the lenticular, and is also gen- erally of a more uniform color. It has sometimes a speckled, dotted, or punctiform appearance. According to the researches of Dr. Stellwag, of Vienna, the opacity in this form of cataract is not seated in the substance of the capsule, but is deposited upon its internal surface. This matter, which can be detected only with the aid of the micro- scope, is either of an earthy or a fatty nature, and is the cause of the mottled appearance in capsulo-lenticular cataract. In its consistence, cataract varies from that of milk to that of cheese, fibro-cartilage, cartilage, and even bone. A fluid cataract, properly so called, is very uncommon, and lias usually a hard nucleus, especially when it is comparatively recent. The consistence of the lens may be equal to that of jelly, curds, a thick solution of isinglass, or the white of a soft-boiled egg. The hard cataract exhibits numerous varieties. Thus, it may be CHAP. IV. CATARACT. 185 of the solidity of hard cheese, cartilage, bone, chalk, or earthy matter, and very dry, in- elastic, and incompressible. Capsular cataract is generally more or less tough, especially when old, and indisposed to yield under the pressure of the needle. It is worthy of note that an opaque lens is usually a few shades darker in the eye than it is after it has been extracted. The size of a lens, in a state of opacity, may be natural, augmented, or diminished. An increase of volume is most common in young subjects ; elderly persons, on the con- trary, have more frequently atrophy of the lens. In congenital cataract, or cataract com- ing on soon after birth, the lens is often completely destroyed, or so much wasted that it may be said to exist only in a rudimentary state. The capsule, in such a case, either retains its normal volume and shape, or it is shrivelled into a small, tough, and irregular mass, hardly as large as a currant. A form of cataract, to which the term lamellar has been applied, was first noticed by Jaeger, and was afterwards well described by Graefe. A short but graphic paper on the subject was also published by Dr. E. Williams, of Cincinnati. It is usually congenital, and essentially consists in a circumscribed opacity of a thin lamella of the lens, the periphery and central nucleus of which generally retain their natural transparency. Its progress is usually very slow, and it frequently remains completely stationary for years, if not during the rest of life. Cataract may exist as an independent affection, or it may be associated with other lesions. In the idiopathic form of the disease, the different structures are generally healthy; but when it lias been caused by inflammation or external injury, it is often con- joined with disease of the cornea, iris, choroid, and retina, which thus seriously compli- cates the capsulo-lenticular malady, and exerts an unfavorable influence upon the prognosis. The general health may be perfectly good, or variously altered; and this circumstance, again, may materially affect the issue of our curative measures. Symptoms Cataract usually manifests itself as an opaque speck immediately behind the pupil, in the centre or at the periphery of the crystalline lens, from which it gradually extends, until the whole of this body is of a whitish, milky, grayish, or drab color. Some- times the affected part, instead of being distinctly opaque, has merely a nebulous appear- ance, as if it were suspended in the interior of the lens ; at other times the opacity shows itself simultaneously at every point, although not with equal distinctness. The pupil is generally natural, and readily dilates and contracts under the influence of the light, its free margin forming a dark circle immediately in front of the cataract. The iris is un- changed in its shape, unless the diseased lens is unusually large, when it may be pushed a little forwards, and thereby rendered slightly convex. The cornea and aqueous humor retain their normal characters. During the formation of cataract, the patient is conscious of impairment of vision, usu- ally very slight at first, but gradually augmenting in proportion to the increase of the opacity of the lens and its capsule. He sees objects indistinctly, and, as it were, through a veil, haze, or mist; his sight is better in cloudy weather than in clear, and in twilight than in the bright sun, because the pupil, being then more dilated, admits a greater amount of light. In general, too, he can discern objects more distinctly by looking at them lat- erally than when they are placed directly in front of him. This is owing to the fact, already adverted to, that the opacity of the lens is generally greater at the centre than at the periphery, thus still permitting a certain quantity of light to come in contact with the retina. It is for the same reason that the sight is always temporarily improved by dilating the pupil with atropia. The formation of cataract is unattended with pain, intolerance of light, lachrymation, or disorder of the general health ; and hence, but for the gradual loss of sight, the patient would not be at all aware of the existence of the disease. In elderly subjects, the starting-point of the opacity is generally the nucleus of the lens, from which it gradually extends towards the exterior until the whole mass is involved in the morbid action. In congenital cataract, it nearly always commences at the centre of the lens, as a grayish-white, faintly striated object, the lines passing outwards towards the circumference. Sometimes the opacity originates as a minute dot, or a little obtuse cone, of a milky whiteness, in the superficial portion of the lens, just behind the capsule. Not unfrequently the whole lens is absorbed, its envelop alone remaining, usually, in a very shrunken, indurated condition. Cataract in children prior to the age of puberty is very uncommon; when it does occur, it is usually the result of injury, or of a congenital vice, which escaped the observation of the surgeon, the defective vision having been ascribed to the effect of shortsightedness. 186 DISEASES AND INJURIES OF THE EYE. CHAP. IV. Traumatic cataract is, at the beginning, nearly always cortical, but, in certain forms of injury, the opacity may occur simultaneously on the surface and at the centre of the lens. The disease, in either event, progresses very rapidly, and the lens, in young persons, brought in contact with the aqueous humor, is speedily absorbed, with the exception, per- haps, of a small portion, which, gradually undergoing the fatty and earthy degeneration, ultimately shrinks into a flattened, disc-like, mottled, or dead-white body, observable deep behind the pupil. The capsule, on the contrary, is seldom, if ever, completely absorbed ; instead of this, it contracts firmly around the remnant of the lens, at the same time that it becomes very tough, and coated with earthy, fatty, and inflammatory matter. When the entire lens has been removed, the capsule generally rolls itself up into a hard, dense, white body, often of a ring-like shape, which either floats about behind the pupil, adheres to the iris, or sinks down into the posterior chamber, where it can be detected only when the pupil is widely expanded by atropia. Diagnosis.—Cataract is liable to be confounded with amaurosis and glaucoma. From these, however, it may, in general, be readily distinguished by the following circumstances, placed, for the sake of greater clearness and more easy reference, in tabular form :— Cataract. 1. Impairment of vision is gradual, several months generally elapsing before it is completely lost. 2. The opacity begins either at the periphery or at the centre of the lens ; it is superficial, com- paratively well defined, and of a grayish, whit- ish, yellowish, or pearl color. It is seen equally well, whether the eye be viewed sideways or directly from before backwards. 3. The pupil is natural, with a dark circle, and promptly obeys the influence of the light; it also readily expands under the application of atropia. 4. Vision is best in cloudy weather, in twilight, in shady places, and when the back is turned towards the light. It is also increased under the influence of atropia. 5. Cataract forms without pain, headache, in- tolerance of light, or constitutional disorder. 6. In cataract, there is merely a mist or hazi- ness before the eye, with a distorted appearance of objects. 7. The sight is seldom entirely destroyed, how- ever protracted the disease. 8. The expression of the countenance is com- paratively natural and cheerful; the only per- ceptible change in the eye is the pupillary opacity. 9. The eyeball retains its natural consistence. Amaurosis and Glaucoma. 1. Vision fails rapidly, and is often lost in a few days or weeks ; sometimes, indeed, in a few hours. 2. It begins simultaneously at different points, is deep-seated, diffused, indistinct, and of a blu- ish, greenish, or azure hue. It is seen most satisfactorily when we look directly into the eye, not laterally. 3. The pupil is widely dilated and insensible to light. It dilates slowly and imperfectly, if at all, under the influence of atropia. 4. The patient sees objects most distinctly in a bright light, and in a particular direction, owing to the fact that the retina often remains sound for some time at one or more spots. No improve- ment of vision follows artificial dilatation of the pupil. 5. In amaurosis and glaucoma, there is often, if not generally, hemicrania, with neuralgia in or about the eye, sick headache, and other marked evidence of gastric and general derang- ment. 6. In amaurosis and glaucoma, objects of gro- tesque appearance may float before the eye, and the patient is annoyed with scintillations or flashes of light. 7. Completely lost in the confirmed stages of the disease ; prior to this, it is often alternately better and worse, in consonance with the condi- tion of the general health. 8. The countenance has a singularly vacant appearance, and the eye looks as if it were dead. 9. In amaurosis and glaucoma, the ball is often very soft, so that it may almost be indented with the point of the finger, or of stony hardness. Much stress was formerly laid upon the value of the catoptric test, as a means of diag- nosis in cataract. It consists in holding a lighted taper before the eye, the pupil being previously dilated, and the examination being conducted in a dark room. If the cornea and lens are in a sound condition, three images will be perceived, two being erect, and the middle, or intermediate one, inverted. Of these images, the anterior is produced by the cornea, and is the most distinct; the posterior depends on the anterior surface of the lens, and is comparatively faint; the central is caused by the concave surface of the posterior wall of the capsule, and is the smallest of all. If the taper be moved, the two erect fig- ures follow the light, but the inverted passes in the opposite direction. Now, in cataract, CHAP. IV. CATARACT. 187 the middle one will be found, even at an early stage of the disease, to be very obscure, if not altogether absent, and the deep, erect one very indistinct. In pure amaurosis, the three images of the candle are quite distinct. The diagnosis of cataract will be most easily made by means of oblique illumination and by the ophthalmoscope, facilitated by the application of atropia, which, by dilating the pupil, enables us to observe the condition of the lens, and to determine the site of the opacity, as well as its nature and extent. Useful information in regard to the con- sistence of the cataract may generally be obtained by a consideration of the age of the patient, the duration of the disease, and the color and size of the opaque body. The cataract of infancy is frequently capsular, or, if any portion of the lens remains, it is quite small ; in children and young subjects, the lens is generally soft; in elderly persons, on the other hand, it is nearly always hard. A very white or pearl-colored cataract is ordinarily soft; so, also, a cataract of unusually large volume. The very hard cataract is commonly small, and of a yellowish, drab, or amber hue. A recent cataract is gener- ally soft; and an old cataract hard. To these rules, however, there are, as might be ex- pected, numerous exceptions, which should have due weight in the establishment of a correct diagnosis. In congenital cataract both eyes are usually affected, and there is nearly always a peculiar oscillatory movement, termed nystagmus. This, however, may accompany ulceration and opacity of the cornea, and is, therefore, unreliable as a diagnostic. In glioma, the disease with which congenital cataract is liable to be confounded, the morbid growth begins in the retina, or, at any rate, deep behind the vitreous humor, and is invariably limited to one side. Traumatic cataract is sometimes difficult of detection on account of injury sustained by the cornea, iris, and sclerotica; in general, however, the history of the case and the nature of the opacity will sufficiently indicate its character. When the disease is of long standing, the anterior surface of the cataract is occasionally covered by blackish specks, caused by a deposit of pigment from the posterior surface of the iris. Such an appearance, which might readily mislead an inexperienced observer, can only be detected by a careful exploration. A brown or black cataract is usually very difficult of diagnosis. In capsular cataract, attended with complete destruction of the lens, the opaque mem- brane is generally remarkably shrivelled and irregular, and of a dead, chalky color ; it is either partially adherent to the iris, or it floats about in the posterior chamber, as a small, dense body, often difficult of detection without the aid of atropia and a concentration of light by means of a convex glass. The posterior portion of the capsule is less frequently cataractous than the anterior. Partial opacity may coexist with a healthy lens; but in the complete variety of the disease this body always participates in the morbid action. What was formerly called a false cataract is merely a layer of organized matter, which either completely fills the pupil, or is stretched from one point of its margin to another. The opacity is immediately within the pupil, which is generally contracted, and often immovable, even under the influence of atropia, and vision is more or less impaired, if not completely destroyed. Treatment When cataract has once commenced to form, no remedies or mode of treat- ment can arrest its progress; on the contrary, it will be sure to advance until the opacity is complete, and vision is almost entirely lost. Should one eye alone be originally affected, the other is extremely liable to become affected also, from the same causes which occa- sioned the disease in the first instance. The result of operation, which alone can prove of any benefit in curing the disease, will be influenced by a great variety of circum- stances, among which the most important are the state of the patient’s health, the presence or absence of complications, and the amount of inflammation consequent upon the inter- ference. Infancy and old age are no bar to surgical interference or its success; I have repeatedly operated, with the most happy effect, within the first six weeks after birth, and also upon subjects after the seventieth year. Indeed, in three cases I have succeeded in restoring excellent vision at eighty, eighty-two, and eighty-three. My opinion is that season exerts no special influence upon the result of the operation, and I, therefore, never postpone it on account of the state of the weather. It is customary with surgeons in operating for cataract to subject the patient to a cer- tain amount of preliminary treatment. This is particularly necessary in middle-aged and elderly subjects ; not so much so in children and young adults; while in infants at the breast it may, in general, be altogether dispensed with. If the patient is otherwise per- 188 DISEASES AND INJURIES OF THE EYE. CHAP. IV. fectly healthy, it need not be carried beyond the observance of rest and light diet for a few days, and the administration of one or two very mild purgatives. When there is a rheumatic or gouty state of the system, or a tendency to inflammation of the eye, it is hardly possible to be too careful respecting the preliminary treatment. In general, it is advisable not to operate until it is certain that the secretions are in a healthy condition, and that all tendency to inflammation of the eyes has disappeared. If the individual is inordinately plethoric, he may take an active cathartic every other night for a week before the operation When a gouty or rheumatic predisposition exists, a preliminary course of colchicum may be necessary, and, unless the case is very urgent, interference should be postponed until the arrival of warm weather. It is a good rule not to operate so long as one eye only is affected, for the reason that, if violent inflammation should arise, it may extend to the sound organ, and thus endanger the safety of both. Besides, even if there were no risk of this kind, which I think has been much exaggerated, be the result ever so favoi’able, the eyes, not being in the same optical condition, could not enjoy a similar amount of vision, although the patient might be rid of the opacity of the lens, and the consequent disfigurement of the part. Such are opera- tions of expediency, and their performance is of questionable propriety. In case, however, cataract exists in both eyes, although in an incipient degree in one, the rule is to operate upon the bad eye first, and at some future period, when the sight shall have more de- clined, upon the other. What should be the rule of conduct when both organs are affected in an equal degree, or when the person is nearly or totally blind ? This question has been answered differently by different writers. For my own part, I never hesitate to attack both eyes at the same sitting, believing that there is no more risk than when the operation is limited to one organ, while the procedure has the great advantage of obviating pro- tracted confinement and mental anxiety. I do not think that I have ever had cause, in a solitary instance, to regret this step. Before any operation is undertaken the surgeon should satisfy himself that the retina remains sensitive, and that the field of vision is of normal extent. This is done by placing before the patient, in a dark room, a lighted candle. lie should be able to recog- nize the general position of the flame at the distance of fifteen feet, and it should not anywhere be lost to view when moved throughout the field of vision. It is also important that the cataract should be “ ripe,” or fully formed. If any clear cortical matter remains it is likely to be scraped off in the passage of the lens through the wound, and, being transparent, cannot be seen or removed. It afterwards becomes opaque and swells, irri- tating the iris, and assisting in the formation of false membranes. Such an occurrence is a fruitful source of failure in cataract operations. Although the operations which have been devised for the cure of cataract are quite numerous, they may all be referred to three principal methods, displacement, division, and extraction. As these methods are not equally adapted to all cases, much judgment is often required in regard to their particular application. Displacement, or couching, an old operation, was so constantly followed by destructive inflammation of the eye that it has become obsolete, although a brief description of it will be given as a matter of his- torical interest. Division or solution is employed for soft cataracts, and in children; extraction is now performed for all forms of the disease in adults. 1. Division of the Lens Division of the cataract, or the operation by solution, con- sists, as the name implies, in cutting the opaque lens and its capsule sufficiently to subject them to the influence of the aqueous humor. The pupil is thoroughly dilated by atropia, and the lids are disposed in the manner exhibited in fig. 124, the patient sitting upon a chair with the head well supported by an assistant. The needle which I generally em- ploy is one of remarkable delicacy, perfectly straight, and sharp-pointed. Some surgeons prefer a curved instrument, as that of Scarpa, represented in fig. 125 ; but I have not been able to satisfy myself that it possesses any advantage over, if indeed it is equal to, the straight. Whatever may be its shape and size, it should be introduced at least two lines behind the cornea, a little below the horizontal diameter of the eye, in order to avoid the long ciliary artery ; the point should then be directed forwards in front of the lens and its capsule, into which several free incisions should be made. The object of the whole procedure is to bring the opaque structures, after they have been properly divided, under the influence of the aqueous humor, and the more effectually this is done the more rapidly will they be absorbed, but it is safer to be content with a moderate effect at one sitting and to repeat the operation several times if necessary. CHAP. IV. CATARACT. 189 Fig. 124, Fig. 125. Operation of Solution, Scarpa’s Needle. 1. Front view. 2. Side view. The late Dr. Hays, of this city, who had much experience as an ophthal- mic surgeon, devised an ingenious instrument for cutting up hard cataracts, and experience has shown that the operation is generally followed by the most gratifying results. The instrument, which is here represented of the natural size, fig. 126, combines both the advantage of a knife and a needle ; it is very acute at the point, and has a double cutting edge, a little over four Fig. 126. Fig. 127. Keratonyxis. lines in length on one side, but much less on the other. The whole arrange- ment bears a very close resemblance to that of an iris-knife. The instru- ment is introduced in the usual manner, and brought in contact with the anterior surface of the opaque lens, which, together with its capsule, is then freely lacerated and divided in front, in order that the remainder of the body may be fully exposed to the action of the aqueous humor, and so become softened and ultimately absorbed. If this be slow in taking place, another operation is performed. If the cataract is comparatively soft, the whole of it may be completely divided at the first sitting. The pupil should be well dilated at the time of the operation, and, also, for some days afterwards. There is another method of performing this operation, in which the needle is introduced at the lower part of the cornea, as in fig. 127, and made to act upon the capsule and lens through the anterior chamber. This is called the operation of kercitonyxis, or, simply, the anterior operation. The pupil being widely dilated, the head and eyelids are secured as in the former procedure, when the cataract is carefully divided with a very delicate needle, either straight or slightly curved. The instrument must be inserted near the outer border of the cornea, so that the resulting inflammation, if severe, may not lead to any injurious opacity, interfering with the transmission of light. I have performed this operation only a few times, but it does not seem to me to possess any superiority over the posterior method. It is, Hays’s Knife- needle. 190 DISEASES AND INJURIES OF THE EYE. CHAP. IV. however, the operation now universally performed by ophthalmic surgeons, as a wound in the cornea is thought to be much less dangerous than one in the region of the ciliary body. In performing this operation, portions of hard cataract sometimes fall accidentally into the anterior chamber, or are pushed there designedly, and cause injurious pressure upon the cornea in a manner similar to any ordinary foreign body. To save the eye, in such a case, from destructive inflammation, recourse should at once be had to linear extraction, by making an opening, not more than the sixth of an inch in extent, through the lower and outer part of the cornea. The offending substance is washed out with the escaping aqueous humor. The operation by solution is admirably adapted to the cataract of infants and young children. The patient, being under the influence of anaesthesia, is supported upon the lap of an assistant, or, what is preferable, his head is placed between the surgeon’s knees, while the body and limbs are held by a second person. If the exhibition of chloroform is undesirable, the little child is wrapt up tightly in an apron, as in the operation for hare- lip. This precaution is indispensable to the success of the undertaking. In other re- spects, the proceeding is the same as in the adult. The question is often asked, At what age is it proper to interfere in cases of congenital cataract? To this I unhesitatingly reply, at any period, provided the eye and general system are in a sound condition. I have repeatedly operated upon children under six months, and once upon an infant hardly four weeks old, with the most gratifying results. Indeed, my experience is that children, in general, bear this kind of meddling much better than grown persons, their nervous system, although easily shocked, recovering much sooner from the effects of the operation than adults. The operation of drilling devised by Mr. Tyrrell, of London, is a modification of kera- tonyxis, and is sometimes employed in false cataract, or in ordinary cataract attended with great contraction of the pupil, or contraction of the pupil and adhesion of its edges to the anterior surface of the lens. It is executed by carrying the common straight needle through the cornea, and thence on across the pupil, into the centre of the opaque lens, which is then perforated in such a manner as to admit the aqueous humor. The process is generally obliged to be repeated from four to eight times before a sufficient tun- nel is obtained for the transmission of light for useful vision. Such an operation is of questionable utility, and might, I should suppose, be advantageously replaced, in every case, by the posterior procedure, or by t lie anterior operation, preceded by iridectomy. The method by suction will be found useful in cases of fluid cataract, or in ordinary cases of needle operation, when the lens has undergone a sufficient amount of softening. A tubular curette, having a piece of flexible India-rubber tube attached to its extremity, will be required. In suitable cases, a puncture should be made in the cornea, through which the curette may be passed, and any dissolved lens material may be withdrawn by suction by the mouth through the tube. 2. Displacement of the Lens In the operation by displacement, more commonly called couching or depression, the lens is removed from the axis of vision, and buried in the substance of the vitreous humor. The pupil being widely dilated, the patient’s head properly steadied, and the lids held out of the way, a curved needle, very delicate, and somewhat spear-shaped, is pushed across the coats of the eye, at least two lines and a half behind the cornea, and carried carefully forwards until the point becomes visible in front of the cataract, as in fig. 128. The point being now applied against the lens, this is next pressed downwards and backwards into the vitreous humor beyond the axis of vision, and out of reach of the retina and the ciliary processes, as shown in tig. 129. The needle, being disengaged, is retained for a few seconds in the eye, to ascertain whether or not the cataract is disposed to rise; if it is, it is again depressed, and now with still greater care. To insure the successful execution of this operation, a certain degree of firmness of the cataract, and a tolerably healthy condition of the vitreous humor, are absolutely neces- sary. If the lens be soft, it cannot be depressed ; and, on the other hand, if the vitreous humor be fluid, or partially dissolved, it will afterwards be impossible to prevent the lens from rising. The result of depression is liable to be marred by the occurrence of retinitis; and the possibility of such a contingency is not limited to the first few days after the operation, but may take place a long time after the patient has completely recovered from its imme- diate effects. The cause of this occurrence is the pressure which the displaced lens exerts C H A P. I V. CATARACT. 191 upon the retina and the ciliary processes, which inevitably excites inflammation, which may be followed by complete disorganization of the eye. The lens, if not too hard, ulti- mately disappears after this operation, if not wholly, at least in part; but cases are met with, as dissection has demonstrated, in which it nearly all remains, much to the detri- ment of the part and system. For these reasons, the operation has been abandoned. Fig. 128. Fig. 129. Depression of Cataract. For many years past, I have been in the habit of performing a mixed operation for cataract, consisting of a combination of division and couching. The procedure, as the name implies, is executed by breaking lip the outer and more fluid portions of the opaque lens, and burying the remainder in the substance of the vitreous humor. It is, conse- quently, not adapted either to the very soft or to the very hard cataract, but to a union of the two ; an occurrence sufficiently frequent to render the operation one of no little impor- tance. Not having preserved a record of my cases, I am not able to state how often I have performed this operation, or with what results; I am, however, positively certain that it has never been productive, in my hands, of violent, much less of destructive, inflammation, and that in nearly every instance the patient obtained good vision. The pupil is dilated, as in the ordinary procedure, and everything else is precisely similar. I do not deem it necessaiy to describe the operation of reclination, as it is termed, a modification of the ordinary process of displacement, inasmuch as it is now obsolete. I have myself never performed it, but the cases of it that have fallen under my notice have all speedily terminated in total blindness. 3. Extraction—Extraction is a much nicer and more delicate procedure than that of depression or laceration ; it requires great coolness and dexterity on the part of the sur- geon for its successful execution. It is said of Wenzel that he spoiled a whole hatful of eyes before he had learned the art of extracting. This statement, without being strictly true, affords an excellent illustration of the difficulties which attend this operation, and a reason why so few practitioners are found who are ready and willing to undertake it. When well executed, and all the preexisting circumstances are propitious, it is the least objectionable operation of all; the whole of the opaque body is disposed of at a single sitting, the corneal wound generally heals by the first intention, and there is no danger either of immediate or secondary injury to the internal structures of the eye. On the other hand, if the greatest precaution is not exercised, there may be a sudden and unex- pected escape of the different humors of the organ, followed by complete collapse, or the eye may be destroyed within the first few days by inflammation. In performing extraction by flap operation, the patient should lie upon a lounge, or narrow table, the head and shoulders being properly supported by pillows, so as to render the former almost horizontal. If the patient is very timid or nervous, I do not hesitate to place him under the influence of chloroform, satisfied that the risk of losing the eye by vomiting is an extremely remote and improbable one. The upper lid is raised by an assistant, with the precaution of not pressing upon the eye. while the globe is fixed by seizing hold of a fold of the conjunctiva a quarter of an inch below the cornea, with the instrument sketched in fig. 130, and which also depresses the lower lid. Or, instead of this, and what will answer better; a pair of fixation forceps, devised for this purpose, may be used, the nibs, which should be rather broad, being gently pressed against the sclerotica a short distance below the cornea. The eye is now drawn somewhat down, when the surgeon, armed with a Beer’s knife, represented in fig. 131, to which I generally give the prefer- ence, inserts the point—supposing he is operating upon the left organ—into the cornea within a third of a line from its junction with the sclerotica, and a short distance below DISEASES AND INJURIES OF THE EYE. CHAP. IV. the horizontal equator. In executing this step of the operation, care must be taken to hold the instrument nearly vertically, otherwise it will pass between the lamellae of the cornea, instead of puncturing this membrane. Seeing now the point of the knife in the anterior chamber, it is carried carefully and slowly across towards the opposite side, in front of the iris, and brought out in such a manner as to divide fully one-half of the Fig. 130. Fig. 131. Beer’s Knife. Fig. 132. Conjunctiva Forceps. Superior Section of the Cornea. cornea, either at its upper, lower, or infero-external aspect, as may be most convenient; for, in point of utility, it really does not matter which, although the upper section is usually preferred. The extremity of the knife should issue at the same distance precisely from the sclerotica as that at which it entered. These several procedures are represented in figs. 132, 133, and 134. The section of the cornea being completed, the eye is im- mediately liberated, and permitted to conceal itself behind the lids, in order to enjoy a moment’s repose. Fig. 133. Fig. 134. Internal and Inferior Section of the Cornea. External and Inferior Section of the Cornea. The next step of the operation consists in gently elevating the upper lid, with a view of ascertaining whether the lens has any disposition to advance through the pupil. If it has, its expulsion is promoted by slight pressure upon the ball of the eye with the handle ot a knife or the end of the index finger. Should this fail, the surgeon introduces a deli- cate hook, represented in tig. 135, and lacerates the central portion of the capsule; the lens, being thus liberated, now issues of its own accord, or at all events with the aid of a little friction upon the globe. Fig. 136 represents the lens as it is passing through the wound in the cornea. CATARACT. 193 CHAP. IV. The third and last stage of the operation consists in replacing the iris, should it be pro- lapsed, in readjusting the flaps of the cornea, and in confining the lids by means of several strips of isinglass plaster, with the twofold object of keeping them quiet and of preventing the ingress of light. A light bandage, or, what is better, a very thin handkerchief, carried round the head, completes the dressing. Several accidents are liable to happen during this operation which should be carefully avoided. Fig. 135. Fig. 136. 1st. The point of the knife may become entangled in the iris in making the section of the cornea; should this happen, the instrument must be disengaged, but not withdrawn, and the iris stimulated to con- traction by gentle friction upon the cornea. This failing, the knife is Lens passing through the Incision of the Cornea, Fig. 137. Curved Cornea Knife. laid aside, and the division completed with a probe-pointed bistoury, fig. 137, or a pair of scissors, tig. 138, one blade of which is blunt at the end. The flap, as already stated, should comprise fully one-half of the circumference of the cornea. 2d. There may be prolapse of the iris ; this occurrence is by no means unusual, and is generally easily remedied, replacement being readily effected with a small probe. 3d. There may be an escape of the vitreous humor, followed by partial or complete collapse of the globe. This may be occasioned simply by the involuntary action of the muscles of the eye, and, therefore, be wholly beyond the control of the surgeon ; or it may be caused by too free a section of the cornea, or by inadvertent pressure upon the globe. However induced, the eye should instantly be closed, and, after a brief period of repose, the parts should be readjusted, as under ordinary circumstances. 4th. An opaque capsule may remain, the lens alone escaping, thus rendering the result imperfect. The proper plan, in such a case, is either to extract the capsule on the spot, or to dispose of it with the needle, when the eye shall have recovered from the immediate effects of the operation. 5th. The extraction is sometimes followed by intraocular hemorrhage, dependent upon the rupture of some of the vessels of the choroid. The blood is generally of a venous character, and, as it escapes, it usually displaces the vitreous humor, forcing it out of the eye, and thus completely defeating the object of the operation, besides inflicting severe suffering upon the patient. The immediate effects of the accident are faintness, nausea, and agonizing pain, seated deeply in the ball of the eye, and radiating through the fore- head, nose, and temples, the lids being so exquisitely sensitive as to render the slightest touch almost insupportable. Inflammation, often of a destructive character, soon follows, Curette, with Silver Scoop. 194 DISEASES AND INJURIES OF THE EYE. CHAP. IV. and greatly aggravates the distress. The treatment should consist of cold applications to the eye, the copious abstraction of blood, and active purgation, with elevation of the head, the careful exclusion of light, and the free use of anodynes. Fig. 138. Probe-pointed Scissors. 4. Linear Extraction This operation, devised by Gibson in 1811, modified soon after by Travers, and lately revived in Germany, consists in making a small incision through the outer and lower part of the cornea, from the eighth to the sixth of an inch in extent, in freely dividing the capsule and lens with a fine cutting needle, and in re- moving the fragments, after they have been brought into the anterior chamber, with a scoop. If thorough comminution has been effected, most of the fragments will probably be washed away by the aqueous humor, as it gushes through the wound ; if not, they should be carefully extracted, unless they are very small, when they may be left in the hope of being speedily absorbed. Linear extraction is, of course, applicable only to soft cataract, and recommends itself by the facility of its execution, the little risk of inflammation, and the rapidity with which it affords relief. Chloroform may be administered if the patient is unusually timid or un- ruly. Great care should be taken not to injure the iris or to contuse the edges of the wound in the cornea. A modification of this operation, proposed by Von Graefe, was further perfected by Waldau, of Berlin, and has been more or less extensively practised in Europe and this country. It consists in making an incision through the cornea, close at its edge, for about one-third of its circumference, in drawing out and cutting off' the corresponding portion of the iris, in tearing up the anterior segment of the capsule, and in extracting the lens with a delicate scoop. Care is taken not to wound the hyaloid membrane, lest there be an escape of its contents. A good deal of blood sometimes collects in the anterior chamber of the eye, and when this is the case it must be dislodged before the rest of the operation can be proceeded with. If the manipulations are properly executed, the entire lens may be removed in one effort. Any fragments that may remain are disposed of by the intro- duction of the scoop, and by gently rubbing the ball through the lids. This procedure is known as the traction method. In the original operation of Waldau, a bit of the iris was left at the ciliary margin, to afford support to the vitreous humor; but it was soon found that the procedure greatly increased the danger of inflammation, without offering any compensating advantage, and it has, therefore, been abandoned. 5. Graefe's Operation An operation which combines all the merits of the flap ex- traction and the linear method with traction, together with superior advantages of its own, was devised by Von Graefe, and termed by him the “ peripheric linear extraction” Fig. 139. method. His extended clinical experience enabled him to render each step of his opera- tion so perfect that it is accepted by ophthalmic surgeons universally as the best now known. It is most readily described by dividing it into four stages : 1st. Inci-ion ; 2d. Iridectomy ; 3d. Laceration of the capsule ; 4th. Removal of the lens. The instruments required are the stop speculum, fixation forceps, iris forceps, and scis- Graefe’s Cataract Knife. CATARACT. 195 CHAP. IV. sors, described under the head of iridectomy, added to which are a capsule tearer, or cys- totome, a caoutchouc spoon, and narrow knife. As the pain in the operation is not severe, and as it is very desirable that the patient should give some assistance in moving the ball, if it should be found requisite, an anaes- thetic should not be given if it can be avoided. The patient having been placed in the recumbent position, the surgeon, if limited to the use of his right hand for his incision, must place himself behind the patient for his right eye, and at his left side for the opera- tion on the left eye. Having secured the eyelids by means of the speculum, the surgeon seizes the conjunctiva, beneath the cornea, with the fixation forceps, and thus gains control of the ball; or, what is better, he grasps, as is the practice of Ur. Levis, the inferior straight muscle. Holding the knife with its cutting edge upwards, he then introduces it at a point a line be- hind the corneal border and a line below an ideal tangent to the cornea at its apex, designated as ci in fig. 140. The point of the knife should be directed towards c, until 3 or 4 lines of it have entered the anterior chamber, when its point is elevated, by depressing the handle ; it is then carried to the point b, and a counterpuncture made through the sclerotica. The edge of the blade is now turned forwards, and the knife carried onwards until its length is exhausted, when the section is to be finished by drawing it backwards until all the tissues have been divided except the conjunctiva, which should be cut so as to leave a flap of not more than a line or a line and a half in extent. If these steps have been exactly followed, the anterior chamber will have been opened at its periphery by an incision which shows little tendency to gape, and which will be from to 5 lines in extent, and, although not strictly linear, yet giving a flap of line in height. Confiding the fixation of the ball to an assistant, the surgeon, with the iris forceps, seizes the iris about one line from the temporal extremity of the cut, draws a portion of it out, and, with successive clips with the scissors, divides it at its ciliary attachment, and gradually making the traction towards the nasal end of the incision, finally excises it there as closely as possible to the ball. The fixation forceps being resumed by the operator, the anterior capsule is lacerated with the cystotome, fig. 141, which should be carefully passed to the lower border of the Fig. 140. Graefe’s Corn- eal Incision. Fig. 141. Cystotome, with Caoutchouc Spoon. pupil, when its sharp point should be turned against the capsule, which should be incised in a direction upwards and outwards; the point should be again passed to the same spot, and an incision upwards and inwards effected ; these two should then be united by a transverse cut across the capsule, when the lens will probably be freed and will be seen to advance. The surgeon still retains control of the ball, while, with the caoutchouc spoon, fig. 141, applied with its convex surface to the lower border of the cornea, he makes a pressure which has for its object the tilting of the upper margin of the lens towards the corneal in- cision. When this has been accomplished, a gentle upward motion of the spoon will cause the cataractous lens to emerge more and more, and finally to escape entirely from the wound. When this manipulation does not succeed, the lens must be withdrawn by one of the traction instruments, the best of which is a delicate wire loop, fig. 142, devised Fig. 142. Dr. Levis’s Wire Loop. by Dr. Levis. Should any cortical matter or blood remain, it should be removed by gentle pressure upon the cornea with the spoon, or, after the withdrawal of the speculum and a little delay, by pressure and counterpressure with the finger tips upon the closed lids. 196 DISEASES AND INJURIES OF THE EYE. chap, i v. All coagula having been removed, and the edges of the wound brought into contact, the lids should be closed, and confined by a piece of soft linen, covered with small tufts of char- pie or cotton, evenly distributed, so as to till the orbital cavity, the whole being retained by a flannel roller passed thrice over the eye and around the head, with the precaution of not making any undue pressure upon the ball. The sound eye should be closed with isin- glass plaster. Graefe was in the habit of removing the dressing late on the evening of the operation ; but, unless there is much discharge or some unusual occurrence, this will not be necessary until the morning visit, after which it should be renewed once a day, the eyelids having been previously gently washed, but not opened. At the end of a week it may be dis- continued, and a shade, to exclude light, be substituted. Should there be pain severe enough to prevent sleep the first night, a subcutaneous injection of morphia may be ad- ministered, and atropia applied. This is the basis of the modern operations for extraction. Most surgeons now prefer to make the section more anterior, and the puncture and counterpuncture lower down. Several modifications in the method of lacerating the capsule have also been proposed, the latest of which is “ peripheral cystotomy.” Two other operations, introduced a few years ago, and known as Liebreieh’s and Lebrun’s, have some advocates, but have not met with general favor. Liebreieh makes a slightly curved incision in the lower half of the cornea, the puncture and counterpuncture of which are one millimetre beyond the margin of the clear cornea, and the lowest part of whose curve is or 2 m. above the lower corneal margin. No iridectomy is made. Lebrun’s incision differs from Liebreich’s in being made in the upper part of the cornea, having a sharper curve, and commencing and ending in the seleroeorneal junction, instead of beyond it. 6. Extraction by Suction.—This is another modification of the operation of extraction, announced by Tangier in 1847, and afterwards improved by Blanchet and Teale. It is applicable only to the very fluid forms of cataract, such, for instance, as that produced by a blow upon the eye, and essentially consists in opening the cornea and sucking out the opaque matter with a curette, attached to a flexible tube held in the mouth. The patient being fully under the influence of chloroform, and the pupil widely dilated with atropia, a small aperture is made with a cutting needle in the inferior portion of the cornea, when the instrument is pushed into the lens so as to rupture its capsule. The curette then takes the place of the needle, and the suction is performed in a gentle and steady manner with the precaution of avoiding injury to the vitreous humor. By this procedure vision is restored in a few minutes, and the patient is generally able to use the eye in less than a week. It should, nevertheless, not be employed indiscriminately, as it is occasionally followed by destructive inflammation, and for this reason the operation by solution is generally decidedly preferable. After-treatment—The after-treatment, in all these operations, is conducted upon mode- rately antiphlogistic principles. The light is carefully excluded from the apartment, the patient’s head and shoulders are constantly maintained in an elevated position, the diet is of the mildest character, but rather nutritious than otherwise, and the bowels are occa- sionally relieved by a gentle aperient. If active inflammation arises, blood is sometimes taken by leeches or cups from the temples, and the eyes are frequently fomented with warm chamomile tea. If there is much pain, especially of a neuralgic nature, calomel, and opium, calomel and Dover’s powder, or what will be found more efficacious than either, wine of colchicum and acetate of morphia, are liberally employed along with suit- able doses of quinine. Depletion after these operations is not carried nearly so far now as formerly. After extraction, in particular, too much caution cannot be used in this respect, inasmuch as too great a drain upon the system might seriously interfere with the union of the corneal wound. When the patient is old or infirm, a nutritious diet and other means calculated to give tone to the system are indispensable to success. The bandage may usually be dispensed with in a w'eek or ten days, a green shade being used as a substitute. The eye must not be employed upon minute objects for several months, and the patient slionld consider himself for a long time as an invalid, avoiding all indiscretions, both bodily and mental. As the sight improves in strength, and after all tenderness consequent upon the operation has disappeared, but not until then, he may begin to wear cataract glasses, of which he should furnish himself with two pairs, with lenses of different degrees of convexity, according as he may wish to view near or dis- tant objects. The best lenses are made of pebble, as it is less liable to be scratched or CHAP. IV. broken than plate-glass. The frame should he very light, and consist of steel. Tinted lenses may be used when the eyes remain lontr weak and intolerant of light. Much of the success which has attended these operations in my hands may, I think, be fairly ascribed to the care which I have always taken in preparing the patient’s sys- tem, and to the practice which I have pursued, for many years, of administering a full anodyne, as a third or even half a grain of morphia, immediately after he has been put to bed. This seldom fails to prevent pain, to secure rest to the eye, and to induce sleep, three circumstances of immense consequence as it respects the favorable issue of the case. The remedy is especially valuable in nervous, irritable persons, and in such as are liable to suffer from nausea and severe shock after trifling accidents and operations. DISLOCATION OF THE CYSTALLINE LENS. Dislocation of the crystalline lens forwards into the anterior chamber, exhibited in fig. 143, is a rare occurrence. It may arise without any assignable cause, although generally it is chargeable to external violence, directly or indirectly applied. A married woman, aged thirty-six, a native of Germany, had been laboring under dislocation of the lens for three years when I first saw her. The accident happened suddenly one night with- out any pain or even any unpleasant feeling, ap- parently while she was asleep. The next day, however, she was seized with violent pain and inflammation, which lasted for nearly two months, when it gradually subsided. It is worthy of re- mark that she had had no sight in that eye for seven years previously. The lens lay in the lower part of the anterior chamber, in close con- tact with the cornea and iris, and was of a coni- cal shape, the apex looking upwards; it was opaque interiorly, but semitransparent above, and was so situated as almost to close the pupil, The cornea was natural, but the iris was tremu- lous, thrust back, or indented below, and changed in color, being much lighter than the right, which was of a grayish hue. The pupil was small and immovable. The sight was completely destroyed. Another case was that of a colored woman, aged forty-nine; the right lens, which had been dislocated for four years, without any assignable cause, was of a dirty drab color, and occupied the anterior chamber ; it rested against the posterior surface of the cornea, and pressed aside the iris, the pupil being contracted into a narrow, slit-like aperture. The eye was completely blind, and had been the seat of neuralgia, off and on, ever since the occurrence, which was followed by severe inflammation. This accident may result from very slight causes, as pressure upon the ball by the finger, the shock of a fall, or even sneezing. It is recognized by the sudden change in the optical condition of the eye, as well as by the presence of the lens, partially or entirely displaced, as ascertained by oblique illumination. The proper remedy for such an occurrence obvi- ously is the extraction of the lens, with the employment of active antiphlogistic measures, to moderate and relieve the resulting inflammation. If the case is one of long standing, the operation would still be proper as a means of improving the appearance of the eye, and preventing secondary effects. Dislocation of the lens, either partial or complete, into the vitreous humor may also occur. It i4 occasionally met with as a congenital defect. AFFECTIONS OF THE VITREOUS HUMOR. The most important affections of this humor are foreign bodies, effusions of blood, ento- zon, inflammation, opacity, and softening. Foreign bodies, ns fragments of gun-caps, steel, and glass, sometimes penetrate the eye, and lodge in the vitreous humor, causing inflammation of its substance, along witli more AFFECTIONS OF THE VITREOUS HUMOR. 197 Fig. 143. Dislocation of the Lens into the Anterior Chamber. 198 DISEASES AND INJURIES OF THE EYE. CHAP. IV. or less opacity, and loss of vision. Eventually the extraneous matter falls down into the lower part of the organ, and coming in contact with the retina and choroid coat, not only produces excessive suffering but complete disorganization of these structures. Detection is usually readily effected with the ophthalmoscope, if the examination be made soon after the occurrence of the accident, otherwise it may be difficult, if not impossible, as the foreign body is soon surrounded by a layer of fibrin, which thus serves to mask its character. Ex- traction is effected either through the sclerotic coat, or through the cornea, the lens, in the latter case, being of course removed as a preliminary step. The operation is not always successful. The probe-pointed magnet will sometimes be found useful. Affusion of blood into the vitreous humor is caused either by external injury, as a blow on the eye, or by a rupture of the vessels of the retina or choroid, more especially of the anterior portion of the latter, as this is more vascular than any other. The fluid is either extensively diffused, or, as not unfrequently happens, it occurs in circumscribed spots, of variable form and size, and of a dark reddish or purplish color. The traumatic variety is generally attended with partial detachment and laceration of the retina or of the retina anil choroid, and with ecchymosis at the bottom of the eye. The nature of the case is generally easily determined with the aid of the ophthalmoscope. If the blood exists in small quantity it will probably be rapidly absorbed, otherwise it may remain permanently, the clot gradually becoming pale, and undergoing fatty degeneration. The treatment is restricted to cold applications and the exhibition of iodide of potassium with minute doses of mercury. The cysticerce has been found only a few times in the vitreous humor. Liebreich, who has given a graphic account of the parasite as it occurs in this portion of the eye, states that it is originally developed behind the retina, from which it at length escapes into the vitreous chamber, where, after it bursts its cyst, its movements may be distinctly seen with the aid of the ophthalmoscope. Although it does not at first cause any inconvenience, it ultimately excites inflammation of the eye, attended with more or less impairment of vision. Liebreich, in one case, not only detected the parasite but successfully extracted it by passing a pair of canula-forceps into the vitreous humor, the operation being greatly facilitated by illuminating the eye with an ophthalmoscope fastened to the forehead, leav- ing thus both hands free for the necessary manipulations. Inflammation of the vitreous humor, technically called liyalitis, is very uncommon as an independent affection, but may occur as a result of choroiditis, the presence of foreign bodies, or injury inflicted upon the eye in operations for cataract. It is attended by deposits of fibrin, leading to opacity of its substance, and by marked impairment of sight. Some- times the vitreous humor is completely dissolved during the progress of the disease, or in- terspersed with fatty matter, particles of cholesterine, or films of lymph, obstructing vision, anil causing all kinds of fantastic objects, as motes, flies, and other insects, to float before the eye. A syphilitic form of liyalitis is occasionally met with, either as an inherited dis- ease occurring about the age of puberty, or as a tertiary accident, usually coexistent with other evidences of a constitutional taint. However induced, the morbid changes can only be detected by careful ophthalmoscopic inspection. The treatment must be managed upon general principles. The vitreous humor is liable, from various causes, to softening, breaking down into a fluid state, which is not, however, necessarily attended with loss of transparency and di- minution of the tension of the eyeball. External injury, surgical operations, and inflam- mation of the choroid coat, retina, and hyaloid membrane are the most common causes of this occurrence, for which there is, of course, no relief. Desmarres and Macnamara have described a curious condition of the vitreous humor, called sparkling synchysis. It is dependent upon the presence of innumerable particles of cholesterine, which, under the ophthalmoscope, “appear like a multitude of grains of gold-leaf, whisking about in all directions when the eye is turned quickly from one side to the other.” The material may arise, it is thought, from degenerative changes in a dislocated lens, a great portion of which is absorbed, while the insoluble cholesterine is left in the vitreous humor. It is, however, met with where the lens is not affected. DISEASES OF THE ItETINA. The retina, like the other tissues of the eye, is liable to inflammation and its various consequences, leading to disorganization of its structure and to loss of function. The dis- ease, at one time, is acute and characteristic, being marked by symptoms which no one can possibly mistake ; at another, slow, chronic, and so obscure as to elude scrutiny ; CHAP. IV. DISEASES OF THE RETINA. 199 now transient and easily combated; now inconceivably obstinate, and hopelessly irreme- diable. Considering the delicate structure of the retina, its concealed situation, the im- portance of its functions, and the extent and character of its connections, it is not surprising that the nature of its lesions should have been so long misunderstood. As these lesions are seldom fatal, few chances have been afforded of inspecting the eye after death, and, therefore, much that has been written about the pathology of this membrane is based upon conjecture rather than upon the results of actual observation. Now, how- ever, that the ophthalmoscope has been introduced, the diagnosis of these affections has been made possible. If the instrument did no more than teach us the utter hopeless nature of certain maladies, and the folly of treating them with harsh, injurious remedies, it would confer incalculable benefit; but, by enabling us to make an early diagnosis in cases hitherto found impossible of recognition, it leads to the establishment of a more rational pathology and more successful practice. The only affections of the retina which will require notice in a work of this kind are inflammation, amaurosis, and amblyopia. 1. Acute retinitis is rare as a pure, uncomplicated disease, but as a secondary affection it is by no means uncommon. There are few cases of violent sclerotitis, iritis, and cor- neitis, in whch the retina does not participate, to a greater or less extent, during the progress of the morbid action. The causes of the complaint are not always obvious. It is usually said to be owing to exposure of the eye to intense light, as in looking at the sun, or at the fire of a furnace ; to excessive and long-continued fatigue of the organ ; and to various kinds of external injury, especially such as involve the iris and ciliary liga- ment. The most frequent cause is probably syphilis. In general, only one eye is affected at the beginning, but as the disease progresses the other may also be invaded, the proba- bility of this being so much the greater if the inflammation is very intense and protracted. Acute retinitis is sometimes observed in lying-in females, within the first ten days after parturition. I have seen several cases of this kind, in each of which the attack seemed to be associated with, or dependent upon, a rheumatic state of the system. Very young subjects rarely suffer from this disease, except as a secondary affection. Finally, the inflammation may invade a part of the retina, or the whole membrane. The most prominent symptoms of acute retinitis are excessive intolerance of light, scintillations, and various kinds of spectres, with rapid failure of sight, frequently even- tuating in total blindness. The patient is sometimes annoyed by flashes of light, sparks, or luminous bodies, and by an endless variety of the most grotesque objects, which float before his eyes and disturb his imagination. The affected organ sometimes feels full and tense, as if it would burst, and the slightest motion or pressure is attended by an increase of the local distress. Photophobia and lachrymation may be present in a marked degree, beginning early, and lasting throughout the attack ; but in a large proportion of cases there is no other subjective symptom than diminution of vision. The field of vision is usually contracted, and, if hemorrhages occur, there will be dark spots in the correspond- ing parts of the field. In the more violent and rapid forms of retinitis there is sometimes total extinguishment of vision in a few hours, before there is any apparent involvement of the other structures of the eye. The pupil, in acute retinitis, is, at first, slightly contracted, sluggish, and irregular; by and by, however, it becomes dilated, and ultimately, when the disease is fully established, it is widely expanded, and totally insensible to light. When the malady continues for any length of time, the other tunics of the eye may participate in the inflammation. Sup- puration of the eye is a rare occurrence. The only reliable means of diagnosis is by ophthalmoscopic examination, any other being merely conjectural. The prognosis is most unfavorable. Even in the milder cases, complete recovery is seldom to be looked for, while, in the more violent, total blindness may be considered as inevitable. Under such circumstances, the retina is apparently completely overwhelmed by the disease, its substance being irretrievably disorganized by the inflammatory action. The treatment of acute retinitis must obviously be of the most rigorous character; for, it need hardly be added, after what has been said respecting the rapid and destructive march of the disease, that, even if only a few hours are lost in indecision, the sight may be hopelessly destroyed. Venesection, leeches to the temples, active purgation, and the use of antimonials and opiates, with rapid ptyalism, are the remedies mostly to be relied upon. Unfortunately, the sight is often completely annihilated before the case is seen, the patient, in fancied security, supposing that the inflammation will soon subside of its own accord, when, in fact, it has probably already done its worst. 200 DISEASES AND INJURIES OF THE EYE. CUAP. IV. 2. Chronic retinitis may be a sequel of an acute attack, or it may exist as an original and independent affection, corning on in a gradual and stealthy manner, slowly, but surely, undermining structure and function. Among the more common causes of the dis- ease are, overexertion of the eye, long-continued exposure to vivid light, external injury, syphilis, and neuralgia of the ophthalmic branches of the fifth pair of nerves. Excessive indulgence in eating and drinking, abuse of sexual intercourse, and suppression of habitual discharges, are also capable of producing the affection. A gouty and rheumatic state of the system has been known to predispose to an attack of this kind. Several years ago, a gentleman was under my care on account of chronic retinitis, contracted while travelling in a railway car, during a long journey; he had formerly been a martyr to rheumatism, and had just suffered from a slight attack of his old complaint, when his eye became affected. The symptoms of retinitis had existed, in a gradually gravescent form, for nearly two months, when, almost suddenly, they disappeared upon a recurrence of inflam- mation in the right knee. One of the most common causes of this disease, according to my experience, is circumorbital neuralgia. In the Southwestern States, chronic retinitis, from this affection, is by no means infrequent. During my residence in Kentucky, I met with many cases which clearly owed their origin to this circumstance alone. The opera- tion for cataract by depression was often followed by chronic retinitis. The peculiar form of retinitis occurring in connection with kidney disease, and called “ albuminuric retinitis,” is not uncommon. The symptoms of the disease are generally strikingly characteristic. The patient rarely complains of deep-seated pain in the eye or neuralgia in the forehead, face, and temple ; he is annoyed with sparks, scintillations, or luminous bodies, and his sight pro- gressively diminishes, growing daily more and more dim, so that at length he can, perhaps, barely distinguish light from darkness. In general, he can see objects better in bright than in cloudy weather, and at noonday than in twilight, especially when his back is turned towards the sun. Various fantastic objects usually float before his eye ; everything looks as if it were veiled in a mist, haze, or spray ; now an insect, as a fly, gnat, or spider, is in the way; now a shower of dust, or particles of dirt; now a thick cloud ; now the bough of a tree, a cobweb, a gauze, or an appearance of shooting stars. If, before the sight is much impaired, the patient attempts to read, the letters will be found to look as if they were fused together, turned upside down, or unnaturally short or long; his eyes become immediately fatigued and painful, and for some hours afterwards, his vision will be proportionately more dim. In many cases, dimness of vision is the only decided symptom. The pupil, at first merely a little sluggish and somewhat dilated, gradually loses all sensibility to light, and expands widely, sometimes forming merely a black, nar- row ring behind the cornea. The interior of the eye looks dead and lustreless, and the countenance has a peculiarly vacant stare, almost characteristic of the nature of the dis- ease. In the more advanced stages of the complaint, the vessels of the conjunctiva may be preternaturally numerous and increased in size. A separation of the retina is by no means infrequent. In general, it presents itself as a bluish or grayish bag, of a globular or ovoidal shape, filled with serum, and projecting into the vitreous humor, which is itself always more or less softened and changed in color. This accumulation of serum constitutes what is called dropsy of the retina, and may occur in any part of the globe, but in the great, majority of cases it will be found at its inferior half, especially when the examination is made after the morbid action is a good deal advanced. The corresponding portion of the field of vision is obliterated. The prognosis in chronic retinitis is bad. If the patient is seen early in the attack, a complete cure may occasionally be effected, although such an event is to be regarded rather as the exception than as the rule. In general, the nature of the complaint is entirely overlooked, both by the patient and the practitioner, and the consequence is that the only time when treatment is likely to be of benefit is allowed to pass by in the delu- sive hope of spontaneous relief. What renders the prognosis worse in this disease is that the morbid action nearly always involves other structures of the eye. The treatment of chronic retinitis must be conducted upon general principles, giving especial consideration to the nature of the exciting cause, the stage of the complaint, and the condition of the system. There is no question that, until very recently, this disease was usually most sadly mismanaged ; for, under the vague name of amaurosis,” by which it was generally known by practitioners, all kinds of remedies, of the most opposite and absurd nature, used to be resorted to, with no other result, commonly, than that of aggra- vating the local mischief, and inflicting serious injury upon the sight. It was almost the CHAP. IV. DISEASES OF THE RETINA. 201 universal custom to bleed, purge, salivate, and starve sucli patients, often reducing them literally to death’s door, by the consequent exhaustion. Such a course was well calcu- lated to ruin both the eye and the system. Now that the mischievous effects of this prac- tice have been fully exposed, there is danger of carrying the error into the opposite extreme, since there is a disposition, at the present day, to cram and stimulate. Anything like general bleeding and active purgation is only to be thought of in the event of decided plethora and great local congestion. Ordinarily all the blood that ought to be removed can be advantageously taken by leeches, or the use of a cup to each temple, 'l'he bowels should undoubtedly be kept quite free, and the best remedy for the attain- ment of this end is blue mass, in union with compound extract of eolocynth, or a few grains of calomel, rhubarb, and aloes. The diet should be plain and simple, but rather nutritious than otherwise, particularly when there is evidence of debility, when it may also be necessary to exhibit some tonic, as iron and quinine. The great remedy, how- ever, in chronic retinitis, is mercury, given either alone or combined with iodide of potas- sium in small doses, twice in the twenty-four hours, for several weeks, or even months, with a view to its general alterative action. The effects of the medicine are carefully watched; for anything even like an approach to salivation must be avoided. The mer- cury’ is administered, not only for the purpose of making a direct impression upon the eye, but in the hope also of ameliorating its condition, by improving the general health. Counterirritation by blister or issue is of doubtful utility; the feet should be immersed every night for thirty minutes in hot mustard water ; the eye should be maintained in a state of the most profound quietude ; a green shade or smoked glasses should be worn to exclude the light; and gentle exercise should be taken daily in the open air. When there is much pain in the branches of the ophthalmic nerve, the use of atropia ointment or a large blister to the forehead often produces a most salutary effect. In such cases, too, strychnia will be useful, either alone, or in union with arsenious acid and aconite, it it being understood that these articles are given in very minute doses, and only with a view to their general action. They are indicated only in the later stages. Any tendency to relapse, which is always very great in this disease, must be counter- acted by perfect quietude of the eye for a long time after all morbid action has apparently vanished, and by special attention to the state of the general health. Moderate exercise, a pure air, and the use of the cool or tepid shower-bath, will go far in securing this result. A sea voyage sometimes proves eminently useful. In addition to acute and chronic retinitis, we may encounter several other forms which are dependent upon constitutional causes. These are albuminous retinitis, met with in many cases of Bright’s disease; retinitis, induced by the syphilitic virus; pigmentary retinitis, observed in the children of marriages of consanguinity ; and a retinitis attended by hemorrhages into the nervous structure of the eye. These conditions can only be diag- nosticated by an ophthalmoscopic examination, and cannot be fittingly described without colored lithographic representations of the lesions. As extensive inflammation of the retina can scarcely exist without involving the optic nerve, and hence neuro-retinitis is a more appropriate term for a large proportion of cases. When the nerve is chiefly affected, and the retina is only involved secondarily, the disease is known as optic neuritis, and constitutes an important symptom of intracranial disease. Embolism of the central artery may be the cause of sudden loss of sight, unaccompanied by any pain ; it is recognized by the blanched appearance of the optic disk, and the attenuated condition of the retinal vessels, as revealed by the mirror. 3. Amaurosis, a term formerly much employed by opthalmic writers, literally signifies obscure vision, from whatever cause arising, but at the present day, it is restricted to dimness of sight, produced by disease of the optic nerve or brain. This lesion may be purely functional, and temporary; or it may be organic, in the worst sense of the word, and therefore more or less permanent. Again, amaurosis may be partial, or complete ; in the one case, the patient is still able to perceive light, and perhaps discern objects with some degree of satisfaction ; in the other, he is totally blind, the retina being perfectly insensible to the strongest light, however concentrated. It will thus be seen that the term amaurosis is used simply to denote the existence of a particular symptom, and not the pathology of the disease; a distinction of much practical consequence, and one which, unfortunately, is too often lost sight of by the practitioner. Amaurosis may arise from numerous causes, many of them of the most opposite and diversified character. A mere catalogue of these causes would form a large chapter. At one time it is purely inflammatory, at another wholly asthenic; in one case it is induced 202 DISEASES AND INJURIES OF THE EYE. CHAP. IV. by plethora, in another hy anemia ; now it is purely functional, depending upon disease in other parts of the body, now entirely organic or occasioned hy the most serious structural lesion. Another circumstance, hardly less interesting in a practical sense, is that amau- rosis sometimes comes on in an instant, literally in the twinkling of an eye, as when the organ is suddenly exposed to an intense light. Thus, persons have sometimes been struck blind in gazing at the sun during an eclipse. Microscopists, artists, and other persons whose avocation demands great minuteness of sight, occasionally sutfer in a similar manner. A flash of lightning has more than once produced irremediable amaurosis. Worms in the alimentary canal, the repulsion of cutaneous eruptions, the suppression of habitual dis- charges, derangement of the stomach, congestion of the brain, neuralgia of the fifth pair of nerves, inordinate sexual indulgence, the excessive use of quinine, profuse chewing of tobacco, exhausting courses of mercury, and overexertion of the eye, may all be enume- rated as so many exciting causes of the disease. I recollect a case in which amaurosis was instantly produced by the ferrule of an umbrella being thrust into the orbit in such a manner as to compress the ball forcibly against its bony walls. In two other examples, the disease was the result of a slightly contused and lacerated wound of the eyebrow, apparently implicating the supraorbital nerve. Compression of the brain, also, whether produced by effused blood, depressed bone, or some morbid growth, often leads to amaur- osis ; similar effects occasionally follow concussion of this organ, although they are usually of a transient nature. Cases occur in which amaurosis pursues an intermittent course, the loss of sight recurring once every twenty-four hours, very much as the chill in an attack of intermittent fever. The symptoms of amaurosis are such as characterize chronic retinitis, and, therefore, need not be described here. A dilated, motionless, and insensible state of the pupil, a peculiar lustreless expression of the eye, total blindness, and perhaps a congested and en- larged state of the vessels of the conjunctiva, with a singularly vacant stare of the counte- nance, are signs which can never be mistaken. It is obviously impossible to lay down any definite rules of treatment for the causes which are so numerous and diversified as of those of amaurosis. The intelligent and con- scientious practitioner will not fail to make the disease, in every instance that may come under his observation, an object of special study and inquiry. Cases constantly occur where the causes of the disease are so apparent as to render it impossible to mistake them, and it is to this class that he should especially direct his skill and attention, since experi- ence has shown that many of them are perfectly susceptible of removal. The old, and per- haps not yet entirely exploded, practice of bleeding, purging, and salivating every patient affected with amaurosis, without any proper regard to the nature of the exciting cause, cannot be too severely censured. It affords a melancholy illustration of the folly of prescribing for the name of a disease instead of the disease itself. Undoubtedly plethora should be removed as well as debility, but this can usually be done by milder and more effective means, less likely to ruin the part and system. When the retina is totally dis- organized, any treatment, however mild, must be wholly out of the question, except in so far as it may tend to improve the general health, and thus prevent a similar misfortune to the other eye, supposing that one alone is originally affected. One important use of the ophthalmoscope is to throw light upon this class of cases, and to afford information for a more rational plan of treatment. 4. Under the term amblyopia may be described an impairment of vision, perhaps slight, or again so serious as to amount to total blindness, unattended with any ophthal- moscopic signs of change of tissue in the early stage. The causes are such as affect the entire system, as, for example, insufficient supply of blood, the debility consequent upon severe illness or prolonged lactation, the toxic effect of alcohol, lead, and tobacco, and the uremic poisoning which attends the latter stages of Bright’s disease. Subsequently the optic nerve will generally be found in a state of atrophy. 'fhe treatment must be varied with the cause of the affection, and every effort should be made whilst the insensibility of the retina may be functional to avert the incurable blindness that ensues upon the atrophy of the nerve. DISEASES OF THE CIIOROID. The only lesion of the choroid requiring special notice is inflammation. That this is rare as an independent malady is well known ; while as a secondary disease it is probably very frequent, often existing as a complication of iritis, retinitis, and sclerotitis. It is CHAP. IV. DISEASES OF THE CHOROID. 203 most frequently seen as a result of syphilis, or of traumatic injury, and as a serious compli- cation of high degrees of myopia. It occurs at all periods of life, but is most common in young and middle aged persons, particularly in those whose avocation compels constant and intense application of the eyes to the purposes of minute vision. It has been asserted by Mr. Tyrrell that, soon after the death of the Princess Charlotte of Wales, when the whole English nation went into mourning, an immense number of cases of choroiditis occurred among the dressmakers of the British metropolis, on account of the severe labor imposed upon them by the mercenary conduct of those who had the control of their time and services. Many of these poor creatures, ill-fed, overworked, and deprived of proper air, suffered from disturbance or loss of vision from the disease, brought on by ex- cessive and long-continued concentration of the eyes upon the black material used as the conventional garb of grief. The inflammation, in many of the cases, began in the choroid ; in some it took its rise in the iris, retina, or sclerotica; while in a third series of cases it apparently commenced simultaneously in all, or, at least, in several, of these structures. Be.this as it may, it is very certain that when the choroid is at all seriously inflamed the other tunics of the eye are extremely liable to become inflamed also; whether the converse of the proposition be true, in an equal degree, the present state of our knowledge hardly permits us to state. Congestion and subacute inflammation of the choroid are probably the cause of the morbid sensibility of the eye so common in young men in college, and in literary persons incessantly devoted to reading and writing; it may also result from the excessive strain due to some defect in refraction. Strumous subjects, and persons enfee- bled by ill health, privation, protracted lactation, and loss of blood, are most liable to suffer. The symptoms of acute choroiditis resemble somewhat those of retinitis, only that there is, in general, much less perception of luminous matter. In violent cases the pain is deep-seated, dull, heavy, and throbbing, shooting about in different directions, especially towards the base of the brain, where it is often exceedingly severe. The eye is tender on pressure ; there is a sense of tension or fulness ; and every movement of the ball is attended with an aggravation of suffering. There is commonly severe pain, of an intermittent character, around the orbit and in the temple, and the patient is harassed with intense cephalalgia and a feeling of weight and tightness in the forehead. The sight soon grows dim, and this may be the only symptom in mild cases. Various fantastic objects float before the eye; at first, as small motes or specks, of a grayish, yellowish, or darkish ap- pearance, and afterwards, as the disease augments in violence, as a thick mist, gauze, or veil. The ball of the eye is of a dull reddish, pink, or brick-dust color, and there is gene- rally a faint zone around the cornea, from which the vessels extend backwards over the surface of the sclerotica in fine radiating lines. The conjunctiva may be congested or cedematous. The iris is dull and discolored, and the pupil, contracted and irregular, soon becomes motionless and may be adherent to the capsule of the lens, which, together with the lens itself, is frequently rendered opaque, either by plastic deposits, or by disease of their proper substance. Gradually the retina and vitreous humor are assailed, the latter being dissolved and broken down, and the globe, in consequence, converted into a soft, flaccid, fluctuating mass. The sclerotica, also becoming implicated, gives way at some particular point, usually towards the cornea, forming a protrusion, of a bluish color, known by the name of staphyloma. The diagnosis of choroiditis merits special attention. The disease with which it is most liable to be confounded is iritis, from which, however, it may, in general, be distin- guished by a careful examination of the eye, and a proper inquiry into the history of the attack. In choroiditis, disturbance of vision is an early and prominent symptom, and always precedes any alteration in the iris; moreover, the loss of brilliancy and the alteration of color of this membrane are always less conspicuous than in the latter disease, and the vascular zone around the cornea is also more faint and dull. In iritis, the sight is often comparatively little affected for some days, although the structure implicated usually undergoes very striking changes within a very short time after the establishment of the disease. Furthermore, in primitive iritis there is always a greater amount of plastic deposit in the anterior chamber, more irregularity of the pupil, and a more distinctly de- fined vascular zone around the cornea. When the two maladies have made considerable progress, the symptoms and appearances are generally so much alike as to defy all attempts at accuracy of diagnosis. In such an event, the only guides are the history of the case and a careful ophthalmoscopic inspection. The prognosis of choroiditis is unfavorable. When the disease has made much pro- gress before an opportunity of interposing remedial measures is afforded, the chances are that the sight is already destroyed, or, at all events, so much impaired as to render its restora- tion impossible. Hence, the importance of an early diagnosis, and of efficient treatment. 204 DISEASES AND INJURIES OF THE EYE. c u a p. i v. The treatment of acute choroiditis must, in the main, be conducted upon antiphlogistic principles, with a proper regard, however, in every instance, to the state of the constitu- tion, the violence of the attack, and the age of the patient. A plethoric condition of the system may demand bloodletting, and, with leeching or cupping of the temple, active purgation, and the use of mercury, carried to rapid ptyalism. Reduction of the inflam- mation must be attempted at all hazards, and in the shortest possible time ; a few days, or even twenty-four hours, passed in temporizing, may lead to hopeless blindness. The use of the eye should be entirely prohibited, and the patient confined to a dark room, or directed to protect the eyes with smoked glasses. A solution of atropia should be dropped into the eye several times daily. If the inflammation involve the entire ball, and advance to suppuration, the extirpation of the globe will save the patient much suffering, and probably restore him rapidly to health. The treatment is, of course, less active when the patient is feeble from previous disease or present suffering, or when the inflammation has already produced serious structural lesion : here our chief reliance is upon local depletion, counterirritation by blisters to the forehead, temple, or nape of the neck, correction of the secretions, mild aperients, and the gentle operation of mercury, with nutritious food and drink. When the disease has assumed a decidedly chronic form, change of air, sea-bathing, and tonics, particularly iron and quinine, will aid in rebuilding the constitution, and contributing to the mainte- nance of what little vision may be left. GLAUCOMA. The term glaucoma was originally employed to designate a greenish opaque appearance, occasionally seen in the bottom of the eye, and generally dependent upon a change of color of the lens, as yellowish, amber, yellowish-red, or reddish-brown. At present, however, it is used in a more definite sense, to denote a peculiar form of blindness, at- tended with various morbid changes of all the structures of this organ. The disease, which may be either acute or chronic, is obviously of an inflammatory character, as is evinced by the nature of its symptoms, by ophthalmoscopic inspection, and by the results of dissection. In the acute form the humors are opaque and increased in quantity ; blood is sometimes effused either in a pure state, or intermixed with lymph ; capillary apoplexy of the retina is common ; the optic disc becomes excavated ; and all the tunics of the eye, both internal and external, are profoundly congested, many of the vessels exhibiting a tortuous, varicose appearance. Thus, it is evident that glaucoma, in the inflammatory form, is not an irido-ehoroiditis, as some have alleged, but merely an ef- fect of ophthalmitis, involving all the structures of the eye, the humors as well as the tunics. Of its point of departure we are completely ignorant ; but the essence of the disease is increased intraocular pressure, to which its characteristic symptoms may be referred. Uncommon before middle life, it is most frequent from the fiftieth to the sixtieth year, usually affects both eyes, although seldom in an equal degree, at least not at first, and is generally preceded by a prodroma, or stage of incubation, the transition from which to the active stage is sharp and sudden in acute, insensible and gradual in chronic, glaucoma. The subjects of the disease are for the most part presbyopic, weakly, thin, and more or less anemic from previous suffering. Among the earlier symptoms of glaucoma is a gradual impairment of vision, objects appearing more dim than formerly, and looking as if seen through a mist. There is a rapid increase of presbyopia, and the eyes are soon fatigued by any exertion, such as pro- longed reading or writing ; occasional flashes of light occur, and a halo with prismatic colors is perceived around the flame of a candle. After a while vague pains are experi- enced in the eye, brow, and temple, the pupil is enlarged and sluggish, the anterior cham- ber is diminished, and the ball is abnormally tense on pressure. Acute glaucoma is generally characterized by great violence. The pain, which is often neuralgic, and ocular as well as circumorbital, is either sharp and darting, or dull, heavy, and aching ; colored spectra dance before the eye, or flashes of light are perceived ; ob- jects appear misty, as if surrounded by smoke ; the field of vision is contracted, and total blindness sometimes occurs in a few hours. The subconjunctival tissues are congested and ocdematous; the cornea is dull and almost insensible to the touch ; the anterior chamber is hazy and abnormally small; the pupil is widely dilated, irregular, oval, and motionless; and the iris, deprived of its fibrous appearance, is of a dirty, grayish, or slaty tint, and pushed forwards by the lens, which is faintly striated, and swollen, as if macerated. The globe, which is almost of a stony hardness, is exquisitely tender, and feels as if it would CHAP. IV. GLAUCOMA. 205 burst. Sometimes tbe veins of the iris are so much enlarged as to be visible to the naked eye. Well-marked fever, nausea, loss of sleep, cephalalgia, and great mental depression usually attend the attack. Opthalmoscopic inspection is frequently impracticable by reason of the opaque condition of the cornea and of the humors. In chronic glaucoma, which may last for months and even years, the patient being alter- nately better and worse, the attack generally begins insidiously. The sight gradually grows dim, the eye loses its brilliancy, and dull, aching pain is occasionally felt in and around the orbit. Bright flashes, coruscations, or colored spectra are perceived, at first at long intervals, but afterwards almost constantly, and usually constitute a source of real suffering. The subconjunctival vessels are purple and varicose, and a faint vascular zone is observable upon the sclerotica, in the ciliary region. The cornea, losing its sensibility, is dull and finely granulated or even slightly vesicated ; the iris is lustreless and traversed by enlarged veins; the pupil is dilated, irregular, fixed, grayish or grayish-green, and occa- sionally partially adherent to the lens; the humors are cloudy; the anterior chamber is almost obliterated ; the eye is uncommonly hard; the field of vision is contracted, usually on the nasal side. The general health is generally considerably impaired, but there is sel- dom any fever, unless the disease suddenly passes into the acute form. Ophthalmoscopic inspection, possible in nearly all cases, reveals a well-defined and cupped appearance of the optic nerve, with engorgement and pulsation of the retinal arteries at the disc, although the latter symptom is frequently absent in very chronic cases. In the treatment of acute glaucoma, ordinary antiphlogistic remedies, however vigorously pushed, are of little, if any, benefit. General bleeding and active mercurialization are not only useless, but positively injurious. Unless prompt relief is afforded, blindness, total and irretrievable, must inevitably result from the rapid changes experienced by the retina from the pressure of inflammatory products, the enlarged and congested condition of the vessels, and the excessive intraocular pressure. Paracentesis of the eye, by taking off some of this pressure, may afford transient amelioration, but complete relief can only be obtained by iridectomy, devised by Von Graefe in 1856, and now almost universally relied upon as the sheet-anchor of our hope in the treatment of this affection. The opera- tion, which consists in the removal of a section of the iris, should be performed early and effectually. Every hour is precious when there is great intensity of action. It affords relief upon the same principle as an incision in external inflammation, by the removal of the excessive tension of the globe, and the drainage of the irido-choroidal and retinal ves- sels, at the same time that it places the absorbents in a better condition for exerting their peculiar influence upon the inflammatory deposits. Iridectomy should be performed, in acute cases, even if there is complete loss of sensibility of the retina. The sight may not, it is true, be restored by it, perhaps not even materially improved, but the agonizing suffering and inflammation will be sure to be speedily arrested. In chronic glaucoma, where there has been total blindness for some time, no improvement of vision is to be ex- pected, and the operation is performed solely to relieve [tain and tension. fhe patient, during the performance of iridectomy, should be recumbent, and thoroughly chloroformed. The lids are separated by a wire speculum. The eye, steadied with a pair of forceps, is penetrated with Graefe’s cataract knife, or keratome, through the cornea, close to the sclerotica, and immediately in front of the iris, the opening being about one- third of an inch in length. The protruding iris is then grasped with the forceps, drawn out, and cut off to the extent of about one-sixth of the entire membrane, as far as its periphery. The gap, if made above, will be measurably concealed by the superior lid. Care must be taken not to injure the lens. The after-treatment is conducted upon the same general principles as in the operations for cataract and artificial pupil. The exces- sive pain and tension rapidly decrease, and a marked abatement also ensues in the inflammation. Several operations have been proposed as substitutes for iridectomy, but the only one that has been adopted to any extent is sclerotomy, which is performed by making an in- cision behind the margin of the cornea, very much as in extraction, except that the cut is not completed, but a narrow bridge of cornea is left to prevent prolapse of the iris. It is well adapted to certain cases, as hemorrhagic glaucoma, to which iridectomy is not applicable, but has by no means displaced the older operation. Eserine, from its property of diminishing intraocular tension, has been found very useful and should always be tried in doubtful cases, or when, for any reason, an operation cannot be resorted to at once. From one to four grains of the sulphate to the ounce of water may be instilled two or three times a day. 206 DISEASES AND INJURIES OF THE EYE. CHAP. IV. STRUMOUS DISEASES. Strumous disease of the eye exists in various forms and degrees; sometimes as a very mild affection, at other times as a most severe one. It may be acute or chronic, and attack both eyes, or be limited to one. The most common exciting causes are, external injury, as a blow, or a wound, long exposure of the eye to a strong light, or excessive fatigue of the organ, induced by read- ing, writing, or sewing, suppression of the cutaneous perspiration, irregularity of the menses, and, above all, derangement of the digestive apparatus. Whenever the predis- position exists, as it always does in this affection, almost anything, however trivial, may bring on an attack. The most common form is phlyctenular ophthalmia. The age at which this disease occcurs is an important circumstance in its history. It is extremely rare after puberty, and in no instance have I witnessed its outbreak in mid- dle or advanced life. It is essentially a malady of infancy and early childhood. Accord- ing to my observations, it rarely appears before the age of eighteen months, or two years. Occurring in both sexes, and in every rank and condition of life, it is more frequent among the poor, ill-fed, and ill-clothed, than among the refined and wealthy. The off- spring of the syphilitic and consumptive, and of those who have suffered from tubercular diseases of the spine, hip, arachnoid membrane, and lymphatic glands, are most liable to it. The prominent symptoms are intolerance of light, excessive lachrymation, and violent pain. The photophobia is usually very distressing. The smallest ray of light is fre- quently productive of the keenest suffering, and the patient, consequently, uses every pos- sible precaution to prevent its intrusion. For this purpose, he generally, if he is a child, as is commonly the case, creeps into the darkest corner of his chamber, where he covers his eyes with his hands, or buries his head in a pillow, or, perhaps, in his mother’s lap. In this condition he often remains for hours, afraid to change his posture, lest the light should meet his eyes, and so increase his distress. Children thus affected frequently experience an aggravation of all their suffering, even from the light of the moon and of the stars, such is the excessive sensibility of the retina. Lachrymation is commonly a prominent symptom. Exposure to light and cold always increases it. The tears are usually hot and scalding, but their discharge is always attended with temporary relief. Sometimes they are so acrid as to irritate and inflame the cheeks. The quantity of fluid that is thus evacuated in the twenty-four hours may amount to several drachms. It is rare, in strumous ophthalmia, to witness a copious discharge of mucus, or of muco- purulent fluid. Even when there are excessive photophobia and great lachrymation, there is seldom much secretion of this description ; often, indeed, not enough to agglutinate the edges of the lids. In this respect, scrofulous inflammation forms a striking contrast with some of the other varieties of ophthalmia, in which an immense quantity of mucus, or of mucus and pus, is discharged during the height of the morbid action, and even during its decline. There is usually comparatively little general redness of the conjunctiva in this variety of ophthalmia. In ordinary inflammation, discoloration of this membrane is a constant occurrence, and is so conspicuous as generally at once to attract attention. In phlyctenu- lar inflammation, the vessels observe a straggling arrange- ment ; they are seldom very turgid, and they extend from the circumference of the ball inwards towards the cornea, where they are often congregated into little bundles, or clusters, beautifully interlacing with each other, as in fig. 144. When the disease is violent, or of long standing, the vessels occasionally pass over the cornea, either singly or in parallel lines, separated by narrow intervals. In ordinary ophthalmia the vessels are extremely numerous, and generally arranged in the form of a confused network. In a word, there are hundreds, where there is one in stru- mous ophthalmia. Another important symptom is the existence of minute vesicles or phlyctenulae at the margin of the cornea, oc- curring either separately or in groups, and varying in size from the smallest perceptible speck to that of an ordi- nary pin-head. They each contain a minute quantity of serum, and are frequently encircled by a delicate plexus Fig. 144. Scrofulous Ophthalmia with a Phlyc- tenula on the Cornea and a Fasciculus of Vessels running into it. STRUMOUS DISEASES. CHAP. IV. of vessels. Their shape is globular, ovoklal, or angular. Sometimes they exist partly on the conjunctiva and partly on the cornea ; or they may occur distinctly in either, constitu- ting phlyctenular conjunctivitis or phlyctenular keratitis. As they are witnessed in no other form of ophthalmia, they are of great value as a diagnostic sign. Phlyctenular keratitis seldom continues long without giving rise to opacity of the cor- nea, presenting itself in different degrees, from the slightest haziness of the part to com- plete loss of transparency. In the latter case, it is always to be greatly dreaded, as it may be followed by total blindness and irremediable disfigurement of tbe eye. The pain attendant upon phlyctenular ophthalmia is sometimes intense, while at other times it is very insignificant, if not wholly absent. It is more severe when the phlycte- nuhe occur in the cornea. In confirmed cases, it is always aggravated by the slightest exposure of the affected organ to the light, by medicated applications, by disorder of the bowels, by indulgence in eating, by rough contact, and by various other circumstances. Occasionally it is situated deeply in the ball of the eye, or in tlie orbit; sometimes it merely affects the lids and brows; occasionally it is most severe in the temple, forehead, or cheek. It may be sharp, shooting, or darting; dull, heavy, or aching; throbbing, or pulsatile ; continued or intermittent. Not unfrequently it assumes a neuralgic character, recurring periodically, like neuralgic pain in other parts of the body. Whatever may be its nature, it is often so severe as to deprive the patient of sleep and appetite, and, indeed, of all comfort, for days and weeks together. Phlyctenular ophthalmia is rarely attended with any tumefaction of the lids. On the contrary, they usually retain their normal shape and size; in consequence, however, of the excessive intolerance of light, they often present a remarkably drooping appearance, owing to the manner in which they are drawn over the eyes. When the disease is very protracted, the edges of the lids frequently become inverted, so that the cilia impinge constantly against the cornea, thereby inducing opacity of this membrane, great increase of pain, and additional inflammation. Although there is, generally, an absence of swell- ing of the lids, yet this symptom occasionally exists in a very marked degree, especially in young children of a leueophlegmatic habit, with a thick upper lip, a tumid belly, and a soft, flabby tongue, along with great derangement of the digestive apparatus. The whole system, in such cases, seems to be surcharged with strumous disease, which, in consequence, it is extremely difficult to dislodge from the eyes, which so frequently become its victims. In many cases little vesicles, not larger than the head of a small pin, and filled with serum, occur on the cheeks, the inferior lids, around the nose, or on the lips. Of a whitish, almost pearly aspect, they are usually discrete, although often closely grouped together, rest upon a slightly reddish base, are most common in children of a deeply-marked stru- mous habit, and seldom come on until after the inflammation has made considerable progress. Their presence almost invariably denotes great obstinacy in the morbid action, and proportionate difficulty in effecting a prompt and permanent cure. The diagnosis of this affection is usually sufficiently easy. The excessive intolerance of light, the unwonted lachrymation, the absence of redness in the conjunctiva, together with the peculiar straggling arrangement of its vessels, the phlyctenular and opaque con- dition of the cornea, the want of tumefaction, and the manner in which the lids are drawn over the ball of the eye, are signs, which, once observed, can never be mistaken. Add to these phenomena the fact that the disease usually arises insidiously and without any assignable cause, the strumous appearance of the features, the coldness of the extremities, the tumid condition of the belly, the formation of vesicles on the face, and various other evidences of the strumous diathesis, and all doubt respecting the true nature of the case must instantly vanish. Ulceration of the cornea is another frequent form of strumous disease. It often begins at an early stage of the disease, and may proceed with more or less rapidity until it ex- tends through the entire thickness of the membrane. The most common form of the ulcer is that of a dimple-shaped depression, with smooth and rather sharp edges, the sur- face looking as if a piece had been scooped out of it. Generally, the ulcer has a hazy appearance, but occasionally it does not differ in its color from that of the adjacent parts, and hence, unless the cornea is examined with great care, while the light is falling upon it at a particular angle, the disease may readily escape detection. Sometimes several such erosions exist upon the eye, forming either simultaneously or in pretty rapid succes- sion. If permitted to progress, they occasionally extend through the different layers of the cornea, as far as the anterior chamber of the eye, the humor of which may, perhaps, escape through the abnormal opening, or, what is more common, the opening is closed up by the membrane of the aqueous humor, or even by the iris itself. 208 DISEASES AND INJURIES OF THE EYE. CHAP. IV. The prognosis must necessarily be influenced by various circumstances, as, for exam- ple, the progress and extent of the morbid action, the state of the patient’s health, and the nature of our remedies. In the milder forms, in the earlier stages of the malady, and under proper management, recovery of the affected organ may generally be reasonably predicted. But, under opposite circumstances, the worst consequences may, not unfre- quently, be looked for. Ulceration of the cornea often extends, despite our remedies, to a great depth, and sometimes even to complete perforation ; an event which is sure to be followed by permanent impairment, if not total loss, of sight. Superficial opacity, even when it is diffused over the greater portion of the cornea, is generally readily amenable to treatment, but when it involves several of the layers of the membranes, or when a consid- erable period has elapsed since its formation, the case will necessarily be unpromising, both as it respects the future appearance of the eye and the amount of vision. Treatment—The great remedy in the treatment of this disease is quinine, either alone, or conjoined with other means. I am very certain, from long experience, that it de- serves to be placed at the head of all the articles used in this variety of scrofulous affec- tions. To produce its full effects, however, it must be administered with due regard to the patient’s system. Injudiciously given, it may not only prove useless, but positively hurtful. There are, according to my experience, two distinct classes of strumous dis- ease of the eye. In the one, the patient is pale and thin, with a languid circulation, and cold extremities; in the other, he is stout and robust, the cutaneous circulation being active, and the hands and feet habitually warm. Other points of dissimilarity readily suggest themselves, but these it is unnecessary to point out, as the distinction must be sufficiently apparent. Now, to treat such cases alike would be a palpable absurdity. It is only by properly discriminating between them that we can expect to arrive at a satisfactory result, as it respects the employment of this important therapeutic agent. Hence, one practitioner will often mismanage a case, which another, having more judg- ment and more experience, will promptly cure, the disease, perhaps, disappearing as if by magic. The use of quinine, in both forms of the complaint, should usually be preceded by the exhibition of a moderately brisk cathartic of calomel and rhubarb, to clear out the bowels and correct the secretions. When there is an acid condition of the alimentary canal, I generally combine with the cathartic a few grains of bicarbonate of sodium. Thus, a most effectual beginning is made in the treatment of the disease. If the case comes under the first division, that is, if the patient is pale, thin, and habitually cold, I begin at once with the use of quinine, commonly in combination with sulphate of iron, tartar emetic, and opium, in quantities proportionate to the age and strength of the individual. For a child, for example, of ten years, a grain and a half of quinine, one grain of iron, the sixteenth, and the fourth of' a grain of opium, carefully mixed, will be a suitable dose, repeated every eight hours, or, if the symptoms are urgent, even every six hours. If pills or powders are offensive to the patient, the articles may be given in solution, laudanum or morphia being substituted for the opium. When there is a highly-marked strumous diathesis, the iodide of iron may sometimes be used instead of the sulphate, but in most instances I give the latter the preference. Tartar emetic I rarely omit in any case, as it is a most valuable remedy in the treatment of scrofulous disease, both of the eye and of other parts of the body. It is a powerful controller of capillary action, and at the same time a most potent sorbefacient, rendering it thus particularly applicable when the malady is attended with a deposit of plastic matter. The opium allays pain and intolerance of light, and prevents the antimony from irritating the stomach and bowels. The quinine and iron, whether in the form of sulphate or iodide, are powerful tonics; they improve and invigorate the digestive organs, increase the plasma and coloring matter of the blood, equalize the circulation, augment the temperature of the extremities, and powerfully aid in correcting the strumous diathesis. Arsenic, in the form of Fowler’s solution or the solution of the chloride of arsenic, is sometimes very useful. By means of these remedies, assisted by a proper diet and due attention to the bowels and secretions, almost any case of scrofulous ophthalmia may, in the class of pa- tients under consideration, be effectually relieved in a comparatively short period. When the skin is dry and inactive, a tepid bath may occasionally be used, or, what is better, the body may be sponged once a day with tepid salt water, followed by frictions with a coarse dry towel. Flannel should be worn next the surface, both in summer and winter; and the greatest attention should be paid to the preservation of the tempera- ture of the feet. When they are habitually cold, they should be plunged twice a day, for a few minutes at a time, into cold water, and then rubbed with a dry cloth. Dover’s CHAP. IV. STRUMOUS DISEASES. 209 powder, in this condition of the system, in doses of two or three grains, thrice in the twenty-four hours, is often highly beneficial, in promoting perspiration and soothing the system. In the second class of cases, where the general health is apparently but little im- paired, where the countenance is florid instead of being pallid, and where the extremi- ties are, for the most part, warm, the quinine is most advantageously conjoined with sulphate of magnesium, tartar emetic, and morphia, in the form of the saiine and anti- monial mixture, described in the chapter on inflammation, in the first volume. When the inflammation is very severe, the quinine may be omitted until the disease has assumed a subacute character, and in that event, also, I occasionally take blood freely from the arm, or by leeches from the anterior part of the temples, within an inch of the outer commissure of the lids. In the strong and robust, iron, in every form, is totally inadmissible. The diet, too, must be more restricted, and there is a greater necessity for more active purgation. Indeed, the treatment should be strictly antiphlogistic, as much so as in inflammation of the eye from ordinary causes. As to counterirritation and irritating collyria, and salves, so much used in this com- plaint, they cannot, as a general rule, be too pointedly condemned. Except in the later stages of the complaint, in some rare circumstances, it is difficult to conceive of any case in which they would be likely to be beneficial. Indeed, I know of no class of remedies which do more mischief, or which are so well calculated to fret and annoy the patient, and to support and perpetuate the morbid action. Setons are abominably filthy and painful, and should be discarded from this branch of surgery; tartar emetic ointment and croton oil cause injurious irritation ; in short, the only eligible article of this class of remedies is a small blister behind the ear, or, what is preferable, because more easily managed and more permanent, a very small issue, in this situation, made with the Vienna paste. This, when the eschar is detached, may be dressed, twice a day, with a little adhesive plaster, and will furnish a free discharge for several weeks, when, if neces- sary, it may easily be reopened by the application of a little more paste, or some irritating ointment. The best collyrium, undoubtedly, is a solution of nitrate of silver ; but, to answer the purpose, it should be very weak, and not be used until the inflammatory action is greatly diminished, when it may assist in expediting and perfecting the cure, by contracting the enlarged vessels of the conjunctiva and cornea, by allaying the morbid sensibility of the eye, and by promoting the absorption of effused lymph. The strength, at first, should rarely exceed half a grain to the ounce of water, which may be gradually increased to a grain, or even twice, thrice, or four times that quantity, according to the circumstances of the case. Sulphate of zinc, acetate of lead, Goulard’s extract, and similar articles are generally worse than useless. One of the most efficient local applications is calomel lightly dusted from a camel’s-hair brush upon the phlyctenula or corneal vesicle. When there are ulcers on the cornea, and they do not yield to the remedies already enumerated, they should be touched, as lightly as possible, once every other day, with the point of a camel-hair pencil wet with a solution of nitrate of silver, in the proportion of about three grains to the ounce of water; or, still more cautiously, with the pure or mitigated nitrate of silver in substance. The former, however, is generally preferable, unless the ulcer is in a phagedenic or gangrenous condition, when the latter should take the place of the solution, as being more prompt and efficacious in its action. The salts of lead should never be used, as dense opacities may result from insoluble deposits upon the cornea. The only salve which I ever employ in this affection is the ointment of the nitrate ot mercury, in a very dilute state; generally in the proportion of about one to five grains to the drachm of cosmoline. The ointment of the shops is entirely too strong, and cannot be used without the risk of materially augmenting the morbid action. Thoroughly diluted it may be advantageously employed in cases attended with great relaxation of the vessels of the affected part, opacity of the cornea, and adhesion of the lids. The proper way to use it is to anoint, every night at bedtime, the edge of the lower lid with a small pencil, dipped in the salve, a portion not larger than half a grain of rice sufficing at each appli- cation. T he ointment of the yellow oxide of mercury in the proportion of one grain to the ounce is a favorite application with many surgeons. Some patients experience great relief from bathing the forehead, face, and temples fre- quently with warm water, strongly impregnated with common salt; while others derive most benefit from bathing with cool, cold, or hot water. Atropia affords relief to the 210 DISEASES AND INJURIES OF THE EYE. CHAP. IV. photophobia, and should he used in solution. The eyes must always be well protected with a green shade, but green glasses and goggles should not be worn. London smoke glasses, however, afford the best protection and are much used. Compresses and bandages should be avoided. I have seen numerous cases in which irreparable mischief was done by the protracted use of these articles. The true practice consists in protecting the affected organs in such a manner that, while they are sufficiently screened from the light to render the patient comfortable, they shall have the full benefit of cool air. As the disease declines, more and more light should gradually be admitted, until at length the eyes receive their accustomed supply, since light is the natural stimulus of the organ, and must, therefore, not be withheld too long, otherwise the eye may be rendered morbidly sensitive. I have rarely derived any essential benefit, in the treatment of any form of scrofulous ophthalmia, from iodide of potassium, so much vaunted by some practitioners. Formerly 1 was in the habit of prescribing this article quite frequently, but it so often totally dis- appointed my expectations that I have, of late years, laid it entirely aside. In obstinate cases, benefit is obtained, especially in weakly children, requiring an alterant and tonic, from the exhibition of bichloride of mercury, in very minute doses, as the twentieth or twenty-fifth of a grain, in union with aromatic tincture of bark. I am well aware that the salt in this prescription undergoes some chemical change; but this renders it, perhaps, only the more efficacious. It is neither necessary nor proper to carry the remedy to the extent of ptyalism to obtain its full effects. Indeed, such an occurrence should always be carefully avoided. Cod-liver oil is frequently of great benefit, especially in the more feeble classes of cases, and should be given in such doses as the stomach will bear without nausea. When the debility is very unusual, the child should be permitted the free use of milk punch and the lighter kinds of meat. When there is hemicrania, or excessive circumorbital pain, anodynes are necessary, particularly at night, to allay suffering and procure sleep. Under such circumstances, some practitioners are in the habit of applying belladonna ointment to the affected parts, and in some cases I have found the remedy of service, although, in general, it has dis- appointed me. During the later stages of the affection, the patient should take gentle exercise daily in the open air, to improve his general health, and to invigorate his constitution. As an excellent means of preventing relapse, a moderate use of the remedies above mentioned should be persisted in for a considerable length of time after all disease has apparently vanished. NEURALGIA OE THE EYE. This affection is very common in this country, especially in the Southwestern States, and may depend for its origin either upon local or constitutional causes. In the former case, it arises most generally from disease of the eye, brain, or neighboring parts, in con- sequence of local congestion, if not actual inflammation, provoked by external injury, the lodgment of a foreign body, the presence of a decayed tooth, the pressure of some tumor, or excessive fatigue of the eye resulting in many cases from some error of refraction ; in the latter, it is usually developed under the influence of miasm, disorder of the digestive apparatus, exhaustion of the nervous system, or the derangement of some important secretion. A species of neuralgia of this organ not unfrequently occurs during the pro- gress of rheumatism, gout, and tertiary syphilis. Neuralgia of the eye may exist as a primary affection, commencing in the organ itself, or it may be secondary, being caused by an extension of disease from the adjacent struc- tures, especially the ophthalmic branches of the fifth pair of nerves. The latter form, according to my observation, is by far the more common of the two. The affection is most frequent in persons of a nervous, irritable temperament, and often occurs in associa- tion with neuralgia of other parts of the body. No age is exempt from it. Of the pathology of this disorder our information is very indefinite. While in some cases it is unquestionably of an inflammatory character, as is evinced both by the nature of the exciting cause and the peculiar features of the symptoms, in others it appears to be dependent solely upon irritation of the ophthalmic branches of the fifth pair of nerves, or upon reflex action, the consequence of derangement of the liver, stomach, bowels, kidneys, or teeth. The disease is frequently, if, indeed, not commonly, ushered in by marked derange- ment of the general health, as dyspepsia, headache, constipation, flatulence, or acidity of the stomach, even when the attack depends upon a strictly local cause. The pain, which CHAP. IV. serves as its distinctive feature, is at first slight and transient, being of a sharp, lancinating character, dull, heavy, and aching, or like an electric shock, darting about in different directions, and recurring, perhaps, several times during the day and night. The eye is morbidly sensitive, and intolerant of exposure and exertion. By and by, the suffering becomes more fixed and severe ; it is deeper seated and more diffused, the lids and con- junctiva often exhibit a tumid and reddish appearance, the circumorbital pain and tender- ness are great, and there is always, particularly during the height of the attack, profuse laclirymation, the tears being hot and scalding. In the more violent attacks, the forehead, temple, and upper part of the face are involved, the eyebrows are knit, the lids are spas- modically contracted, and the slightest ray of light is a source of intense agony. The pain, which is nearly always most severe at one spot, generally comes on gradually, in- creasing steadily until it reaches a certain point of intensity, when it slowly, if not sud- denly, abates, or perhaps altogether disappears. In the miasmatic variety of neuralgia, the paroxysm, in its mode of invasion, closely resembles that of intermittent fever, the suffering recurring regularly once a day, or every other day, lasting a few hours, and then going off entirely, leaving, perhaps, merely a slight degree of tenderness in the eye, orbit, temple, and forebead. The constitutional symptoms vary. In general, they are very mild, even when the local suffering is unusually violent, being limited to some derangement of the digestive apparatus, along with more or less headache, want of appetite, and a sense of lassitude and despondency. Anything like marked fever rarely exists. It is only when the affec- tion is very protracted, as when it depends upon organic disease of the eye, or of the ophthalmic branches of the fifth pair of nerves, that the general health is apt to become permanently impaired. Neuralgia of the eye, or of the eye and neighboring parts, is easily distinguished by the situation and peculiarity of the pain and by the history of the case. The principal affections with which it is liable to be confounded are rheumatism, gout, and tertiary syphilis. The prognosis is usually favorable, provided the affection receives early and proper at- tention, otherwise it will be very liable to induce permanent blindness, whether it is originally seated in the eye or in the circumorbital region. It is, of course, unamenable to treatment when it is caused by organic disease of the brain or optic nerve. In the treatment, a primary object should be the prompt detection and removal of the exciting cause. When this has been effected, the disease generally yields to the most simple measures. The refraction of the eye shonld be carefully studied, and if any defect is found it should be corrected with proper glasses. Gastro-enteric disorder is rectified by emetics, mercury, antacids, and other suitable remedies; the foreign body is extracted ; the decayed and worrying tooth is lifted from its socket. The miasmatic form of the malady is usually speedily relieved by quinine, in doses of five to ten grains twice or thrice a day, either alone or in union with strychnia and arsenious acid. If the patient is bilious, as indicated by nausea, want of appetite, and aching of the back and limbs, the adminis- tration of the salt is preceded by an active emetic, or emetico-cathartic, to remove vitiated matter, and aid in restoring the secretions. Purging must not be neglected, and the diet must be properly regulated. When the affection is very obstinate, the most suitable general remedy is a combination of quinine, belladonna, strychnia, phosphide of zinc, and arsenious acid, given in moderate doses, perseveringly continued for a number of successive weeks, with an occasional intermission of a few days. The rheumatic form of the disease is best met w ith colchicum and morphia; the syph- ilitic, with mercury and iodide of potassium. Sometimes a change of air will effect a cure when everything else apparently fails. During the violence of the attack, relief is sought by the exhibition of morphia, atropia, and diaphoretics, sinapisms to the forehead and temple, and the immersion of the feet in hot water. The most reliable local remedies, in a soothing as well as curative point of view, are leeches, especially when there is marked congestion or actual inflammation ; vesication with ammonia or cantharidal collodion ; friction with Granville’s lotion, aconite lini- ment, or veratria ointment; the hypodermic injection of morphia; the application of electricity ; and the use of anodyne plasters, as the opium, belladonna, or stramonium. In some cases the moxa, so highly extolled by Larrey in the treatment of this affection, will be found useful, the cauterization being made over the eyebrow, along the course of the supraorbital nerve. Excision of this nerve has occasionally been practised, but rarely with any beneficial effect. NEURALGIA OF THE EYE. 212 DISEASES AND INJUKIES OF THE EYE. CHAP. IV. PYOPHTHALMITIS. This most destructive form of inflammation of the eye, originally described as phlebitic ophthalmitis, but which, under the improved system of nomenclature, is more appropri- ately designated by the term pyophthalmitis, occurs under a variety of circumstances, and, as the name implies, owes its origin to thrombosis of the veins, or to the same causes as pyemia. It is most frequently observed in lying-in females, in connection with puer- peral fever, in erysipelas, in typhoid fever, and after severe injuries and surgical opera- tions, especially those involving the veins of the extremities. Occurring always as a secondary affection, its attack is generally, if not invariably, coincident with symptoms of pyemia, or a slow form of fever, preceded by rigors, and accompanied by excessive nervous depression, delirium, pains in the back and limbs, swelling of the joints, great restlessness, gastric irritability, and dryness of the mouth and tongue, the latter of which is covered with a brownish coat. The eye becomes involved at a period varying, on an average, from the fourth to the tenth day, the first evidences of disease being deep-seated and excessive pains, redness and tumefaction of the conjunc- tiva, swelling of the lids, contraction and immobility of the pupil, and a hazy appearance of the cornea which soon runs into complete opacity. Pus is rapidly effused into the chambers of the organ, as well as among its coats, which finally slough and collapse. The only affections with which pyophthalmitis is liable to be confounded are gonor- rhoeal and purulent inflammation ; but from these it can always readily be distinguished by the history of the case, independently of any other consideration. It must be obvious that a disease which runs its course with such frightful rapidity, and which is characterized from its inception by such excessive violence, can be but little influenced by treatment, however judiciously or vigorously prosecuted. The most relia- ble means are free division of the chemosed conjunctiva, with medicated lotions to the lids, temples, lace, and forehead, and puncture of the cornea to relieve the eye from intraocular pressure. General bleeding is inadmissible, but anodynes should be freely employed. OSCILLATION OF THE EYE. Oscillation of the eye, or nystagmus, consisting, as the name implies, in an almost perpetual rotatory or horizontal motion of the eye, is occasioned by a want of harmony in the action of the oblique or straight muscles. It may be produced by a great variety of causes, some of them operating directly upon the eye, others indirectly through the brain. Of the former are congenital cataract, and albinism, or a want of black pigment, and inflammation of the choroid, retina, and iris, with or without disorganization of the vitreous humor; of the latter, apoplexy, cerebral tumors, and serous effusions, attended with permanent compression of the ophthalmic nerves. Morbid growths in the orbit may exert a similar influence. However induced, it is usually aggravated by excessive fatigue of the eye, and by whatever has a tendency to disorder the general health. The motion of the eye in this affection varies in degree, in different cases and under different circumstances, from the slightest aberration from the normal standard to the most disagreeable deformity. In general, it is rotatory, but now and then from side to side; the patient is entirely unconscious of it, and cannot control it, although it ceases during sleep. Vision, except in rare instances, is more or less defective, the eye is easily fatigued, and a sense of weariness is often complained of upon the slightest exertion. Shortsightedness is a common phenomenon. The prognosis is nearly always unfavorable. The treatment is altogether empirical. Even after the removal of the exciting cause, a cure can seldom be effected, it being apparently quite impossible, in almost any case, to overcome the antagonizing action of the affected muscles. In congenital cataract the os- cillation continues, in a greater or less degree, no matter how early an operation may be performed for the relief of the disease. When the motion depends upon paralysis of the muscles of the eye, or disorder of the brain, the treatment must be conducted upon gene- ral principles, and so also when it is caused by the pressure of an intraorbital tumor. IMMOBILITY OF THE EYE. Immobility of the eye, technically termed luscitas, may be induced by a variety of causes, of which the most prominent are external injury, inflammation of the orbital tis- sues, orbital tumors, and paralysis of the ocular muscles, the result of lesion of the oph- CHAP. IV. MALIGNANT DISEASES OF THE EYE. thalmic nerves, or disease of the brain and its membranes. The immobility may be complete, the patient having lost all control over the organ, or he may still be able to in- cline it in a certain direction, although, perhaps, with great difficulty. The affection is sometimes congenital, and is then always irremediable, especially when it is dependent upon hydrocephalus, defective organization of the brain, or the presence of some morbid growth in this organ. In the treatment of luscitas, the first object should be to ascertain the nature of the ex- citing cause; when this cannot be removed, no hope can, of course, be indulged in regard to a cure, whatever the means employed. MALIGNANT DISEASES OF THE EYE. The only two forms of intraocular malignant tumors are glioma and sarcoma, the affec- tion formerly known as encephaloid cancer or fungus hematodes being nothing more than an advanced stage of the former neoplasm. Of carcinoma, properly so termed, I have never seen an instance in this organ, and it is questionable whether there is a perfectly reliable case of it on record, notwithstanding all that has been said respecting it. 1. Glioma—Glioma, glious sarcoma, or neuroglioma, as this affection is variously termed, generally occurs in children from the second to the eleventh year; I have, how- ever, seen it several times within less than six months after birth ; and cases are occa- sionally met with rather late in life. The oldest patient in whom 1 have observed it was forty-two years of age. Of the influence of sex and temperament in the production of the disease in this organ, nothing is known. The malady always begins in the depths of the eye, generally in the retina, from which, as it proceeds, it gradually extends to the other structures, until, at length, they are in- volved in one confused and disorganized mass. The earliest symptom is generally a yel- lowish, amber, golden, or buff-colored spot, far back in the organ, which, upon inspec- tion, is found to look very much like the eye of a cat. This spot rapidly increases in volume, but finally entirely disappears, being replaced by dark matter; the pupil, at first sluggish, becomes permanently dilated and insensible to light; the lens is thrust for- wards against the iris; and the anterior chamber is completely obliterated. These ap- pearances are well illustrated in fig. 145. As the malady progresses, the eye, enlarged in every direction, presents a distorted appearance ; and, the cornea at length giving way, a fungous, cauliflower-looking mass is formed, which, projecting beyond the lids, soon becomes the seat of a copious, sanious, Fig. 145. Fig. 146. Glioma, in its Earlier Stages. Glioma, after Ulceration. fetid discharge, and a source of frequent and abundant hemorrhage. The patient now experiences a great deal of pain, the lymphatic glands in front of the ear sometimes take on disease, and the constitution breaks down. Finally, hectic fever sets in, the body is rapidly emaciated, and death soon follows, from the joint effects of irritation and hemor- rhage, the period which intervenes between its occurrence and the commencement of the malady varying, on an average, from six to nine months. The annexed drawing, fig. 140, from a clinical case, exhibits the appearances presented after the occurrence of ulceration. 214 DISEASES AND INJURIES OF THE EYE. c H A p. iv. There is no disease with which it is possible to confound glioma; glaucoma and amau- rosis bear, it is true, some resemblance to it in its earlier stages, but any doubt upon the subject may usually be promptly dispelled by a thorough inspection of the interior of the eye with the aid of the ophthalmoscope, which will always reveal the existence of a tumor in the one case, and the entire absence of it in the other. Besides, glaucoma and amaurosis are extremely rare in infancy, especially as simple and independent affections ; hence, the very fact of there being serious disease deep in the interior of the eye is calculated to awaken suspicion as to its malignant character. After the morbid growth has made some progress, its features are generally too well marked to admit of mistake. The absence of black pigment will always distinguish glioma from melanotic sarcoma. The entire mass is generally very soft and spongy, especially in the more advanced stages of the disease, and is largely composed of vascular material. In 1857, I removed from a child, two years of age, a gliomatous eye, in which these characteristics existed throughout in a marked degree. The tumor, which had commenced nearly twelve months previously, projected slightly beyond the lids, and involved all the structures of the orbit, excepting the bony fabric. The lachrymal gland was greatly indurated, as well as con- siderably enlarged ; and the crystalline lens, of a yellowish color, and more than twice its natural size,.had undergone the earthy degeneration. Glioma is nearly always fatal ; if removed, however early, it is almost sure to recur, or show itself elsewhere ; if left to itself, it gradually involves the different structures of the orbit, and even extends along the optic nerve to the base of the brain and its membranes. The eyelids generally escape, although they are always much enlarged, discolored, and infiltrated with serum. 2. Sarcoma Sarcoma of the eye, fig. 147, is much less common than glioma, and, with few exceptions, belongs to the melanotic variety. It is rarely met with before the age of thirty-five or forty; and its starting point is in the choroid. The first evidence of the disease is the presence of a dark, black, or purple mass deep in the vitreous body, appa- rently in contact with the retina, and entirely devoid of the yellow, metallic lustre so conspicuous in glioma. The pupil is indolent in its movements, vision is materially im- paired, and the eye loses its natural expression. As the morbid growth extends, it gradually disorganizes the humors of the eye, thrusts forward the iris, obliterates the anterior chamber, and causes ulceration of the cornea, or of the cornea and the sclerotica, Fig. 147. Fig. 148. Melanotic Sarcoma of the Eye. Melanotic Sarcoma of the Eyeball. with a consequent fungous protrusion, from which there is always a dark, fetid, and abundant discharge, with occasional slight hemorrhage. In the latter stages of the malady, the ball of the eye is generally more or less lobulated, and of a characteristic black color, not uniformly but at different points of its extent, the dark hue strikingly contrasting with the white appearance of the sclerotica. The tumor, which sometimes equals the volume of an orange, generally projects a considerable distance beyond the level of the lids. The appearances of this disease are well seen in tig. 148; the iris has been partially detached, and the mass is making its way through the sclerotica, near the cornea. Although the progress of melanotic sarcoma is generally considerably slower than that of glioma, its termination is not the less certainly fatal. The a verage duration of the disease is from nine to eighteen months. Sometimes a case occurs which lasts several years. Of 77 cases analyzed by Ilirschberg, only 5 were cured by the removal of the CHAP. IV. EXTIRPATION OF THE EYE. 215 disease. There is seldom much pain until ulceration sets in, when the suffering rapidly increases, and sadly tells upon the constitution. The disease gradually extends to the structures of the orbit; and death finally occurs from exhaustion, very much as in glioma, which it likewise resembles in its disposition to relapse after extirpation. The only remedy for glioma and melanotic sarcoma is extirpation, which, if done at all, should be done early and most thoroughly. If deferred until ulceration has begun, speedy relapse will be inevitable. During my pupilage, I saw Professor George McClellan remove this organ in three instances for these affections, and in each there was a reproduction of the malady in less than a month. The patients were children under nine years of age, in two of whom the symptoms were such as to hold out strong inducements for the operation. I have myself extirpated the eye in nine cases, in seven for glioma, and in two for melanotic sarcoma, and in every one, so far as I have been able to judge, mischief was done and the fatal crisis hastened. In one instance I performed not less than three operations in almost as many weeks, first removing the ball and then portions of the lids and neighboring parts, but without any ulterior benefit, death occurring a few months from the time of the first excision. In 1844 I saw a lad, thirteen years of age, upon whom the late Professor Mussey had already operated twice, with the result of a speedy relapse in each instance. When the case fell into my hands, some weeks after the last operation, the morbid growth had advanced so far as to preclude the propriety of further interference. EXTIRPATION OF THE EYE. Extirpation of the eyeball alone, known as the operation of enucleation, is necessary wdien, either from disease or injury, it is placing the sound eye in danger of loss of vision from sympathetic ophthalmia ; it may also be proper in the incipient stage of malignant disease, as then the removal of the entire globe affords the only chance of successful treatment. The patient is placed recumbent, under the influence of anaesthesia. The lids being separated by a speculum, the conjunctiva is incised immediately behind the cornea in its entire circumference. The tendon of each muscle is divided at its attachment to the globe by scissors, after having been brought into view with a strabismus hook. Finally, the optic nerve is divided by a pair of blunt-pointed, curved scissors, and the entire globe may be then removed. The operation is followed by little hemorrhage, and is comparatively free from danger. A light water-dressing, with attention to clean- liness, will suffice to prepare the cavity for an artificial eye, which may be introduced in a month. Extirpation of the globe and the contents of the orbit is sometimes required on account of malignant disease of the eye. The operation is sufficiently easy of execution, but, as it is liable to be attended by copious hemorrhage, it should not be undertaken without proper precaution. The patient being under the influence of an anaesthetic, and the head firmly secured upon a low pillow, an incision, which need not exceed three quarters of an inch in length, is made from the outer canthus towards the temple, with a view of facili- tating the remaining steps of the operation. The tumor being transfixed by a double hook, or by a double ligature, the knife, a narrow and rather sharp-pointed bistoury, is passed circularly around it, dividing the conjunctiva, and thus separating the morbid mass from the lids. The excision is completed by including all the soft structures of the orbit— muscles, cellulo-adipose matter, and lachrymal gland—sometimes, indeed, even the peri- osteum itself, and the nerve as far back as possible. The deep dissection will be much facilitated by the use of the scissors and a pair of slender dressing-forceps. The blood, which often flows in torrents, is wiped away with a sponge mop, and, when the operation is over, the cavity is stuffed with lint wet with a saturated solution of subsulphate of iron, a thin compress moistened with sweet oil being placed upon the lids and gently supported by a bandage. This effectually prevents further hemorrhage. The incision in the outer canthus is closed by suture. Clearance of the orbit is not attempted until the establish- ment of suppuration. Extirpation of the eye, performed early in life before the body has attained its full growth, is nearly always followed by a partial arrest of development of the orbit. The lids usually experience a similar fate. Optico-ciliary neurotomy or enervation of the globe of the eye, as a substitute for ex- tirpation, was first performed by Rondeau in 1866, but found no other advocates at that time. The operation was revived by Boucheron in 1876, and has since then been fre- 216 quently performed and extensively discussed. It consists in making a perpendicular incision over the tendon of the internal rectus muscle, one line from the margin of the cornea, dissecting up this tendon from the sclerotic coat, rotating the ball of the eye forci- bly outwards, and dividing the optic and ciliary nerves along with the bloodvessels deeply in the orbit of the eye with a pair of strongly curved scissors. The tendon of the rectus muscle is then drawn forwards, and maintained in place by a suture introduced with two needles, one being passed through the conjunctiva over the site of the superior rectus muscle and the other over that of the inferior. The operation is attended with consider- able bleeding, which, however, is always easily arrested. The blood which is temporarily retained in the deep portion of the wound, instead of proving disadvantageous, adds to the success of the operation by pushing the fatty matter in the socket of the eye backwards and the ball forwards, thus separating the extremities of the severed nerves, and preventing their reunion, as might otherwise readily happen. The suture should be removed at the end of seven or eight days, and the inflammation combated in the usual manner. The oper- ation is always followed by an immediate cessation of pain, and the eye retains its natural position, movements, and good looks. A number of cases have recently been reported in which the effect was not permanent. The operation is opposed by some good authorities, and can scarcely be considered as having an established position in ophthalmic surgery. ARTIFICIAL EYE. When an eye has been partially destroyed, the defect may often be admirably remedied by an artificial substitute; but, before this can be done to advantage, the stump of the original organ must be placed in a healthy condition, otherwise much annoyance, if not positive suffering, may ensue. For this purpose it will generally be necessary to subject the patient to a mild antiphlogistic course, and to the use of astringent collyria, in order to relieve morbid action, and induce contraction of the dilated vessels. Thickened con- junctiva, bands and bridles, inverted lashes, and, in short, whatever interferes with accu- rate adaptation, must receive preliminary attention. I have rectified a squinting stump by the division of the internal straight muscle, and in several instances I have been com- pelled to excise considerable portions of the lower lid before the patient could comfortably wear the false eye. The best stump for an artificial eye is one which has sustained very little loss, and which, consequently, is just a little below the natural size. A collapsed ball does not afford adequate support, and the case is still worse when the eye has been extirpated. It is very important, also, that the stump should retain its muscular power, otherwise it will be impossible for it to move in concert with the sound organ. The morbid sensibility and pain so frequently experienced in wearing an artificial eye are generally dependent upon the cornea, and it is, therefore, a good rule, whenever the sur- geon has his choice, to remove the whole of this membrane as a pre- liminary measure,. A want of attention to this point might seriously endanger the safety of the sound eye. An artificial eye, fig. 149, is merely a thin, light shell of enamel, highly polished, almost hemispherical in shape, and accurately cor- responding in size and color to the sound organ. Establishments for its manufacture exist both in this country and in Europe. To obtain a good fit, the patient should apply in person, or, if this be impracti- cable, send a proper model, accompanied with a drawing of the color and appearance of the healthy eye. The insertion of a false eye is readily effected after it has been dipped in cold water by passing it, with the broad end out, under the upper lid, and then holding it there with the forefinger of one hand, while the lower lid is forcibly depressed with the other until the edge of the shell sinks into the inferior palpebral sulcus. Removal is accomplished by an opposite procedure, that is, by drawing down the lower lid, and insinuating a hook, a large pin, or a piece of wire, beneath the lower edge of the disc, which, lest it fall and break, should be received into the hand or dropped upon some soft substance. As cleanliness is of the greatest importance, tlie eye should be taken out every night at bedtime, and well washed, the stump and lids thoroughly bathed, and any undue irrita- tion that may arise promptly combated by suitable collyria and aperients. At first the eye should not be worn longer than a few hours each day, but as the parts become accus- tomed to its presence the interval may gradually be increased. In about a year a new DISEASES AND INJURIES OF THE EYE. CHAP. IV. Fig. 149. Artiticial Eye. CHAP. IV. DISEASES AND INJURIES OF LACHRYMAL APPARATUS. 217 one will probably be required, the old being rendered useless by the corrosive action of the humors of the diseased organ. DISEASES AND INJURIES OF THE LACHRYMAL APPARATUS. The lachrymal organs consist of the lachrymal gland, canals, and sac, together with the nasal duct, which are all liable to inflammation and its effects, and also to some of the morbid growths, either as primary or secondary affections. a. Lachrymal Gland.—The principal affections of this little body are inflammation, cystic tumors, and chronic enlargement. 1. Inflammation of the lachrymal gland, technically called dacryadenitis, is most com- mon in young subjects of a strumous diathesis, as an effect of cold or external injury. In disease of the globe and orbit the gland is sometimes involved secondarily, and this, in fact, appears to be the way in which it usually suffers, idiopathic disease being exceed- ingly infrequent. There are no signs by which the affection can be discriminated from other maladies in its immediate vicinity, although its presence may always be suspected when there is pain, more or less severe, in the situation of the gland, accompanied with swelling and tenderness on pressure. Confirmatory evidence is afforded by the absence of lachrymal secretion, or the existence of inordinate dryness of the conjunctiva, oedema, pain, and tension of the upper lid, and displacement of the ball of the eye, which is gen- erally pushed somewhat downwards and inwards by the pressure of the enlarged gland, as well as embarrassed in its movements. The conjunctiva always participates in the inflam- mation, becoming red and painful; the periosteum of the orbit is also liable to be involved, and the bone itself may be attacked. Fever and headache are among the more common symptoms, and in many cases the patient is delirious. Dacryadenitis may terminate in abscess, or pass into the chronic form, the gland re- maining enlarged and tender for many months. The formation of matter is usually indicated by the occurrence of delirium, or an increase of it if it previously existed, a disposition to rigors, and an aggravation of the circumorbital inflammation. The treatment is rigidly antiphlogistic ; by general bleeding if there is much suffering conjoined with plethora; by leeches to the forehead and temple; by active purgation; by antimonial and saline preparations; and by the application of medicated dressings, either in the form of light poultices or fomentations. If suppuration occur, the matter is evacuated by an early incision through the upper part of the conjunctiva, beneath the corresponding lid. The chronic form of the disease is combated by milder means; principally by purgatives, occasional leeching, and tonics. Now and then the puncture made for the relief of the abscess is disposed to remain fistulous, and must then be lightly touched, from time to time, with nitrate of silver or the end of a fine probe, dipped in a weak solution of acid nitrate of mercury. 2. A cystic tumor occasionally forms in the lachrymal gland, in consequence, appa- rently, of the obstruction of one of the lachrymal ducts, and the retention of lachrymal fluid. The contents of the cyst are of a whitish color, of a thin, watery consistence, and of a saline taste; sometimes they are thick and viscid, like synovia. The tumor varies in volume from that of a pea to that of an almond, is irregular in shape, bears a very close resemblance, in its appearance, to a small bladder, is composed of a single layer, is always unilocular, and chiefly occurs in young subjects, under thirty years of age. The diagnosis is necessarily obscure, if not altogether uncertain. When the tumor approaches the surface, and is elastic to the touch, an exploring needle, carefully inserted, may assist in determining its nature; but, in general, this can be done only by an incision, large enough to expose it. The eyeball is usually displaced forwards and inwards, but as this protrusion may be caused by other affections, such, for instance, as morbid growths of the orbit, entirely unconnected with this gland, it is evident that a useful hint only can be deduced from that circumstance. The treatment is the same as in cystic formations in other parts of the body. The safest remedy is an injection of a very weak solution of iodine, or the introduction of a little mercurial ointment, to excite adhesive inflammation. Extirpation of the sac should only be attempted when the tumor is large and indisposed to yield to other and milder means. 3. Neoplasms of the lachrymal gland are very uncommon, but adenoma, sarcoma, and carcinoma are occasionally met with. They are all characterized by exophthalmos and other suffering, and should be extirpated without delay. 4. The lachrymal gland is liable to chronic enlargement, attended with induration and 218 DISEASES AND INJURIES OF THE EYE. CIIAP. IV. other textural changes, producing a state of things which has occasionally been confounded with adenoma and carcinoma. It is most frequent in children ; and its progress is marked by great slowness and the absence of signs of inflammation. When it is not amenable to discutient means, the enlarged and indurated gland should be removed. 5. Extirpation of this body is accomplished by making an incision through the outer commissure of the lids, and raising the upper flap from the corresponding portion of the ball; a procedure altogether preferable to cutting through the substance of the lid, as often advised. The enlarged gland being thus exposed is carefully liberated with the finger or handle of the scalpel, and lifted from its bed along with any other suspicious- looking structures. The cutaneous wound is approximated by suture, and supported by a light compress, confined by a suitable bandage. /3. Lachrymal Canals These little passages, which convey the lachrymal secretion to the tear-bag, are liable to laceration, inflammation, obstruction, and stricture. 1. Laceration of the lachrymal tubes, one of the effects incident to injury in this region, is usually caused by a blow, or by a fracture of the nasal and maxillary bones. Walton mentions an instance in which it was produced by a slight scratch on the inner corner of the eye in a scuffle. It is characterized by a puffy, emphysematous swelling, crackling under the finger, and gradually spreading over the cheeks and eyelids, which are some- times completely closed. The symptoms generally disappear spontaneously in a few days. 2. Inflammation of these passages, whether primary, or propagated from the neighboring structures, is attended with thickening of the lining membrane, more or less uneasiness, muco-purulent discharge and watering of the eye, the tears being unable to reach their natural destination. The subjects of the disease are generally persons of a strumous pre- disposition, who are very prone to take cold, and to suffer from other ophthalmic affec- tions, especially chronic conjunctivitis. The proper remedies are attention to the general health, which is often much impaired, and gentle, but steady, purgation, with a leech occasionally to the inner canthus, and the use of slightly astringent injections. 3. Obstructions of the lachrymal canals may be produced in different ways, as chronic thickening of their lining membrane, direct adhesion of their walls, or deposit of lymph in the submucous connective tissue. It may also be caused by the presence of an earthy con- cretion, a detached and intercepted eyelash, or inspissated mucus. A wound of these pas- sages is a serious accident, inasmuch as it is very liable to be followed by loss of function. The closure, however induced, may be partial or complete, temporary or permanent ; in some cases it affects merely the orifices of the tubes. The characteristic symptom is epi- phora, but the nature and situation of the obstruction can only be determined by an ex- amination with the probe. When the obstruction is extensive, or dependent upon firm adhesions, or the presence of organized lymph, no benefit will be likely to result from treatment; under opposite cir- Fig. 150. Ariel’s Probe. Fig. 151. Auel’s Syringe. cumstances, relief should be attempted by gradual dilatation, and mildly astringent injec- tions, the proper instruments for performing these operations being Anel’s probe and syringe, depicted in tigs. 150 and 151. Great tact and caution are necessary in the use 219 CHAP. IV. DISEASES AND INJURIES OF LACHRYMAL APPARATUS. of these instruments, otherwise they will he sure to increase the disease instead of dimin- ishing it. The probe should not, at first, be introduced oftener than once every fourth or fifth day, and the operation should never be commenced without some preliminary treatment, with a view of rendering the parts more tolerant of manipulation. The eye should always be well bathed for some time after the passage of the instrument, and, if considerable irritation arise, a brisk purgative must be given, and a leech applied over the region of the lachrymal sac. The dilatation may generally be greatly promoted by the daily use of some astringent injection, composed, for example, of the eighth of a grain of nitrate of silver to the ounce of water, or a weak solution of zinc, alum, or lead. Without, however, some constitutional treatment, local measures will generally afford very little benefit; and even then, under the most favorable circumstances, much time and patience will be required to effect a a permanent cure. Foreign bodies in the lachrymal canal must be extracted with the forceps, or forceps and knife. The intruded eyelash is sometimes seized with difficulty, owing to the fact that it is almost completely buried in the passage. In consequence of accident or disease, the orifice of the inferior lachrymal canal is occasionally displaced, being turned forwards or upwards, away from the ball of the eye, so as to allow the tears to flow over the edge of the lid. When this is the case, relief may be afforded by a very simple operation, suggested by Mr. Bowman, consisting in the com- plete division of the canal by means of a very delicate knife, carried from below upwards over a grooved director. During the after-treatment care must be taken to prevent the edges of the incision from growing together, by the occasional use of a probe. The object of this procedure is to extend the orifice of the duct backwards to the point where the tears naturally accumulate. When the orifice of this canal is obliterated, the canal itself remaining pervious, an incision should be made just below the seat of the obstruction, across the tube, which should then be slit up on a probe. y. Lachrymal Sac The tear-bag is liable to laceration, inflammation, both acute and chronic, abscess, and fistule. 1. Laceration of the lachrymal sac usually occurs as a complication of fracture of the nasal and maxillary bones. In a case related by Dr. Taylor it was occasioned by blowing the nose. However induced, it is liable to be followed by excessive swelling of the parts, with a tendency to emphysema, the formation of abscesses, and obliteration of the sac from inflammatory deposits. To prevent these untoward effects, the treatment should be prompt and vigorous, our main reliance being upon leeches and cold water-dressing, with active purgation. 2. Inflammation of the lachrymal sac, the dacryocystitis of ophthalmologists, commonly occurs in strumous and syphilitic subjects, either from exposure to cold, disease of the neighboring structures, or, as is more generally the case, from obstructions of the nasal canal, the inferior outlet of the sac. The sac, under these circumstances, is placed in the same condition as the urinary bladder in stricture of the urethra, or chronic enlarge- ment of the prostate gland. In either event there is retention of the natural contents of the reservoir, which, undergoing chemical decomposition, become thereby a source of inflammation, suppuration, and even ulceration. I imagine that most of the more simple cases of dacryocystitis are induced in this way. The disease may occur at any period of life, but is uncommon in infancy and childhood. The acute form of the malady is characterized by unusual violence, the symptoms, both local and constitutional, being generally much more severe than the size and importance of the affected part would seem to indicate. The reason, however, is sufficiently apparent when we reflect upon the organization of the sac, and the nature of the structures immediately around it. The disease begins in the form of a hard, circumscribed swelling, immediately below the tendon of the orbicular muscle, which, gradually increasing in bulk, soon be- comes the seat of the most exquisite pain, deep-seated, throbbing, and extending in dif- ferent directions ; the skin has a red, erysipelatous blush, and slightly pits on pressure ; the eyelids, cheek, and nose are deeply involved in the morbid action ; the lachrymal canals no longer perform their office; there is high fever, with agonizing headache ; and the patient is often violently delirious. If the excitement is not arrested, as it rarely will be when it has attained this height, suppuration will set in, thus greatly augmenting the suffering. The treatment of acute dacryocystitis is rigidly antiphlogistic. Leeching, and even venesection, may be necessary ; purgatives and antimonials are freely used, along with anodynes, to allay pain and promote sleep ; and the parts, painted several times a day with dilute tincture of iodine, are kept constantly wet with a strong solution of acetate 220 DISEASES AND INJURIES OF THE EYE. CHAP. I V. or lead and opium. A small blister applied to the swelling is occasions »iiy or great service. I lot stoupes or a poultice often give most relief. 3. The formation of abscess of the lachrymal sac is denoted by the pointed character of the swelling, by the erysipelatous blush of the skin, by the throbbing nature of the pain, and by the sense of fluctuation, which is always present when the matter has made some progress towards the surface. In that event, too, there is often a small vesicle of the epidermis with sin attenuated state of the skin, showing where the abscess, if left to itself, will ultimately open. The treatment consists in affording free vent to the pent-up fluid, and the earlier the operation is performed the better, both for the part and the system. The tendon of the orbicular muscle, made tense, serves as a guide to the knife, which is carried perpendic- ularly down over the most prominent part of the swelling. Some surgeons prefer to open the abscess by slitting up the canaliculus, but this is an inefficient procedure. The inflammation having subsided, the artificial opening may close, although, generally, it will remain, especially if there is any obstruction in the nasal canal, or disease of the lachrymal bone, as may happen when the affection is of a strumous or syphilitic origin. In such a case, the bone may be so completely necrosed as to require removal. When the sac continues open, or breaks at intervals, it discharges more or less pus, or puriform mucus, constituting what is called a lachrymal fistule. Under such circumstances, the cure may be promoted by astringent injections, or simply by washing out the sac several times a day with tepid water and soap, or common table tea. 4. Chronic dacryocystitis is often a troublesome and obstinate disease. It may be a sequel of the acute form, or it may exist as an original lesion, coming on gradually and stealthily, without any evident cause, and unaccompanied by any marked symptoms. It is most common in strumous persons, in consequence of attacks of measles, scarlatina, or smallpox, and frequently lasts for months and years, producing thickening of the lining membrane, and obstruction of the lachrymal and nasal ducts. Sometimes it is de- pendent upon disease of the pituitary membrane, caries of the bones of the nose, or the presence of a nasal polyp. The disease is recognized by a small tumor at the side of the nose just below the ten- don of the orbicular muscle, and by a constant feeling of uneasiness of the part; there is generally some inflammation of the conjunctiva, as well as of the lids, and occasionally, also, some discoloration of the skin in the situation of the sac. The swelling is caused by the retention of the tears and the accumulation of the mucous secretion, which thus serve to keep up the morbid action. By pressing the tumor gently with the finger, its contents discharge themselves through the lachrymal canal, and partly, also, through the nasal duct ; a method usually adopted by the patient to obtain temporary relief, being often performed three or four times a day. Epiphora, or watering of the eye, is generally another of the annoyances experienced by persons laboring under this affection. Chronic dacryocystitis is treated upon the same principles as the acute form of the disease, only that the remedies must be plied less vigorously. Attention to the general health is indispensable ; the secretions, which are often much at fault, must early be corrected; the diet must be properly regulated; and the bowels must be kept under the influence of mild purgatives, containing a small quantity of blue mass or calomel. Locally, the best application is dilute tincture of iodine, painted upon the skin over the sac once every twenty-four hours. Benefit, of a very important character, will also acrue from the daily employment of mildly astringent injections, thrown into the sac along the lower lachrymal canal with an Anel’s syringe. We cannot be too cautious, however, in the use of these means ; for should they be at all irritating, the morbid action will be sure to be increased instead of being diminished. The practitioner has a great variety of articles from which to select, and he has only to be careful that he properly graduates their strength to the tolerance of the parts. When the disease is dependent, as it often is, upon partial obstruction of the nasal duct, an attempt should be made to effect clearance with the probe, used upon the same principle as in the correspond- ing affection of the lachrymal canals. For this purpose, the short probes described by Dr. I la ys may be employed ; or those introduced by Mr. Bowman, consisting of six sizes, which are to be preceded, in their employment, by his operation of slitting up the inferior canal from its orifice to the lachrymal sac, upon a small grooved director, or with the probe-pointed canaliculus-knife of Weber, fig. 152. Fig. 152. Canaliculus Knife. 221 CHAP. IV. The introduction of the probe necessarily involves a very thorough acquaintance with the anatomy of the lachrymal passages. The operation is usually performed upon the inferior canal, while the patient is seated upon a chair, with his head resting against the breast of the surgeon. The lower lid being made slightly tense by placing a linger over the outer commissure, the probe is inserted from above downwards, and gradually brought to a horizontal position, until the point reaches the farther side of the sac; the instru- ment, being now raised against the superciliary arch, is passed steadily downwards, with a slight inclination backwards, along the nasal canal, into the inferior chamber of the nose, care being taken to execute the whole proceeding in the gentlest possible manner. The operation is repeated at first twice a week, then every other day, and finally every twenty-four hours until all necessity for its employment ceases. The use of much larger instruments than those of Bowman has recently been recom- mended. When the patient can be seen only at long intervals, or in the case of children, where it may be impossible to introduce a probe without an anaesthetic, a lead wire of the same size is sometimes used instead of the probe, and allowed to remain in the duct, the exposed end being bent down over the edge of the .orbit to retain it in place. Some surgeons, after slitting the canaliculus, pass the knife down through the duct, and then at once introduce a probe of large size. If the obstruction is irremovable, the proper plan is to drill a suitable opening—a pretty large one—into the upper portion of the lachrymal bone, to allow the tears and mucus to pass into the upper chamber of the nose. 5. Fistu/e of the lachrymal sac is nearly always the result of abscess, dependent upon closure, partial or complete, of the nasal duct. Disease of the lachrymal and turbinated bones, or of the pituitary membrane, and various morbid growths of the nose, as polyps and exostoses, may also give rise to it. A congenital lachrymal fistule is an occasional occurrence. The external opening of the fistule is usually situated just below the tendon of the orbicular muscle, as in tig. 153, and is subject to temporary closure. The discharge is either mucous or muco-purulent, being of a yellowish or whitish appearance, and of a thick, ropy consistence ; the parts around are generally somewhat tender and inflamed, and the tears often flow over the cheeks, in consequence of the congested condition of the lachrymal passages. As the cause of this affection is obstruction of the nasal duct, it is evident that the only remedy is its removal. This is to be accomplished in the manner already pointed out under the head of chronic inflammation. When the patency of the nasal duct has been reestablished, the fistule will usually close spontaneously in a few days ; should it be slow in healing, the cicatrization may be promoted by the application of nitrate of silver, or a weak solution of acid nitrate of mercury. I have occasionally seen the orifice close promptly, after the failure of other means, under the use of a small blister. 6. Having already spoken of the principal diseases of the nasal duct, and the means of overcoming them, in connection with inflammation and fistule, it is not necessary to enter into any formal disquisition of them here. This is the less called for, because they are of infrequent occurrence, most obscure in their diagnosis, and, in great degree, beyond the reach of remedies. . INJURIES AND DISEASES OF THE LIDS. The lids are subject to various affections, some of which are peculiar to them, others common to them and to other parts of the body. The most important of these affections are wounds, boils, tumors, malpositions, paralysis, and inflammation. 1. Wounds of the lids should be treated on general principles. A clean cut should be united by suture, with wire in preference to thread, introduced in such a manner as not to interfere with the mucous membrane, or the tarsal cartilage. Pins are quite out of the question, and plaster alone should never be trusted to on account of the great mobility of the parts. The nicest adaptation of the divided surfaces is to be aimed at, as any mal- approximation is liable to be followed by trichiasis, entropion, or ectropion. When a lid is severed from its connections, torn through at the centre, or divided at the commissure, the edges should be well trimmed, and then united by suture, aided by adhesive strips. Occasionally a compress and bandage will be required ; but, in general, INJURIES AND DISEASES OF THE LIDS. Fig. 153. Lachrymal Fistule in its Chronic Stage. 222 DISEASES AND INJURIES OF THE EYE. CHAP. IV. the globe of the eye will afford sufficient support to the affected parts. When the lach- rymal orifice is involved in the laceration, the greatest care should be exercised to prevent its closure. Wounds of the eyebrows demand the same attention as similar lesions of the lids, both in regard to accuracy of adaptation and retentive measures. A disfiguring cicatrice of these parts may often be advantageously dissected out and exchanged for a more seemly one ; but such a procedure usually requires proper prepara- tion of the system, lest, erysipelas arising, the beauty of the result be thus marred. 2. A congenital fissure sometimes occurs in the eyelids, especially in the upper; it may exist by itself, or in union with harelip, or with harelip and cleft of the iris, as in a case observed by Heyfelder. The defect is rectified by an operation similar to that for harelip, apposition being maintained by the finest suture and isinglass plaster. 3. Emphysema of the lids may arise from external injury, from disease, or from blow- ing the nose violently. A case of this occurrence, from a gunshot wound of the frontal sinus, is related by Baudens. In the majority of instances, the air gains admission from the nasal cavity, in consequence of ulceration of the Schneiderian membrane and bony wall. The characteristic symptoms are, a tumid condition of the affected lids, and a peculiar crackling sensation perceived on pressing them with the finger. The affection generally rapidly disappears under the application of cold water and a dose of aperient medicine. When the distension is very great, a few punctures may be made into the skin. 4. A stye is a small, inflammatory swelling at the edge of the lid, of a furuncular nature, attended with pain, heat, and itching, with a tendency to suppuration. It is, in fact, nothing but a boil, modified by the structure of the parts in which it is developed, 'fhe disease probably has its origin in one of the bulbs of the cilia, and is most frequently met with in persons of a strumous constitution, laboring under derangement of the diges- tive apparatus. I have seen it much oftener in females than in males, particularly in young girls who take but little exercise, and are subject to irregularity of the menses. Some individuals are peculiarly prone to this disease, suffering almost habitually for months together, one stye appearing after another, or each having a disposition to assume a chronic course. The upper lid is more frequently affected than the lower. Fig. 154. Snellen’s Clamp. The proper practice is to encourage the suppurative process with warm fomentations, or a light poultice, and to lay the swelling freely open as soon as matter has fairly begun to form. If the stye is very painful, a leech may be applied to its surface, and a brisk ca- thartic directed. When the affection becomes chronic, or has a tendency to frequent recurrence, special attention must be paid to the correction of functional derangement, by the use of purgatives, alterants, tonics, and a judicious regulation of the diet. The 223 CHAP. IV. best local remedies are a weak solution of iodine, and slight scarification to relieve vas- cular engorgement. When the matter is deep seated, the knife must be carried down to the tarsal cartilage, and the sac of the abscess well scraped. 5. Various kinds of tumors—horny, warty, sebaceous, cystic, hairy, benign, and malignant—form upon the lids, in their substance, or along their free edges; but, as they do not differ from similar growths in other regions, it is not necessary to enter into any elaborate account of their nature and treatment. Most of them are easily recognized and treated, the proper remedy being excision, performed as soon as the morbid growth acts hinderingly or disfiguringly. Those seated along the edge of the lid may usually be snipped off' with the scissors, or, if the patient dreads pain, they may be removed with the ligature, any tendency to reproduction being afterwards repressed with nitrate of silver. When the tumor occupies the substance of the lid, a horizontal incision, embrac- ing the skin and fibres of the orbicular muscle, is made across it, when it may be seized with the tenaculum, and either dissected or dug out, as may be most convenient, care being taken, if it is encysted, not to leave any of the sac behind, nor. in any case, to injure the palpebral cartilage. The edges of the wound are approximated by the inter- rupted suture, which is the only dressing required. Snellen’s modification of Desmarres’s ring forceps, or lid clamp, fig. 154, will be found very useful in giving complete control of the lid, and arresting hemorrhage during the operation. One of the most common tumors in the upper lid—it occurs less frequently in the lower —is the sebaceous, which often attains the size of a currant, in the course of two or three months, and is productive of more or less impediment of motion, as well as of some de- gree of soreness. It is almost always associated with derangement of the digestive or- gans, occurs at various periods of life, sometimes even in young children, and originates in the Meibomian glands. It is usually somewhat globular in shape, hard to the touch, and unaccompanied with discoloration of the skin. Its pressure sometimes causes partial absorption of the cartilage. Laid open, it is found to consist of a soft, fatty substance, frequently intermixed with a few drops of pus, and contained in an imperfect cyst. It is usually known as tarsal cyst or chalazion. The proper remedy is excision ; it never recurs, but similar growths are liable to form in its vicinity. Attention to the con- stitution is generally necessary to counteract this tend- ency. A fibrous tumor is occasionally met with in the lids, especially in the lower; it is usually solitary, of a rounded or ovoidal shape, of a dense consistence, and of an imperfectly fibrous structure. Situated between the orbicular muscle and the fibro-cartilage, its tendency is to perforate this substance, and as it increases, to ex- tend towards the inner surface of the lid, where it often presents itself as a soft, fungous, vascular excrescence. Such a growth is seen in fig. 155. The proper remedy is excision, performed by carrying the knife horizontally across the lid. No local applications are of any avail. I had recently at the College Clinic a man, forty-six years old, with a cystic tumor at the outer commissure of the lids, which had made its appearance twelve years previously, and gradually increased in size until it had attained the volume of a hazelnut. It was perfectly translucent, tense, and smooth, free from pain, and firmly imbedded in the skin, which was otherwise perfectly healthy, it contained about one drachm of clear serum, slightly saline to the taste, but without any marked coagulability. The cyst was unilocular, and very thin. Wart-like excrescences, of a florid color, and of a soft, fleshy consistence, are sometimes seen upon the inner surface of the lids ; they are generally small, and, when attached by a narrow pedicle, occasionally exhibit an appearance similar to that of a nasal polyp. Re- moval is readily effected with the scissors, repullulation being prevented by means of sul- phate of copper. The horny tumor of the eyelid is very uncommon. Examples of it have been observed by Voisin, Damon, and others. In one reported by Dr. Henry L. Shaw, of Boston, the growth was nearly two inches in length, and was attached by a very broad base, firmly imbedded in the substance of the lid. The patient was a man fifty-six years of age. INJURIES AND DISEASES OF THE LIDS. Fig. 155. Fibrous Tumor of the Lower Lid. 224 DISEASES AND INJURIES OF THE EYE CHAP. 1 V. In my private collection is a calcareous concretion, kindly presented to me by Dr. Herschel Foote, of Hestonville, who removed it from the margin of the upper eyelid of a lady, forty-four years of age. It had made its appearance ten years previously, was of a rounded shape, and lay immediately be- low the skin, to which it imparted a whitish aspect, as if it might be a sebaceous tumor. It had occasioned no pain. After removal it was of a brownish hue, and of the size of a small currant. In a case described by Dalrymple, in a middle-aged man, the calca- reous tumor was situated in the upper lid, be- neath the tarsal cartilage, in a distinct cyst. It was about the size of a large pea, and was composed chiefly of phosphate of lime. • Carcinoma of the eyelids, generally in the form of epithelioma, fig. 15G, occasionally presents itself, either as an original affection or as a secondary involvement. In the former case, it usually begins as a fissure, a shot-like tubercle, or a warty excrescence, either at the free border of the lids or in their cutaneous structure, and gradually involves their entire thickness, thus producing a foul, painful, and intractable ulcer. Care must be taken not to confound the disease with syphilis. Its slow progress, the puckered con- dition of the affected parts, and the slight swelling which attends it will generally be suf- ficient to establish the diagnosis. Elderly persons are most subject to it; and it is more common in the lower lid than in the upper. The treatment is the same as in carcinoma in other situations. Several cases—probably four or five—have been recorded, in which the lower lid was the seat of a small tumor, containing a cellular cysticerce, fig. 157. The patients were nealy all children, the subjects of slight injury, as a blow or contusion. Such a tumor cannot, of course, be diagnosticated previously to its removal. G. Syphilis of the eyelids may occur from direct inoculation, or as an ef- fect of a constitutional taint. In either event, the disease usually attacks the edge of the lids, in the form of an irregular ulcer, with hard, everted edges, and a foul, unhealthy bottom, with little discharge. Sometimes the disease breaks out upon the surface of the lids, from which it gradually ex- tends until it causes complete perforation. Considerable pain and swelling with oedema of the conjunctiva generally attend its progress ; and these phenomena, together with its great obstinacy, always serve to distinguish it from carcinoma. Not unfrequently, evidence of syphilis exists in other parts of the body. Syphilis of the lids is sometimes congenital, evidences of its effects showing themselves within a few weeks after birth. The infant is always puny, and covered with scales, scabs, pustules, and cop- per-colored blotches, either alone or in association with excoriations about the anus, nose, lips, and ears. The treatment is by mercury and iodide of potassium, assisted by the topical application of nitrate of silver and of the dilute ointment of acid nitrate of mercury. 7. Inversion of the lids, as seen in fig. 158, the entro- pion of ophthalmologists, is generally the result of severe and protracted inflammation of the eye, attended with ex- cessive intolerance of light, compelling the patient to make constant and powerful efforts to exclude it from the retina. The consequence is that the lids are drawn with great firmness over the ball, not severa times during the day, but incessantly, thus inducing relaxation of the skin and orbiculai muscle, and, also, as a necessary result, inversion of the cilia. Granular and strumou diseases of the eye, resulting in contraction and distortion of the cartilage, are the mos common causes of entropion : cases occasionally occur where it is produced by very slight inflammation, especially if, as not unfrequently happens, the individual has natu rally a very redundant lid, or a sort of hypertrophic condition of its cutaneous am muscular tissues. Entropion sometimes affects all the lids, either simultaneously or successively, as I have witnessed in a considerable number of cases; more commonly, however, it is lim- Fig. 156. Epithelioma of the Lower Lid. Fig. 157. Cysticerce of the Lower Lid. Fig. 158. Entropion of both Lids. 225 CHAP. IV. INJURIES AND DISEASES OF THE LIDS. ited to one or two. In degree it varies from the slightest change in the natural position of the organ to the complete curling up of its inner edge, the cilia being perfectly con- cealed from view. In the advanced stage of the affection, the skin of the lid is thrown into numerous horizontal folds, the fibres of the orbicular muscle are stretched and re- laxed, the tarsal cartilage is rendered concave in its vertical diameter, and the lashes are stiff and straggling. The injurious effects which entropion exerts upon the eye may readily be imagined. The lashes, constantly pressed against the anterior part of the ball, fret and irritate the conjunctiva and cornea, keeping up inflammation, with muco-purulent discharge, profuse lachrymation, and intolerance of light. The mischief is particularly apparent in the cor- nea, which, in consequence of the friction of the lid, soon becomes the seat of plastic de- posits, interfering with the transmission of light, and often eventuating in total blindness. Although various remedies have been suggested for the cure of this disease, the most simple, and in many cases the best, is the excision of an elliptical portion of integument, extending from one extremity of the lid to the other, and embracing a few of the fibres of the orbicular muscle. Much judgment is required in order accurately to proportion the amount of substance to be removed, the great danger generally being that the ope- rator takes away too little, thus favoring speedy relapse. Particular instruments, as that, for example, sketched in fig. 159, have been devised for pinching up the skin and giving the flap a proper shape ; but the scientific surgeon needs no such aid, a pair of dissect- ing forceps and scissors being quite sufficient for his purpose. Excision having been Fig. 159. Entropion Forceps effected, the edges of the wound are neatly tacked together by three or four points of suture, to be removed at the end of the third day. Very little, if any, after-treatment will be required. If all the lids are inverted they may be operated upon at one sitting, as I have done in numerous instances. When, as is frequently the case, there is great contraction of the commissure it should be enlarged by canthoplasty. This operation consists in slitting the outer canthus freely with a bistoury or a pair of strong scissors, and uniting the cut edges of the skin and conjunctiva with several fine sutures. When excessive contraction of the conjunctiva and cartilage render something more than the simple excision of a piece of the integument necessary, Arlt’s operation, or one of the numerous modifications of it, is the best. The Fig. 160. Fig. 161. Graefe’s Operation. Ectropion of the lower Eyelid. lid is held in Snellen’s clamp, and its free edges split, to the depth of about £ of an inch, by an incision made just within the line of the lashes. The anterior portion is then drawn upwards, and the lashes turned out, by the excision of an elliptical piece of skin, as described above. Graefe made two vertical incisions commencing at the ends of the first 226 DISEASES AND INJURIES OF THE EYE. CHAP. JV. incision and passing down to the cartilage and drew the anterior portion of the split lid upwards by removing an oval piece of skin. The steps of the operation are shown in fig. 160. 8. Ectropion, exhibited in fig. 161, the reverse of the above condition, may be caused by long-continued inflammation, attended with excessive thickening of the conjunctiva, as in granular lid; but in the great majority of cases it is produced by the contraction of vicious cicatrices, especially by such as are the result of scalds, burns, and escharotic applications. Loschge, Schiette, and others, have witnessed ectropion as a congenital malformation. The eversion presents itself in various degrees, being sometimes very slight, and at other times so great as to turn the lid completely inside out, hanging off from the eye like a shutter. However this may be, it is always accompanied by an inflamed, thickened, and indurated condition of the palpebral conjunctiva, and generally also by more or less disease of the eye, owing to the constant exposure of the ball to light and dust. In cases of long standing the ocular conjunctiva is dry and hypertrophied, and the cornea often exhibits opaque specks, obstructing vision. The affection is most common in the lower lid, and, in its worst forms, is often attended with a remarkable elongation of the part in its horizontal diameter, so that the lid is not only everted but turned away considerably from the ball. Slight ectropion, depending upon inflammation, may sometimes be relieved solely by antiphlogistic means, which, by promoting the contraction of the enfeebled and relaxed structures, gradually restore the lid to its pristine position. The removal of the thickened and indurated palpebral conjunctiva, in the form of an elliptical fold, sometimes greatly facilitates the cure. When the affection has been caused by a vicious cicatrice, an ex- tensive dissection may be necessary to effect the object, and even then success is by no means always certain, owing to the remarkable reproductive tendency of the inodular tissue. I have, however, repeatedly effected excellent cures by this procedure, in appar- ently the most unpromising cases. The operation consists in dissecting up the lid freely from its unnatural attachments, placing a well-oiled compress upon the raw surface, and making the part heal by granulation, elevation of the lid being assisted by adhesive plaster, or by a thread passed through its edges, and secured to the forehead or cheek, according to the site of operation. If the lid is very large and ill-shaped, it may be necessary to Fig. 162. Fig. 163. Operation for Ectropion. The same, completed. cut out a triangular flap, figs. 1G2, 103, and a very good cure is sometimes effected, in the more common cases of ectropion, simply by this means. 9. Blepharoplasty—When an eyelid is much disfigured by disease, morbid growths, or cicatricial tissue, or is partially or completely lost, whether by accident or any other cause, an attempt should be made to form a substitute, although the surgeon need not flatter himself that his efforts will generally be very successful, especially if serious injury has been sustained by the tarsal cartilage, as in such an event it will be very difficult, if not impossible, to obtain a good support for the new organ. The risk of failure will be increased if there has been serious disease of the bony orbit, or if the lid has been the seat of syphilis, epithelioma, or sarcoma. CHAP. IV. INJURIES AND DISEASES OF THE LIDS. 227 The flap may be borrowed from the cheek, temple, forehead, or nose, or, conjointly, from two of these regions. At least one case is upon record in which the skin was taken from the back of the hand. The rules which govern the surgeon in the transplantation of his material do not differ from similar procedures in other parts of the body. The leading points to be observed are, first, to cut away all diseased structure ; secondly, to pro- vide a flap considerably larger than the bed into wdiich it is to be fitted, to allow for shrinkage ; thirdly, to guard against hemorrhage ; and lastly, to unite the edges of the wound in the most careful manner with delicate silk sutures. The pedicle should alwaiys be of ample dimensions and the dressings should be applied with the greatest possible care, the best material being cotton moistened witli oil, and con- fined with a roller carried round the head. During the after-treatment the usual precautions are of course observed. In the annexed fig. 1G4, the skin is taken from the cheek, and in fig. 165, from the temple. The manner in which the wound is closed after the operation is well seen in fig. 166, from Stellwrag. Skin-grafting has been resorted to with success in a number of cases in wdiich no sound flap could be found near the cicatrice ; and Dr. Wolfe, of Glasgow', has recently made Fig. 164. Plastic Operation on the Eyelid. Fig. 165. Fig. 166. Plastic Operation for Ectropion Mode of closing the Wound. what is considered by some as an important advance in blepharoplasty by transplanting bodily, or without a pedicle, large flaps from one to three inches in diameter, to fill up gaps left after wounds, injuries, or operations, involving loss of the eyelid. Although in the hands of a skilful surgeon, and under specially favorable circumstances, as it respects the patient, such a procedure may occasionally have a favorable issue, yet, as a rule, failure will be sure to follow it, most, if not the whole, of the transplanted structures perishing from insufficient nourishment. 10. The lids are sometimes attached by morbid adhesions to the ball of the eye, thus not only impeding its movements, but occasioning serious deformity, known ixssymblepharon. The most common causes of the occurrence are scalds and burns, and the contact of escharotic substances, as nitric acids arid quicklime. The defect is sometimes congenital, although this must be extremely rare, as I have never seen an instance. Relief may be attempted by the cautious use of the knife, the contiguous surfaces being afterwards kept apart by soft lint, and by the daily destruction of the new adhesions with the probe. The cure will necessarily be tedious, and generally not permanent, the original condition being reproduced by cicatricial contraction. The methods of operating, that offer most hope of success, are those of Teale and Arlt. After freeing the adhesions, Teale covers the bared portion of the ball by transplantation of conjunctiva from a neighboring portion, 228 DISEASES AND INJURIES OF THE EYE. CHAP. IV. while Arlt inverts the connecting band so as to bring its sound surface in contact with the bared surface of the ball. The latter is accomplished by passing a thread armed with two needles through the edge of the flap formed by dissecting away the adhesion, passing the needles, from within outwards, through the skin near the edge of the orbit, and fastening the threads on the outside of the lid, to keep the flap doubled down with its fresh surface in contact with the fresh surface of the lid and its sound surface opposed to the ball. 11. Inversion of the eyelashes, technically called trichiasis, represented in fig. 167, may exist as an independent affection, or as a complication of entropion. Generally caused by chronic disease of the lids, especially psoriasis and eczema, it sometimes comes on without any assignable cause, and at a period of life so early as almost to induce the belief that it may occasionally be congenital. In some per- sons the cilia are naturally very short, stiff', and straggling, and hence the slightest inversion of the edges of the lid3 may produce a very severe trichiasis. The lashes are generally bent in different ways, some towards the eye, some out- wards, and some in the direction of the length of the lids. The constant rubbing of the faulty cilia against the ball keeps up serious disease, and often leads to opacity of the cornea, not unf're- quently followed by total blindness. Trichiasis, dependent upon entropion, generally disappears the moment the lid is put in a condi- tion to resume its proper position. When the cilia alone are inverted, the only feasible remedy is excision of the part of the lid in which they are implanted, care being taken not to injure the palpebral cartilage; the little wound soon heals, and no deformity ensues. When all the cilia are turned in, the procedure which I usually adopt is to include them in two horizontal incisions, extending the whole length of the lid, from one end to the other. Nothing short of this ever answers the purpose, nor will this suffice, unless every bulb is taken away with its corresponding hair. Save the unseemly appearance caused by the absence of the lashes, it is astonishing what little disfigurement such an operation occasions. It has been proposed to cure this affection by inoculating the bulbs of the faulty cilia with dry tartar emetic, with a view of causing their destruction by the resulting inflam- mation. I must confess I have an aversion to such a procedure. Evulsion, or drawing out the cilia by their roots with a pair of forceps, is equally objectionable ; it is merely palliative, and never succeeds in giving permanent relief. 12. The edges of the lids are liable to a troublesome eruptive disease, the characteristic symptom of which is a distressing itching ; it is evidently a species of herpes, or eczema, seated in the orifices of the Meibomian glands, and is generally known by the name of tarsal tetter, or ciliary blepharitis. The affection is almost peculiar to young subjects, of a strumous predisposition, with light hair, eyes, and complexion. When it becomes chronic, as it is wont to do, it is a source of much annoyance, if not positive suffering, keeping the parts constantly sore, itchy, watery, and irritable. Persons thus affected are often unable to read or sew for months and years together. The disease is aggravated by exposure to light, the use of stimulating food, loss of sleep, and, in short, whatever has a tendency to disturb the secretions or damage the general health. It is sometimes kept up by optical defects. It is characterized by a reddish appearance of the edges of the lids, by more or less itching, and by the presence of bran-like scales at the roots of the cilia, accompanied by an inspissated, glutinous secretion of the Meibomian follicles, lachrymation, injec- tion of the conjunctiva, and intolerance of light. In the milder forms of the disease, some of these symptoms are either wanting, or they exist only in a slight degree, or they are altogether absent at one time and present at another. In chronic cases, the edges of the lids, losing their angular shape, are gradually rounded off, and assume a rough, villous, or granular appearance; the mucous membrane is abnormally thickened, the orifices of the lachrymal canals are closed, and many of the lashes drop out from the Fig. 167. Trichiasis. CHAP. IV. PTOSIS. 229 destruction of their bulbs. In this stage of the complaint, the affected lid is often con- siderably everted, and, being at the same time very red and watery, it produces the pecu- liar state, termed blear eye. As this disease is essentially of a constitutional origin, it demands more than mere topical treatment. Without entering into minuthe, it will be sufficient to remark that a steady and persistent course of purgatives, alterants, and dieting is indispensable, in almost every case, to a satisfactory and permanent cure. Blue mass and compound ex- tract of colocynth, in five-grain doses each, every fourth or fifth night, will act sufficiently upon the bowels and secretions, without weakening the system ; iodide of iron and iodide of potassium will afford a good alterative effect; and bread, vegetables, and milk, will be a suitable diet. A tonic is usually required, and great confidence may be placed in the efficacy of iron and quinine, and cod liver oil. The most valuable topical remedies are astringent lotions and stimulating unguents, properly diluted and applied by means of a camel-hair pencil. The article which has always been most beneficial in my hands is the ointment of the oxide of zinc, in the proportion of two parts to six of cosmoline. An ointment of red oxide or yellow oxide of mercury, or of nitrate of mercury, diluted with ten times its weight of cosmoline is also a valuable agent. Sometimes the happiest effects follow the application of a weak solution of nitrate of silver. The great secret, in the use of any article, is to make it sufficiently weak, to apply it not oftener than once, or, at most, twice, in the twenty-four hours, and to bring it fairly in contact with every portion of the diseased surface. To accomplish the latter object, care should be taken previously to remove, by weak alkaline solutions, or by means of a needle, the scaly deposits at the roots of the cilia, as well as any other matter that may have a tendency to interfere with the action of the remedy. When the lids are very red and tender, poppy fomentations, or an elm poultice, may be necessary. Agglutination of the edges of the lids is prevented by the application of a little cosmoline at bedtime. In obstinate cases, counterirritation may be proper. 13. Lice, generally of the family of body lice, occasionally lodge at the roots of the cilia, where they excite much irritation and itching. As their ova are deposited on the lashes like beads on a thread, a great deal of care is often required to distinguish them from the little furfuraeeous scales attendant upon herpes. The most efficient remedy is a mixture of equal parts of castor oil and alcohol. PTOSIS. The term ptosis implies an inability to raise the upper lid, owing to some defect in the elevator muscle. This defect may consist in mere atony of the muscle, in paralysis of the third pair of nerves, in mechanical injury, or in hypertrophy of the common integument. Occasionally it is found to exist as a congenital vice ; and in several instances of this kind I have seen it associated with divergent strabismus and permanent dilatation of the pupil. It is seldom met with simultaneously on both sides. Ptosis varies in degree from the slightest dropping of the lid to its complete closure, and always produces a corresponding defect in the sight, in consequence of the manner in which the affected structures conceal the cornea and pupil. The treatment of this affection must be regulated by the nature of the exciting cause. When it is dependent upon mere weakness of the elevator muscle, the most appropriate remedies will be tonics, as iron and quinine, the shower-bath, stimulating embrocations, and electricity, with change of air. In the paralytic form, the disease often disappears spontaneously, subsiding with the cause which gave rise to it. In plethoric subjects, general and local depletion, with an occasional purgative, is sometimes necessary, in addition to the use of a small blister to the forehead and eyebrow, the surface being kept raw by means of some irritating unguent. In a case of this variety of ptosis, in a young man of twenty, under my care, I derived signal benefit, as I supposed, from the repeated application of the moxa, and powerful vesication of the occipito-cervical region. Ptosis from hypertrophy is relieved by the excision of a portion of the redundant in- tegument, in the form of an ellipsis, the edges of the wound being afterwards approximated by several points of suture. The operation is performed in the same manner as in entro- pion, and great judgment is generally required to determine the amount of substance to be removed. In the traumatic form, the difficulty depends upon the division of the fibres of the 230 DISEASES AND INJURIES OF THE EYE. CHAP. IV. elevator muscle, and their consequent separation from each other. If possible, the muscle should be reunited to the lid; if this cannot be done, it has been proposed to cut out an elliptical portion of the integument of the lid, and to tack together the orbicular and occipito-frontal muscles, so as to enable the latter, by the hold thus acquired, to coun- teract, in some degree, the action of the former. The procedure has been employed with marked success in several instances, and is worthy of further trial, although it cannot always be expected to answer the purpose as fully as could be desired. A similar [dan may be adopted in the congenital variety of ptosis. When the affection is irremediable, or while the proper remedies are being used for its cure, temporary relief from obstruction to vision may be afforded by holding the affected lid out of the way with a piece of adhesive plaster, or by means of a small, blunt hook, attached to a pair of spectacles. EPICANTHUS. A very unseemly expression is sometimes imparted to the eyes by the projection over them of a redundant portion of integument at the root of the nose, concealing the lach- rymal caruncle and the inner part of the globe. It is always congenital, and occasionally exists in such a degree as to interfere materially with the opening of the lids, if not also with vision. Sichel and others have seen cases in w hich it was hereditary. The treatment of epicanthus, as this affection is called, is entirely limited to the excision of the central portion of the redundant integument, in the form of an elliptical flap, the edges of the wound being afterwards approximated by the twisted suture. The result, however, is seldom satis- factory, owing to the tendency of the skin to stretch and elongate itself. In a case which I had at the Clinic of the Jefferson Medical College in 1858, in a girl seven years of age, little, if any, permanent benefit accrued, notwithstanding the removal of a very large flap. The character of the operation and the appearance of the affection are depicted in fig. 108. i STRABISMUS. Strabismus, or squint, is an aberration of the optic axes from their natural direction, by which the consent between the eyes is destroyed, and vision is more or less impaired. The deformity varies in different cases, from the slightest deviation to the most disagreeable obliquity. The affected organ may be turned inwards, outwards, upwards, or downwards, according to the muscle upon the derangement of which the squint depends. When it is inclined inwards, the complaint constitutes what is called convergent strabismus ; if, on the other hand, it is directed outwards, it is said to be divergent. The upward and downward obliquities have been called strabismus sursum and strabismus deorsum, but these terms are not often used. The most common form, by far, of strabismus is the convergent, in w'hich the eye is directed inwards, or inwards and upwards. The degree of obliquity may be very slight, or so great that when the person looks directly forwards with the sound eye, the cornea of the other shall be almost completely buried at the inner canthus. The organ, in this variety of the complaint, often inclines a little upwards, but hardly ever downwards. Divergent strabismus is comparatively rare; and the two other forms are almost unknown as separate and independent affections; they are usually the result of paralysis. There are few cases of strabismus in which both eyes are not implicated, although not in an equal degree. Usually one is more affected than the other; the patient, therefore, always considers the latter as his good eye, as it is the one which he habitually employs Fig. 168. Epicanthus. CHAP. IV. STR ABISM US. 231 in viewing objects. It occasionally happens that the vision of the two eyes is equal and the patient can, at will, fix with either, allowing the other to deviate. This is called “alternating” strabismus. True strabismus, in contradistinction to paralytic strabismus, is always “concomitant,” that is, the two eyes move together and to an equal extent, the angle of deviation remaining the same. If the unaffected eye is screened and the patient made to fix with the squinting eye, the same degree of squint will be transferred to the other eye. Either eye, alone, has almost perfect motion in all directions, but they cannot both be directed to the same object at the same time. In paralytic squint, on the con- trary, the motion of the eye is limited in the direction of the paralyzed muscle, and when the patient fixes with this eye the nervous influence used in the effort to contract the para- lyzed muscle causes a contraction of the associated muscle of the other eye. The result- ing “ secondary deviation” of the sound eye is greater than the primary deviation of the squinting eye. The exciting causes of strabismus are various. Ophthalmia, convulsions, eruptive dis- eases, as measles, scarlet fever and smallpox, whooping-cough, derangement of the digestive organs, injuries of the head and eyes, difficult dentition, and looking fixedly at particular objects, may all be mentioned as so many exciting causes of the lesion. The most common causes of all, however, are the optical defects known as hypermetropia, or long sight, giving rise to convergent, and myopia, or short sight, to divergent, strabismus. When arising from these causes it usually at first occurs only when the patient looks at near objects, as in reading, and is then called “ periodic.” In this stage it may often be cured, without operation, by the use of suitable glasses. The affection frequently comes on with- out any assignable reason in the most healthy persons. I have witnessed examples in which it was congenital, and in which it existed in several members of the same family. There is no evidence that the complaint is hereditary. Young subjects are most liable to it. Its association with congenital cataract is sufficiently frequent. One of the most disagreeable concomitants of this disorder is the deformity which ac- companies it, and which renders the individual so frequently an object of remark and ridicule. Were this confined to infancy and childhood, little evil would accrue from it ; but when it is remembered that it continues through life, and that it is a source of con- stant annoyance and mortification, the influence which it exerts upon the temper of the sufferer must often be most unhappy. But there is another effect, still more deplorable, and this is the impairment of the vision of the affected eye. This defect, which is never entirely absent, always varies with the extent of the deformity and the length of time that has elapsed since its occurrence. In some instances, especially in those of long standing, the sight is almost destroyed, the retina being insensible. In another series of cases, the person is myopic, or sees objects only at a short distance. In a third series, the vision is, perhaps, double, or objects appear indistinct, or run into each other, the image depicted on the retina being confused and imperfect. It is well known that strabismus has rarely any tendency to spontaneous cure ; on the con- trary, it generally manifests a disposition to increase, especially in children of a nervous, excitable temperament; and the question, therefore, arises, at what period ought the surgeon to interfere? My opinion is that the operation should be performed early; but, in coming to a conclusion on the subject, we should carefully weigh the circumstances of each case, as the condition of the patient, and the nature of the exciting cause of the complaint. If this be an optical defect the deformity is likely to be reproduced if the patient is too young to wear glasses. If the child is otherwise healthy ; if there has been no cerebral disease ; and if the squint is fully formed, there should be no hesitation. There are valid reasons for such a course. In the first place, if the deformity is permitted to persist, the probability is that both eyes will ultimately require interference ; secondly, so long as the squint remains, the subject of it will be an object of unfeeling remark, if not ridicule ; and, thirdly, the invariable tend- ency of the affected organ is to become weaker and weaker, in proportion to its want of exercise. Besides, children invariably bear such operations well; they are unattended with hemorrhage and shock ; and an anaesthetic is always at hand to insure the requisite quietude during their performance. The instruments that are required for the successful performance of this operation are a spring speculum, to control the lids, a blunt hook to bring the tendon into view, a pair of forceps for pinching up the conjunctiva, and scissors for dividing this membrane, the ocu- lar fascia, and the affected muscle. I generally perform the operation without the aid of anaesthesia, as a much better oppor- tunity is thus afforded of judging of the effects of the division of the muscle. If the patient, 232 DISEASES AND INJURIES OF THE EYE. CHAP. IV. however, is a child or a very timid person, anaesthesia is indispensable. In either event, the body should be recumbent, with the head and shoulders well supported by pillows. The lids being separated with the speculum, the surgeon with a pair of toothed forceps seizes a fold of conjunctiva at the lower border of the insertion of the rectus tendon and divides it with a pair of sharp-pointed scissors, in a direction parallel to the fibres of the muscle. The ocular fascia, if not included in the first incision, is similarly seized and divided. The blunt hook is then passed through these apertures, behind the tendon, rendered tense by making traction towards the cornea. One of the blades of a pair of blunt-pointed scissors is now passed beneath the tendon, which is next divided by successive snips subcon- junctivally, or the tendon may be brought fully into view upon the hook and severed with the scissors. Lastly, the blunt hook is passed in various directions in search of any bands or attachments that may have escaped division. The operation being completed, the eye is bathed in cold water, to free it of blood, and then carefully bandaged, the patient being confined for a few days in a dark chamber. Light diet is enjoined, inflammation is restrained by antiphlogistics, and pain controlled by anodynes. Considerable ecchymosis occasionally follows, but requires no particular treatment, as it usually disappears spontaneously in a few days. The extremity of the divided muscle contracts new adhesions to the ball of the eye, and thus aids in maintain- ing its parallelism after the cure is completed. The practice, recommended by some surgeons, of making the patient turn the eye out- wards as soon as he has recovered from the more immediate effects of the operation, to cause it to regain its natural position in the orbit, is, I think, decidedly objectionable. When the eye still retains some degree of obliquity after the operation, it may be sus- pected that the section of the affected muscle, or of the fibrous cords connected with it has not been complete, llow, then, if this be the case, can we expect success? Again, the eye operated on may be perfectly straight, and yet not move in concert with its fellow. Such a result is by no means uncommon, especially in old cases, and the proper plan then is to divide at once the corresponding muscle of the other eye. In children, and in cases generally of recent standing, one operation is usually quite sufficient, even when the ob- liquity remains for some time after. Indeed, the greatest caution should be employed even in the division of one muscle, lest the eye be permanently inclined outwards, and so distortion be produced in the opposite direction. When the squint is of high degree it is better to divide the operation between the two eyes. This will, usually, be necessary if the deviation is greater than three lines. If an excessive effect is produced it can easily be diminished by drawing the edges of the wound together by a conjunctival suture, thus bringing forward the end of the divided muscle. The principal causes of failure after this operation are, first, as just stated, the imperfect division of the affected muscle and fascia; secondly, excision of a portion of the conjunc- tiva, eventuating in undue contraction of this membrane during the process of cicatriza- tion ; thirdly, premature exercise and exposure of the eye; fourthly, the coexistence of epilepsy, hydrocephalus, or other cerebral diseases; fifthly, readherence of the muscle at an unfavorable point of the sclerotic coat, by which it is again enabled to exert a prejudicial influence over the movements of the ball; and, lastly, the fact that only one operation is performed, when it is certain that both organs are affected nearly in an equal degree. Of all these causes the first and last are the most frequent and efficient. Failure frequently arises from the neglect to correct by suitable glasses any existing optical defect that may have been instrumental in inducing the strabismus. The effect of the operation upon vision is at first rather disagreeable than otherwise; at least in some cases. It is only by degrees that the eye regains its functions ; and oc- casionally, whether from long disuse of the retina, or from other causes, little or no im- provement of this kind is to be looked for. Another unpleasant effect, but not a very common one, is double vision, evidently due to a want of consonance between the optic axes, but rarely continuing beyond a few days. When the operation for convergent strabismus is followed, as it occasionally is, by ever- sion of the ball of the eye, the proper means of rectifying the defect is, to expose the divided muscle with the scissors, to sever its connections with the sclerotica, and to fasten its free extremity, by means of two very delicate silk threads, to the fibrous structures in front of the eye, underneath the conjunctiva, in the natural line of the muscle. Care must be taken not to bring the muscle too far forward, otherwise the original deformity will be sure to be reproduced, thus necessitating a third operation. The sutures should CHAP. IV. AFFECTIONS OF THE ORBIT. 233 be removed at a period varying from three to five days, the case, in the mean time, being treated upon general antiphlogistic principles. AFFECTIONS OF THE ORBIT. The orbit is subject to wounds, foreign bodies, tumors, and various diseases, seated either in its bony walls, or in its soft textures. One of their most disagreeable effects is that which arises from the pressure which they exert upon the ball of the eye, thereby thrusting it out of its natural position, and endangering its structure and functions. Wounds of the orbit are of various kinds, and must be treated upon general principles. Special attention must be paid to the removal of foreign bodies, which often lie concealed at a great depth, and may, therefore, unless great care be exercised, readily escape detec- tion. Copious hemorrhage often attends wounds of the orbit, but may usually be readily arrested by compression, conjoined with the use of Monsel’s salt. When the ordinary means fail, ligation of the common carotid artery must be performed. Periostitis is a violent form of inflammation, seated, as the name implies, in the fibrous covering of the orbit, from which it is sometimes propagated through the foramina in the sphenoid bone, and the fibrous sheath of the optic nerve, to the dura mater and the base of the brain. The morbid action may originate in the periosteum of the orbit, or it may extend to it from the face, temple, or forehead. The most common exciting causes are, external injury, and a syphilitic, gouty, or strumous state of the system. Children and adults of a dilapidated constitution are its most frequent subjects. The symptoms are well marked. The pain is deep-seated, constant, agonizing; the eye feels tense and full, as if it would burst, and the slightest motion of' the organ is attended with an aggrava- tion of suffering; the conjunctiva is greatly congested, and of a scarlet hue; the patient complains of intense headache and excessive photophobia; there is high fever; and de- lirium is an early and prominent phenomenon. If matter forms, as it will be very apt to do if the disease is permitted to proceed, its presence will be announced by rigors, and by great increase of the local and general distress, succeeded by obscure fluctuation, which will become more and more conspicuous as the suppurative process advances. Further- more, there will, usually, in such an event, be an erysipelatous condition of the face and head, and a marked protrusion of the eyeball. If the attack is misunderstood, or improp- erly treated, the disease will spread to the brain and its envelops, causing coma and death. The best means for arresting this frightful disease are, leeches, bleeding at the arm, active purgatives, depressants, and anodynes. Tension must be relieved by punctures, and matter let out as soon as there is the slightest evidence of its existence. In perform- ing the operation, the knife must be inserted in such a manner as not to injure the globe of the eye. The fluid is often very deep-seated. In dilapidated subjects, tonics and stimulants will usually be required, instead of depletion. A chronic abscess of the orbit occasionally occurs, commonly as a consequence of dis- ease of the bones and periosteum, or of a slow form of inflammation of the connective and adipose tissues. The symptoms are less severe than in the acute form of the attack, and there is much less risk of serious cerebral involvement. The treatment is conducted upon general principles. Caries and necrosis of the walls of the orbit are sometimes observed, chiefly in tertiary syphilis; I have met with a considerable number of such cases, and have invariably found them troublesome and tedious. When the margin of the orbit is involved, serious deformity of the lid will generally be the consequence. The bones of the orbit are subject to hypertrophy, chiefly as the result of a syphilitic taint of the system ; the disease usually occurs in union with hypertrophy of the cranial bones, and may exist in such a degree as to encroach very seriously upon the ball of the eye. Intraorbital tumors are of two kinds, the solid and the cystic, the former being either of a fatty, fibrous, osseous, cartilaginous, vascular, or sarcomatous character. Their de- velopment generally begins deep in the socket, and instances occur, although rarely, in which they take their rise at the base of the brain, from which they gradually proceed through the openings in the sphenoid bone. However this may be, they sooner or later seriously encroach upon the ball of the eye, displacing it in different directions, and ulti- mately pushing it completely out of its socket. Their growth is commonly very tardy, except when the neoplasm is of a sarcomatous nature, when it advances with its usual rapidity. The amount of suffering attending it is variable, being sometimes extremely severe, while at other times it is remarkably slight. As the tumor increases in bulk, the eyelids are 234 DISEASES AND INJURIES OF THE EYE. CHAP. IV. thrust apart, and rendered tumid and oedematous, the cheek swells, and the patient is dis- tracted with circumorbital pain. In some cases the ball of the eye is merely pressed to one side by the new growth, their position being defined by a distinct line of demarca- tion ; in general, however, they are more or less intimately blended together, especially at the optic nerve, which is not unfrequently completely surrounded by the new struc- ture, thus rendering it extremely difficult, if not impossible, to separate them from each other. The cystic tumor of the orbit, fig. 169, from Mackenzie, generally contains a clear, limpid fluid, of a sero-albuminous character; sometimes, however, the contents are more or less turbid, or partly solid and partly fluid. A very curious case of cystic tumor of the orbit, in a lad seventeen years of age, has been recorded, in which there was an im- Fig. 1(59. Fig. 170. Cystic Tumor of the Orbit, Anastomotic Aneurism of the Orbit. perfectly developed tooth ; and Sir Everard Home met with an instance in which a cavity of this kind was filled with an inflammable oily fluid. The cyst, although usually single, is occasionally multilocular, and of extraordinary thickness and density. Acep/ia/ocysts and echinococci have been observed in the orbit, hut their occurrence is extremely rare, and their detection must necessarily be purely accidental. The orbit is occasionally the seat of vascular or pulsating tumors, to which attention was first directed by Mr. Travers in 1809. They comprise aneurisms of the intraorbital and postorbital divisions of the ophthalmic artery, aneurisms of the cavernous portion of the internal carotid artery, aneurism by anastomosis of the arteries of the orbit, varicose enlargement of the ophthalmic vein, and varicose aneurism of the internal carotid artery and the cavernous sinus. In fourteen cases post-mortem examination has disclosed enlarge- ment and varicosity of the ophthalmic vein in eight, in one-half of which there was a pulsating swelling during life ; but from the success which has attended ligation of the common carotid artery in this affection, it would appear that a large proportion of exam- ples are due to spontaneous or false aneurism of the ophthalmic and internal carotid arteries. In the congenital cases the tumor is generally of an angiomatous nature. Of 73 examples of so-called intraorbital aneurism, analyzed, in 1875, by Mr. Walter Rivington, of London, 32 were idiopathic, and 41 traumatic, the majority of the latter having been caused by falls and blows resulting in fracture of the base of the skull. The mean age of the idiopathic cases was forty-three years, while it was between thirty and thirty-one years for the traumatic cases. Of the latter thirty-one occurred in males, and of the former only nine were met with in males. Exostosis of the orbit is extremely uncommon. It may spring from any portion of the cavity, and is precisely of the same structure as an exostosis in other parts of the body. CHAP. IV. AFFECTIONS OF THE ORBIT. 235 As it increases in size, it causes more or less pain by its pressure upon the surrounding tissues, and gradually but effectually displaces the eye, pushing it sometimes completely out of its socket. Amaurosis and total blindness are occasionally among the first symp- toms of the disease. The growth not unfrequently begins very early in life. The diagnosis is generally easily determined by the history of the case, and by the remarkable firmness of the tumor, which is greater than that of any other morbid structure. The adjoin- ing sketch, fig. 171, represents an ivory exostosis springing from the anterior part of the cranium, and filling the left orbit. Cartilaginous, fbrous, and fatty tumors are even more rare than exostosis. The fibrous formation grows as a rule, from the periosteum near the edge of the orbit, and rarely attains any considerable volume. Sarcoma is the only malignant affection of the orbit, and does not differ here, in its general characters, from sarcoma in other parts of the body. Arising in the fatty tissue of the cavity, as glious, myxomatous, or pigmented sarcoma, it forms large, soft, medullary, lobulated masses, which surround the optic nerve, displace and flatten the ball, by the side of which they may make their appearance at the lids, or, as in the case especially of the melanotic variety, penetrate into and nearly fill the globe. On the other hand, the structures of the orbit may be affected secondarily, a glious tumor of the retina, or a melanotic sarcoma of the choroid, perforating the sclerotica, and extending behind and around the eye. Cases have also been observed of impaction of the orbit with a small round-celled sarcoma, which originated in the nose or maxillary sinus. Sarcoma evinces a great disposition to disseminate itself, involving the neighboring bony cavities, as the ethmoidal cells, the frontal sinus, and the antrum of Highmore, and even extending along the course of the optic nerve to the base of the brain and its mem- branes. Hence, the prognosis is in the highest degree unfavorable. The various forms of orbital tumors are often difficult of diagnosis. The points which should more especially claim attention with a view to an accurate discrimination are the history of the case, the consistence and progress of the morbid growth, and the presence or absence of pulsation. The solid growth may, in general, be easily distinguished by its firmness; the fluid by its softness. The fatty tumor has a doughy feel; the fibrous an elastic one. An exostosis is always remarkable for its extreme hardness. The cystic tumor of the orbit is not only soft, but distinctly fluctuates under pressure. The hydatid tumor possesses similar properties, but cannot be distinguished from the cystic, properly so called. The prominent symptoms of intraorbital aneurism are pulsation and protru- sion of the eye, as in fig. 170, from Walton, a soft tumor beneath the orbital arch, which is frequently the seat of a perceptible thrill, and a low, whizzing bruit, chemosis and dis- tension of the vessels of the conjunctiva, paralysis of the iris and orbital muscles, pain, and noises in the head. In the majority of the idiopathic cases the disease begins sud- denly with violent pain and a peculiar noise in the head, as if something had given away, and these precursory signs are soon followed by exophthalmos and pulsation. In the trau- matic cases, two-thirds of which are complicated by fracture of the base of the skull, the symptoms do not appear until a few weeks after the reception of the injury, and protru- sion of the eyeball precedes the pulsation and the bruit in more than one-half of the cases. If the tumor is formed by varicosity of the ophthalmic vein, it will constitute a com- pressible swelling, which is most prominent at the upper and inner part of the orbit, but which is devoid of bruit, thrill, and usually of pulsation. It increases in expiration and stooping, and diminishes during inspiration and the erect posture. The diagnosis cannot be determined between aneurism by anastomosis and true aneurism of the ophthalmic or internal carotid artery. Arterio-venous aneurism of the internal carotid artery and the cavernous sinus is characterized by a vibratory thrill, and the whining bruit, which is continuous with both the systole and tiie diastole of the heart. The innocent tumor is generally tardy in its development; the malignant rapid, with a tendency to early ulceration and adjacent implication. In all cases of doubt, recourse should be had to the judicious use of the exploring needle, the instrument selected being of the smallest size. Fig. 171. Ivory Exostosis of the left Orbit. 236 DISEASES AND INJURIES OF THE EYE. CHAP. IV. In the examination of supposed orbital growths, the surgeon should not forget that great protrusion of the eye may be caused simply by an anemic condition of the system, by exophthalmic goitre, by inordinate deposits of fat, or by infiltration of the orbital connective tissue consequent upon inflammation or external injury. The treatment of these various formations must be conducted upon general principles, or according to the rules laid down for their management in different parts of the work. Unless there is reason to believe that they may be removed without any material detri- ment to the eye, the best plan will be not to meddle with them, unless it is previously understood that this organ is to be sacrificed if it be found to be seriously involved in the morbid structure. This should not, of course, be thought of so long as the abnormal growth is comparatively small, does not encroach obstructingly upon vision, nor occasion severe suffering. The situation, shape, and extent of the incisions must be regulated according to the exigencies of each particular case. When the tumor occupies the outer or inner canthus of the eye, the object may generally be attained by slitting up the lids in the direction of their commissures, otherwise it will probably be necessary to cut through their substance. In the solid tumor, complete riddance should always be aimed at, and care should be taken not to inflict injury upon the optic nerve and other important structures. The cystic tumor may be removed entire, or, if its connections are intricate, a portion of the wall may be left, the secreting surface being destroyed with Monsel’s salt, nitrate of silver, tincture of iodine, or sulphate of copper. For the cure of intraorbital aneurism, or supposed aneurism, the common carotid artery has occasionally been tied. Of 44 cases analyzed by Mr. liivington, 2G were cured, 7 were partially successful, 5 were failures, and G perished. In 17 of the cures, vision was restored ; and of the failures, 2 were cured by ligation of the opposite carotid, and 1 by injection. The injection of a coagulating fluid has been attended with success in three out of the four examples in which it has been resorted to. Digital compression of the common carotid artery, first employed by Gioppi, has resulted in a cure in only three of the six- teen instances in which it was practised, and it uniformly failed when the aneurism was traumatic. Instrumental compression of the carotid was unsuccessful in the four traumatic cases in which that measure was used. Local compression has been tried in ten instances, and it was productive of slight benefit in two, the remainder having been failures. In two cases galvano-puncture was followed by a fatal issue. Mr. Lansdown, in 1875, opened the orbit, and ligated the diseased vessels on each side of the small sac of a varicose aneurism. The sac was discharged from the wound on the fourth day, and the patient made a complete recovery. Finally, Dr. T. G. Morton, of this city, enucleated the erectile growth, and arrested the hemorrhage by the actual cautery and by pressure. In a case of this affection, reported by Dr. E. L. Holmes, of Chicago, a cure seems to have been effected by the conjoined use of tincture of veratrum viride and fluid extract of ergot, administered during a period of about six weeks in such a manner as to keep up a constant and decided impression upon the heart’s action. In three other traumatic cases, recorded by France, Erichsen, and Collard, simple measures, as, for example, attention to the patient’s habits, arterial depressants, and the application of cold lotions, resulted in a cure, respectively in eight months, fourteen months, and two years and a half. An idiopathic case reported by Dr. Freeman was cured in a few weeks by digitalis, the appli- cation of cold, and direct mechanical compression ; and Juillard succeeded in two months in curing a similar affection by digitalis and the application of ice to the eye. In a case observed by Herpin, in which a pulsating tumor of the left orbit was completely relieved by ligation of the common carotid artery, the opposite eye became affected nine months subsequently, but the symptoms disappeared in three months under the constant use of ice. A case of spontaneous cure of congenital aneurism by anastomosis of the orbit has been reported by Dr. Harlan; and he also met with a case of traumatic pulsating exophthalmos which entirely recovered in three years with no other treatment than occasional compres- sion by the patient. An exostosis of the orbit has occasionally separated spontaneously, as in a remarkable case recorded in the first volume of Guy’s Hospital Reports. The growth, situated at the inner part of the orbit, weighed nearly fifteen ounces. When excision is carefully performed, the patient may not only regain his sight, when this has been impaired, but the eye may ultimately return to its natural position, and recover its accustomed freedom of motion. Hypertrophy of the bones is generally irremediable. CHAP. V. DISEASES AND INJURIES OF THE EAR. Tumors of the Optic Nerve.—The primary tumors of the extracranial portion of the optic nerve are myxoma, sarcoma, fibroma, neuroma, and glioma, of which the first two are the most common. Of fifteen cases analyzed by Knapp, including two of so-called can- cer, the principal symptoms were exophthalmos, restricted motility of the eyeball, de- scending neuritis in the early stages, and atrophy of the nerve in the later stages, impairment of vision, and the presence of a swelling behind the globe. Pain is usually not prominent. The tumor, whatever may be its constitution, increases slowly, and rarely attains any considerable volume; the most bulky of which I have any knowledge being the case described by Dr. J. A. Liddell, in which the growth had attained the size of a goose egg in eight years. During their progress the eyeball becomes flattened, and pro- trudes ; the cornea becomes opaque, ulcerates, and is finally perforated ; and the coats of the eye are so closely pressed together that the optic disc touches the cornea. The prog- nosis is determined by the histological peculiarities of the growth. The treatment con- sists in the removal of the tumor without, if possible, interfering with the eyeball, as has been happily effected by Knapp and Gruening. CHAPTER V. DISEASES AND INJURIES OF THE EAR. No satisfactory exploration of the ear can be made without a good light. The best is that afforded by the direct rays of the sun; but in cloudy weather, and in many other in- stances, artificial illumination will be required. In using the former method, the patient being seated upon a chair, with the ear inclined towards the opposite side, facing the sun, the light should be permitted to fall directly upon the tympanic membrane, as can easily be done by pulling the auricle upwards and backwards with the thumb and forefinger of one hand, while the tragus is drawn forwards with the index-finger of the other. The ear may also be examined by reflected sunlight, that coming from a northern sky being preferable. The method of l'eflecting daylight into the ear is like that used in reflecting artificial light into this cavity, and is generally known as the method of Yon Troltsch. Fig. 172. The speculum which I prefer is that of Kramer, represented in fig. 172. It is very light and convenient, and may be adapted to almost any ear, however small, as its terminal extremity is not more than two lines in diameter, while its movable blades readily admit of this distance being increased to any extent, compatible with the size of the canal. Although light may be reflected through the speculum by the ear-mirror of Von Troltsch, the speculum required by this aurist’s method is known as the conical form. There are many varieties of the conical specu- lum, all of which, whether of metal or hard rubber, possess good fea- tures ; but it will be found that the best instrument of this kind is that known as Gruber’s, fig. 178, made of several sizes. Its great superiority depends simply upon the fact that a transverse section of that part which enters the meatus will be found to be an ellipse, corresponding exactly with a similar section of the human auditory canal. By its use, therefore, the greatest amount of light is thrown upon the membrane of the tympanum. Kramer’s Ear-speculum. Fig. 173. Gruber’s Speculum. 238 DISEASES AND INJURIES OF THE EAR. CHAP. V. The method of Yon Troltsch, now much employed, recommends itself by its great simplicity and convenience, as the requisite degree of illumination may generally be readily effected, even in cloudy weather, by reflected daylight, and at any time with the aid of artificial light. It consists in the use of a conical speculum and a concave mirror of glass, three inches in diameter, with a central aperture for the eye of the observer. The speculum is inserted and held in position by the left hand of the surgeon, while the mirror is grasped in his right. The light should always come from beyond the patient from a window or flame, about four feet six inches above the floor, for a sitting patient, and towards the physician’s right. In thus examining the ear, only the patient changes his position, so as to bring his right or left ear under examination, unless he is lying in bed, when the examiner must change his position and that of the light, from side to side, the patient remaining supine, rolling his head slightly to the right or left as required by the surgeon. To the same kind of mirror a frontlet with a socket, to grasp a ball on the periphery of the mirror, may be attached, so that the surgeon may be provided with a fore- head mirror, tig. 174, and the free use of both hands if desired. In using this mirror, the surgeon must not look through the aperture, but so adjust the mirror as to look under, or alongside of it. The reason for this is that, in using the contrivance, the glass can be moved constantly although slightly to suit any position of the surgeon or the patient, but no mirror suspended to the forehead can be adjusted or moved with sufficient deli- cacy to keep the aperture constantly before the examiner’s eye, and the rays of light in the ear at the same moment. The ear-mirror has a focal distance of six inches. An argand gas burner, placed on a table, beside which the patient may sit, will answer admirably every purpose of illumination in an office or chamber, if the patient can sit up ; but, if he has to be examined in bed, a candle, held by an assistant, will supply a safe and amply efficient source of light. While the light is thus playing about the passage, the examiner takes a rapid survey of the appearances of the parts, noticing particularly the condition of the membrane of the tympanum, as to whether it is transparent or opaque, red, injected, convex or con- cave, ulcerated, perforated, or destroyed ; also, the state of the auditory tube, the color and quantity of the cerumen, and, in short, everything else calculated to furnish matter of diagnostic and practical value. Should the parts be obscured, or concealed from view, by the presence of pus, wax, epithelium, or hair, clearance must be effected, as a prelimi- nary step, by syringing the tube with tepid water. A very suitable instrument for this purpose is depicted in fig. 175. It must be capable of holding at least from two and a Fig. 174. Forehead Mirror. Fig. 175. Ear Syringe. half to three ounces of fluid, which should be thrown up with some degree of force, yet at the same time so cautiously as not to shock or pain the affected structures. It should be held firmly in the hand, with the nozzle, which should be inserted only a few lines, directed obliquely downwards and forwards, the water, as it regurgitates from the tube, being received into a large, flattish basin, fig. 170, held under the patient’s ear and chin. A small ear-douche, fashioned after Tluidichum’s nasal douche, forms an excellent con- trivance for washing out the meatus, and is, in fact, superior to every other. The force of the CHAP. V. AFFECTIONS OF THE EXTERNAL EAR. 239 stream is easily regulated by the height at which the tank is placed above the level of the ear. The use of the probe is not admissible in these examinations. The forceps or scoop may occasionally be employed in the removal of solid matter. For the purpose of applying caus- tic, acid, and other fluids, a hard rubber, glass, or porcelain speculum will be found useful. Fig. 176. The Basin used in Syringing the Ear. The manner of exploring the Eustachian tube will be described along with the diseases of that passage. A watch held near the ear, or placed between the teeth, will determine, by its ticking, perceived by the patient, the degree of hearing. The best test of the hearing will be found in the use of isolated words chosen with a view of employing a great variety of consonant and vowel sounds. The condition of the auditory nerve may be at least proximately ascertained by placing the handle of a vibrating tuning- fork, tig. 177, upon the patient’s vertex. It will be found that if the nerve is impaired the fork will not be well heard ; if paralyzed, the fork will not be heard at all, and, if the cause of deafness lies in the middle ear, the fork, vibrating on the vertex, will be heard best in the affected ear, because the altered resonance and conducting power of the ear prevent the ordinary outflow of the sound waves produced by the fork. The experiment should be repeated at each visit, and the result carefully noted, as it affords important information relative to the progress of the treatment. Finally, to render such an examination complete, we must carefully inspect the patient’s throat and tonsils, take particular notice of the state of his voice, percuss the mastoid region, and auscultate the ear while the air is being forced into it along the Eustachian tube. SECT. I AFFECTIONS OF THE EXTERNAL EAR. The auricle is liable to various malformations. Thus, in the first place, it may be entirely absent, without any vestige whatever of an external opening. Such an affection is not necessarily attended with deafness even when it involves both organs, although audition must be much impaired. Secondly, there is occasionally an absence of the lobule of the ear ; or this structure is divided, by a vertical fissure, into two portions, an anterior and a posterior; or, lastly, it is attached to the side of the head, either partially or completely. Thirdly, there may be a deficiency of the helix, this body being either wanting, or so small and flat as hardly to deserve to be considered as a distinct pro- cess. This defect is sometimes congenital, but is much oftener produced, there is reason to believe, by the pressure of the hat in early life. Fourthly, the tragus and antitragus are occasionally bilobed, or split, as it were, into two portions ; sometimes they are inverted towards the meatus, thereby partially closing it; and sometimes, again, they are more or less extensively united, particularly along their lower borders, producing a similar effect. Finally, excessive development of the ear may be enumerated as one of its malformations. In 1860 I had a case at the College Clinic, in an infant three months old, of super- numerary ears, in a very rudimentary state, situated immediately in front of the tragus, Fig. 177. Clinical Tuning-fork, 26 cm. long. 240 DISEASES AND INJURIES OF THE EAR. chap. v. over the temporo-maxillary joint. In some instances the additional organs occupy the side of the neck. Some of the above defects admit of remedy by surgical operation ; others do not. Thus, a cleft lobule might readily be united by a procedure similar to that for harelip; an inverted tragus might be retrenched or excised; and abnormal adhesions might be sev- ered by a simple dissection, a piece of lint being constantly kept during the healing pro- cess between the raw surfaces. In the case of supernumerary ears, above referred to, no diiliculty was experienced in effecting thorough excision. Wounds of the external ear are treated upon general principles. The parts being prop- erly cleansed, the edges are closely approximated with a needle and fine thread, aided, if need be, by a few strips of isinglass plaster, which answers much better here than ordinary adhesive plaster. Should a bandage be required, it must be applied with great care and gentleness, arid with the precaution of filling up the hollow between the ear and the head with cotton wool, or lint, to ward off injurious pressure. On no account must the ear be cut away, however much it may be bruised or lacerated. A fibrous tumor, a variety of keloid, composed essentially of dense, white, fibro-elastic tissue, is occasionally observed in the lobe of the ear, as a consequence of the perforation of this body, and the wearing of rings. I have seen at least twenty such cases, all, except four or live, in negresses. The affection is sufficiently common in thisclass of females in this city. Professor Stille and Dr. George Pepper have each met with a number of examples, and cases have been reported by other practitioners. The growth is of frequent occurrence among the negresses in the An- tilles, where the ornaments worn are unusually heavy and com- posed of brass. Young females are its most common subjects. In one instance I met with a tumor of this kind in a child three years old, whose ears had been pierced eighteen months previously. The tumor is pendulous, of tardy development, insensible, hard, and inelastic, without malignancy, although extremly prone tore- cur after removal, and free from discoloration of the skin, which also retains its normal thickness and pliancy. It is generally some- what rounded or ovoidal in its shape, and is capable of acquiring a volume equal to that of a hen’s egg. In some instances it is tabulated. It is of a fibrous structure, whitish in color, and of a dense, almost uniform consistence. A good idea of this variety of tumor is afforded by fig. 178, from one of my clinical cases. The patient was a negress, twenty years of age. The lobe had been perforated early in life, and the growth had been progressing for upwards of ten years. The remedy is excision, care being taken to save as much integument as possible, in order to prevent deformity. The edges of the wound are carefully approximated by the twisted suture. Rapid recurrence is the rule after extirpation. Constitutional treatment is, of course, useless. The sebaceous tumor of the ear is uncommon. I have, how'ever, met with it several times, particularly in the lobule, where it occasionally acquires a size equal to that of a filbert. It is of an irregularly globular shape, soft in consistence, free from pain and dis- coloration, and of slow growth, without any tendency to ulceration, features which suffi- ciently declare its nature. The treatment is by excision. Such a tumor occasionally forms in the external auditory canal, wherefrom its confined position it may become the seat of irri- tation, as it enlarges, and finally ulcerate and erode the bone of the canal. In such a case the results may be fatal. As soon as the tumor is recognizable in this position, it should be extirpated, and the surface cauterized. In this way the worst results of continued growth may be prevented. Hematoma of the ear, is, as the name implies, a sanguineous tumor, varying in size from a small bean to that of an almond, of a bluish-red color, more or less tender to the touch, generally seated upon the antihelix, the concha and adjacent parts, caused by pres- sure in lying, gradual in its formation, and occupied by blood, fluid at first and afterwards coagulated. Left to itself, it commonly slowly disappears by absorption, the contents during the progress of the disease often assuming a thin, viscid, serous character, inter- mixed with fibroid matter. A spontaneous cure is seldom effected without a certain de- gree of deformity at the site of the disease. The subjects of this singular affection are, for the most part, insane persons, and males, according to Dr. Hun, suffer much more frequently than females. Thus, of 24 cases reported by him, 23 were males. Although generally associated with incurable disease of the brain, it is occasionally the result of Fig. 178. Fibrous Tumor of the Ear. CHAP. V. AFFECTIONS OF THE AUDITORY TUBE. 241 violence, and is then of more favorable import. The treatment is by sorbefacient reme- dies, aided, if necessary, by evacuation. Dr. Gray, of Utica, has suggested ligation of the posterior auricular artery. Epithelioma of the ear is seen chiefly in elderly persons. It is most common in the lobule, commencing in the skin, from which it gradually extends to the other structures. The resulting ulcer is callous, painful, intractable, and bathed with a thin, foul, sanious discharge. In some cases, as in several that have been under my observation, the entire ear is eventually involved, leading to great suffering and disgusting deformity, with en- largement of the glands in front of the ear. The treatment must be conducted upon general principles. Ncevus of the external ear is uncommon. A few examples of it have, however, fallen under my observation. The affection is easily recognized, and must be treated upon the same general principles as nan us in other situations; by subcutaneous ligation in the milder forms, and by excision in the more severe. Amputation may be necessary when the tumor is very large, or when it has completely disorganized the original structures, and is a source of serious disfigurement and annoyance. Great deformity of the ear, with extraordinary induration, is sometimes met with, chiefly in elderly females, from repeated attacks of erysipelas, eczema, and other eruptive affections. The immediate cause of the disorder seems to be the retention and organization of the plastic matter that is poured out during the progress of these diseases. The auricle is thus rendered hard, lumpy, and inflexible, so as to resem- ble a piece of thick, wet sole leather ; it is somewhat short- ened in the antero-posterior diameter, and the meatus is so much encroached upon as to look like a mere slit. The skin is of a dusky brownish color, and the seat of more or less itch- ing. The disease, which is generally tedious and troublesome, requires a mild course of alteratives, the best local application being oxide of zinc or mild citrine ointment or lead lotion. The annexed cut, fig. 179, from Wilde, affords a good illus- tration of the nature of this affection. A very unseemly fissure is sometimes found in the lobe of the ear, from the accidental tearing out of the ear-ring. The mishap is usually caused by the infant as it lies at the breast, watching the ornament. I have several times met with it on both sides. The treatment consists in refreshing the edges of the cleft, and in approximating them by suture. White, chalky or plaster-like concretions, occupying the lobe of the ear, within the helix, are occasionally met with, as the result of a gouty diathesis. They occur as small, round prominences immediately beneath the skin, and are com- posed of the same material as articular tophi, uric acid crystals, very delicate, needle- shaped, and of all possible sizes, forming conspicuous ingredients. Left to themselves, these concretions are sometimes eliminated spontaneously, a slight scar marking their exit. When they are productive of pain and irritation, they may be liberated by a small incision, aided by pressure. SEC. II AFFECTIONS OF TIIE AUDITORY TUBE. The auditory tube is liable to malformations, the introduction of foreign bodies, accu- mulations of wax, morbid growths, and various forms of inflammation. 1. Malformations The most common malformation of this passage is occlusion of its external orifice by an extension of the common integument, producing a condition similar to that occasionally met with in the anus, vagina, and other outlets. A person thus affected is not always deaf, although his hearing must of necessity be very defective. The cutaneous cover may be very thin, consisting, perhaps, merely of a sort of translucent layer, but, in general, it is very thick and opaque; it may be the only aberration, or it may be associated with absence of the auricle. Such a malformation obviously admits of easy relief. All that is necessary is to make a crucial incision in the situation of the natural orifice, to remove the angles of the wound, and to prevent reunion by the inter- position of tents of gradually increasing sizes. But there is another case where relief is either impracticable, or where patency can be established only after much trouble and Fig. 179. Deformity and Induration of the Ear from Chronic Eczema. 242 DISEASES AND INJURIES OF THE EAR. CHAP. V. delay. This is where the occlusion is effected by fibrous or fibro-eartilaginous matter, ex- tending some distance down the passage, but not completely obliterating it. Here only the most cautious and patient attention will be likely to be of any avail. The dissection is made in the direction of the canal, the ear being drawn upwards and backwards during the operation. Reunion is prevented by the steady and protracted useof tents. Of course no operation is attempted when the interior canal is entirely impervious, or, more properly speaking, when none whatever exists. The use of a delicate exploring needle will be of great assistance in the investigation of these various conditions of the ear. Finally, children are occasionally born with the ears completely filled with unctuous matter similar to that which covers the skin, and which is probably derived either from the sebaceous follicles, as a depurative secretion, or from the amniotie fluid. However this may be, if the matter is allowed to remain, the deafness, which was at first, perhaps, only partial, may, in time, become complete; or the adventitious substance, acting as a foreign body, may excite inflammation, and ultimately lead to destruction of the tympanic mem- brane. Clearance, if demanded, is effected by means of the syringe and warm water. A few drops of oil, or glycerine, poured upon the mass, might assist in detaching it or rendering it more soluble. 2. Foreign Bodies—Substances of various kinds find their way into the auditory canal, either by accident or through design. The most common are grains of corn and coffee, beans, peas, cherry-stones, beads, pebbles, pellets of paper, wool, cotton, bugs, and flies. Insects sometimes deposit their larvae in the ear, being evidently attracted thither by purulent discharge, which, if at all abundant, may afterwards serve as a nidus for the de- velopment of the new being. It is surprising that pins, which are so frequently used by females for picking and scratching the ear, do not more frequently drop into the tube than they seem to do. The effects occasioned by the presence of a foreign body in the ear vary according to its nature, size, and shape. A grain of corn, bean, or similar substance, may, if retained for a few days, not only expand under the influence of the heat and moisture of the part, but, per- haps, even germinate, thereby causing severe pressure upon the parts in which it is im- pacted, and increased difficulty of extraction. No such effect, of course, follows when the body is of an inorganic nature. Nevertheless, any substance of whatever character, may, by its pressure alone, induce severe pain and inflammation, eventuating in an abundant discharge of matter, excessive constitutional irritation, headache, and delirium. Professor Parker, of Charleston, has reported a case in which a flea lodged for six months on the tym- panic membrane caused severe otalgia, hemicrania, orbital neuralgia, and cough, which were promptly allayed on the removal of the insect. A large substance generally causes more trouble than a small one, a rough than a smooth, a heavy than a light, a sharp than a blunt. A foreign body may excite ulceration of the membrane of the tympanum, and thus finally make its way into the middle ear; an occurrence which is sure to be followed by severe suffering, if not death. Maggots developed in the ear have been known to cause the most intense distress, such as violent pain, buzzing noises, and a sensation of gnawing or rasping of the drum. Several cases have been reported, among others one by Dr. Routh, of London, in which convulsions were thus produced. Maggots may be instantaneously driven out of the ear, or killed while still there, by a few drops of ether or chloroform poured into the meatus; oil and glycerine are also good remedies. In gunshot injuries, the ball sometimes lodges in this tube, or in this tube and the petrous portion of the temporal bone. The late Dr. F. F. Maury showed me a case in which a body of this description had been impacted upwards of a year, in the right ear of a young man who was shot at the battle of Chancellorville, in 1863, without causing any other inconvenience than slight deafness, and occasional dizziness. The ball had entered through the zygomatic fossa, and could easily be felt with the probe. Instances are recorded in which violent neuralgia, paralysis, epilepsy, and even mania were induced by the protracted sojourn of an extraneous substance in the ear. On the other band, a foreign body occasionally remains in the auditory tube for a long time without occasion- ing the slightest mischief. Not long ago, a girl, aged eleven years, was brought to the College Clinic with a large cherry-stone in the right ear, in which it had been harmlessly impacted for seven years, and a case has been communicated to me by Dr. William II. Wenrich, in which a body of this kind had remained deep in the meatus for thirty-one years, without having produced any other effect than slight neuralgia a short time prior to its removal. In a case reported by Mr. Winterbottom, of England, a cherry-stone had been retained in one of these organs fox; sixty years. Dr. C. H. Burnett informs me AFFECTIONS OF THE AUDITORY TUBE. 243 CHAP. V. that he removed a glass bead from the ear of a woman, where it had lain without any injury to the part, for fifty years. The removal of a foreign body from the ear is by no means always an easy undertaking. The difficulty, generally of itself not very great, is frequently very much enhanced by the tortuous, contracted, or constricted condition of the auditory tube, and by the pain, tume- faction, and discharge which are likely to be present whenever the substance has been re- tained for any length of time, or when unskilful or rough manipulation has been practised for its removal by the patient, his friends, or, in some cases, by his physician. Various methods may be employed for accomplishing the object, the choice of which must be regulated by the circumstances of each individual case. If the body is relatively small to the size of the tube, and not very rough or heavy, dislodgment may usually be effected with a light syringe, charged with tepid water, the fluid being thrown up in a full, steady, and forcible stream, with sufficient care, of course, not to injure the drum. This pro- cedure should always be employed most thoroughly when the substance lies deeply in the auditory passage; for, although it may not cause its expulsion, it will often bring it within reach, and thus favor extraction. During the operation, or, rather, as a preliminary step, the ear should be drawn upwards, outwards, and backwards, so as to efface the angle of the canal. The syringe, which should hold at least four ounces, should have a long, slender nozzle, in order that the current may pass readily by the side of the for- eign body. When the substance is comparatively superficial, it may frequently be seized and ex- tracted without difficulty, one of the best instruments for this purpose being a pair of very Fig. 180. delicate forceps, fig. 180. But such a procedure is not admissible when the substance is smooth, hard, or deep seated; for, in the former case, the instrument will be likely to slip off, and, in the latter, it will be impossible to give the blades the requisite degree of ex- pansion for grasping it. In such an instance the surgeon may find admirable assistance from an instrument devised by Dr. Samuel Sexton, of New York. If, however, with a a clumsy instrument, and inadequate skill in illuminating the auditory canal, the surgeon is determined to succeed, his efforts cannot fail to be productive of serious mischief. The foreign substance will be thrust about in various directions, and perhaps pressed rudely against the membrane of the tympanum, until it is buried in blood, and the patient is put in great agony. Cases have occurred where the surgeon, in his anxiety not to be baffled, severely lacerated the auditory canal and even the drum of the ear, causing violent in- flammation, followed by death. For a number of years past, I have depended entirely, in these operations on the ear, upon the use of the little instrument represented in fig. 181. It is composed of steel, is Delicate Forceps for removal of Foreign Body from the Ear. Fig. 181. Instrument for the Removal of Foreign Matter from the Ear. five inches in length, and is now regularly put up in the ordinary pocket-case, manu- factured in this city. One extremity is spoon-slmped, while the other, which is exceed- 244 DISEASES AND INJURIES OF THE EAR. chap. v. ingly narrow, is provided with a very delicate tooth placed at a right angle. The small end is the one which I generally prefer, as it may always be easily insinuated between the auditory tube and the intruder, which is then gently dislodged, the instrument acting either as a lever or a hook, or both, according to circumstances. The large extremity is best adapted to the extraction of wax. As to the ordinary pocket probe, bent at the point, no sensible surgeon ever employs it. The object may sometimes be attained, as suggested by Riverus and Celsus, and recently revived by Lowenberg, by attaching a stout camel-hair point charged with glue to the foreign substance, withdrawal being effected as soon as the glue is properly hardened. When the foreign body is unusually large, or so firmly impacted as to defy the ordi- nary procedures, it has been proposed, as a means of facilitating extrusion, to detach the auricle from the auditory canal. The authority of Paul of AKgina, Von Troltsch, and others, is quoted in favor of the operation, although it is difficult to conceive of any case in which it would, or could, be required. With patience, skill, and well-directed efforts, any foreign substance, however bulky, deeply-seated, or firmly wedged into the ear, can, I am sure, be extracted without resorting to so harsh a measure. Children are often brought to the surgeon with the ear in a high state of inflammation from previous attempts at extraction. In such a case, the proper plan is to wait until, by warm anodyne fomentations, the application of a few leeches over the mastoid process, and the administration of a brisk cathartic, the morbid action has been sufficiently sub- dued to justify further interference, although thorough syringing with warm water is always in order. When a foreign body finds its way into the middle ear, through an opening in the drum, dislodgment will be extremely difficult, if not impossible. Deleau relates a case of a small pebble imbedded in this cavity, in which he effected clearance by throwing a stream of warm water into it through the Eustachian tube. Insects are generally easily dislodged with the syringe. It is only when they are large, or much expanded, that forceps, hooks, or curettes will be likely to be required. When a suitable instrument is not at hand, they should instantly be destroyed, or forced out of their hiding-place, by filling the ear with olive oil, tepid mucilage, or a mixture of spirit of camphor and water. Dr. II. F. Kingsley has succeeded in removing live bugs from the ear by simply holding a lighted taper or candle before the meatus, the insect leaving its hiding-place apparently from sheer fright. , Finally, in all operations of this kind, the head must be properly supported by an assistant, and resistance, if offered, counteracted with anaesthetics. The hairs which naturally grow upon the tragus occasionally attain an extraordinary length, and, projecting inwards towards the bottom of the meatus, may thus fret the drum of the ear and the ceruminous glands, causing more or less uneasiness, as in several cases reported by Dr. Robert F. Weir. The proper remedy is removal of the offending struc- tures. In obstinate cases, destruction of the hair follicles may be necessary. 3. Accumulations of Wax This substance sometimes collects in such quantities in the auditory tube as to produce complete occlusion ; at other times the obstruction is only partial, attention being directed to the subject before the accumulation has made much progress. The effects, in either case, are more or less noise in the ear, generally of a buz- zing, ringing, or explosive character, and impairment of hearing on the affected side. Occasionally there is complete deafness. This result may depend solely upon the long disuse of the ear from the protracted retention of the secretion, or it may be produced by the pressure of the wax upon the membrane of the tympanum, eventuating in organic disease of its substance, as ulceration, induration, or thickening. When the wax is very hard and dry, and the meatus is completely impacted with it, it may press so firmly against the tympanic membrane as to cause constant giddiness, often conjoined with a sense of weight and fulness in the head, confusion of ideas, hallucina- tions, tottering in walking, and various kinds of noises in the ears. An accumulation of wax does not necessarily imply an inordinate secretion of this sub- stance ; on the contrary, it may be deposited very sparingly, and yet, owing to its inspis- sated character, it may proceed until it completely fills the external meatus. Indeed, so long as this secretion retains its natural qualities, and no obstacle is opposed to its evacu- ation, it seldom manifests any disposition to collect ; but such an occurrence is very liable to take place when it is deprived of its fluidity from exposure to the air, and other causes. However this may be, when the wax is long retained it is always remarkably hard and tough,and then often contains a considerable quantity of hair and epidermic scales, the whole forming a dry, tough mass, accurately moulded to the auditory tube, excluding the air, and inducing more or less deafness. The presence of the substance is generally easily CHAP. V. AFFECTIONS OF THE AUDITORY TUBE. 245 detected by its dark brown or blackish appearance, and by our inability to discover the membrane of the tympanum. Collections of wax occur at all periods of life ; and they are generally caused either by suppression of the cutaneous perspiration, by the admixture of dust with the cerumen, by disorder of the general health, or by disease of the auditory canal. Ear-wax being in great measure soluble in water, the best method of softening and de- taching it is to throw this fluid freely into the auditory tube with a large syringe with a slender, narrow nozzle. The water should always be used warm, and its efficacy will be much increased if it be mixed with a small quantity of soap, or carbonate of sodium, as twenty or thirty grains to the ounce of the fluid, which, by combining chemically with the wax, gradually convert it into a soapy mass. Many practitioners are in the habit of employing oil for this purpose, but, as this substance is destitute of soluble pro- perties, the only way in which it can prove serviceable is by lubricating the walls of the external meatus. A much better article would be glycerine. When the wax is very abundant, or firmly impacted in the tube, if it cannot be removed by syringing with warm water, I am in the habit of dislodging it with the spoon-shaped extremity of the instru- ment delineated in fig. 181. Care must be taken, in performing the operation, to proceed as gently as possible, picking out piece after piece, until the whole mass has been removed, as the long retention of this substance always renders the parts remarkably sensitive. Any fragments that remain at the sides and bottom of the cavity, may afterwards easily be dis- lodged with the syringe and tepid water. Clearance having been effected, all that is necessary is to protect the ear, provided it is unusually tender, with a pellet of cotton to exclude the air; otherwise, even this precaution may be dispensed with. When the drum is very vascular, inflamed, or ulcerated, it will be proper to apply a few leeches over the mastoid process, to cover the ear with cloths wrung out of hot water, and to administer an anodyne diaphoretic. When the tendency to reaccumulation continues, the ear should be frequently syringed, and means employed to check the inordinate action of the ceru- minous glands and the skin of the canal, upon which it depends, by the use of purgatives, by attention to the general health, which is often much disordered, and by the daily appli- cation of a solution of nitrate of silver, as ten to twenty grains to the ounce of water. Some remarkable cases are recorded of persons who, after having been long deaf, were suddenly relieved by the discharge of hard plugs of wax during bathing, the expulsion having generally taken place with a loud report, like that of a small pistol. Such an oc- currence can only be explained by supposing either that the steam of the hot water pene- trating the meatus, softens the indurated mass ; or, what is more plausible, that the bathing excites perspiration in the walls of the tube, thus detaching the substance, the noise being produced by the rarefaction of the atmosphere behind it, or by the tearing away of the sticky mass from the walls of the canal. Dr. Burnett has found that the ulcerated condition of the walls of the auditory canal, often observed after the removal of these long-retained plugs of wax and epithelium, is most promptly cured by blowing into the canal finely powdered boracic acid, under perfect illumination, with the forehead mirror. 4. Polypoid, Fungous, Parasitic, and other Growths There are two distinct kinds of morbid growths in the ear, the polypous and the polypoid, the former of which are simi- lar to the tumors which are so often observed in the nose and other mucous canals, while the other essentially consist of a mass of granulations, bearing only a faint and distant resemblance to genuine polyps. Of polyps of the ear there are several varieties, of which the most common are the mucous and the fibro-vascular. Their structure is sufficiently indicated by their names. They are generally somewhat of a conical, pyriform, or globular shape, having a small, narrow pedicle, by which they are attached to the surface from which they grow. Occa- sionally, although rarely, they spring from the membrane of the tympanum itself, or very low down in the canal. They most frequently arise from the mucous membrane of the tympanic cavity. Their surface is commonly smooth, and of a florid, pale, or pink hue, according to the character of their structure, or, rather, the extent of their vascularity. A polyp of the ear has sometimes the form, color, and consistence of a mulberry, or of a bunch of small grapes. Their number rarely exceeds one, unless they are very small, when they may be multiple. As they increase in size, they gradually approach the exter- nal orifice of the ear, and sometimes partially fill up the concha, forming a hard, cuticular mass, several shades lighter than the part which is buried in the tube, and also much less sensitive. Myxoma and angioma are rare in the ear. Steudener has described one case of the former, and A. II. Buck one of the latter. These bodies, of whatever structure, size, or shape, are attended with more or less dis- charge, which is either of a thin, sanious, or truly purulent character, very fetid, and 246 DISEASES AND INJURIES OF THE EAR. chap. v. often so acrid as to erode the surrounding surface. The hearing is always impaired, and in many cases completely destroyed. The nature of the tumor is easily recognized by its history and appearance. Its point of attachment is generally ascertainable with the probe, which may be readily insinuated between the growth and the auditory canal, no matter what may be its age. The annexed sketch, fig. 182, represents a gelatinoid polyp, which I removed from the right ear of a man of twenty-six, where it had been growing for nearly three years. It was attached to the floor of the meatus, not quite as low down as its centre, by a narrow, slender pedicle, the base protruding slightly at the outer orifice. It was of a pale, whitish color, like an oyster, somewhat elastic, insensible, and smooth on the surface, with here and there a straggling vessel ramifying beneath its lining membrane. The drawing is of the natural size. Fig. 183, copied from Wilde, represents a singularly lobulated form of aural polyp. Fig. 184, from a drawing by Dr. Packard, illustrates the microscopical Fig. 182. Fig. 183. Fig. 184. Gelatinoid Polyp. Lobulated Polyp. Microscopical characters of a Sarcomatous Polyp. characters of a sarcomatous polyp, which I removed from the ear of a young woman at the College Clinic. It occupied the whole of the auditory canal, and had already been operated upon twice. Polyps of the ear may be removed by avulsion with a pair of delicate forceps, either straight or curved, as in fig. 185, applied, if possible, close to their pedicle, and rotated Fig. 185. Ear Forceps. upon their axis. Tlie portion of the tumor left behind, deep in the cavity, may he tho- roughly touched with a dossil of cotton twisted on the cotton holder, fig. 18G, and satu- Fig. 186. rated with a strong solution of nitrate of silver, as from one drachm to one drachm and a half to the ounce of water, or even chromic acid, if the operation is performed under perfect illumination of the auditory canal,.and the greatest care be exercised to touch no part but the cut pedicle. Various instruments have been devised for ligating these growths, of which one of the most ingenious and most useful is that of Dr. Samuel Sexton, of New York, represented in fig. 187. Caustics should never he employed for removing Cotton Holder. 247 CHAP. V. polyps of the ear, as it is extremely difficult to regulate the application so as to prevent pain and oilier mischief. When there is a strong repullulating tendency, recourse may be had to the cautious use of nitrate of silver, sul- phate of copper, dilute acid nitrate of mercury, or, what is better than all, chromic acid. Polypoid growths, or granulation tumors, of the ear are much more common than polyps. They con- sist, essentially, of a mass of granulations, of a soft, spongy consistence, and of a pale, florid color, which have their origin generally in an ulcerated condition of the auditory passage, the membrane of the tym- panum, or the canal and drum together. Occasion- ally, the immediate cause of their production is caries or necrosis of the petrous portion of the temporal bone, or disease of the ossicles of the ear. However induced, the growth often attains a large volume, filling up the meatus, and projecting sometimes a considerable distance into the concha. It is often quite sensitive, readily bleeds when rudely touched, and is always attended with a profuse, foul dis- charge. As these formations are always of a secondary na- ture, it is evident that they cannot be permanently cured until the cause, under the influence of which they are developed, has been effectually eradicated. The first object of the treatment, therefore, should be to get rid of the primary affection, whatever this may be. Meanwhile, however, any exuberant growth is removed either with the scissors, the knife, the forceps, or the snare, as may seem most convenient, repression being afterwards controlled by the cautious application of the ordinary escharotics. Cleanliness is an object of paramount importance in this form of the affection, and is best promoted by the frequent use of injections of tepid water, with castile soap and a small quantity of the chlorides. Parasitic groioths are liable to form in the external auditory canal, and to cause un- pleasant effects, as inflammation, suppuration, noises in the ear, pain, and even deafness. Among the more common of these growths are true fungi, the aspergilli, as they are termed. Their presence is always attended with preternatural vascularity and other evi- dences of inflammation of the meatus, and also of the membrane of the tympanum, which, in the more simple cases, is usually covered with a thin, whitish incrustation, almost characteristic of the nature of the affection. If allowed to remain in the ear, all the results of inflammation are produced by the irritation of their presence and growth. Fig. 188, from Burnett, shows the spores in the stage of the full aerial fructifi- cation. There are two varieties found in the ear, namely, the flavescens or glaucus, a, fig. 188, not often seen, and the nigricans, B, fig. 188, the kind most commonly found in the human ear. These sporules occur at all periods of life, often multiply with great rapidity, and are generally readily destroyed by very weak solutions of chloride of ammonium, chloride of lime, and common salt. Dr. Burnett has found that the best remedy is very finely powdered boracic acid, blown into the canal and upon the fungus at the fundus, by means of a slender rubber tube, to the end of which a goose-quill is at- tached for guiding the powder, through the speculum, well illuminated by a forehead mirror. The meatus is subject to osseous growths, caused either by hypertrophy of the osseous portion of the tube, by pro- tracted inflammation, simple or specific, or by the de- velopment of veritable exostoses. The latter formations are the most common, and they generally occur as small, irregular masses, of variable shape and size, having all the density and firmness of ordinary bone. Lying immediately beneath the lining skin, they arise from AFFECTIONS OF THE AUDITORY TUBE. Fig. 187 Sexton's Polyp-snare. Fig. 188. A, B. Fully developed Fruit Stalks of Aspergillus, c. The Spores being cast off from the ripe head. 248 DISEASES AND INJURIES OF THE EAR. chap. v. different parts of the canal, which they sometimes so completely occlude as to occasion permanent deafness, and other suffering, as pain in the ear and various kinds of noises. Two, three, and even four of such growths have been found in the same subject. They are always easily distinguished by the tardiness of their development, and by their great hardness, as revealed by the contact of the probe. Now and then they project at the orifice of the meatus. When they excite ulceration, there is always more or less discharge of fetid matter ; or, instead of this, the matter may find its way through the membrane of the tympanum into the middle ear, where, not meeting with a ready outlet, it may produce intense distress. An exostosis, developed deep in the passage, may destroy the tympanum, and even encroach more or less seriously upon the vestibule and auditory nerve. The treatment of these growths is altogether unsatisfactory. In their earlier stages, their progress may sometimes be arrested, and their volume even considerably dimin- ished, by the careful application of dilute tincture of iodine; but, as a general rule, all such efforts are unavailing. When the tumor is situated near the orifice of the canal, and has a very narrow attachment, it may sometimes be safely removed with the gouge or chisel. A very delicate trephine, or the drill of the surgical engine, might advantage- ously be employed when the tumor fills the entire tube and impedes the flow of matter. The bony growth might thus be broken up, and removed piecemeal, or, at all events, a hole might be drilled through its centre, answering the purpose of a subsidiary canal, for the escape of pus and the introduction of medicated fluids. A sebaceous tumor occasionally forms in this canal, and, although it may acquire a con- siderable bulk, its presence is rarely suspected until it causes deafness, more or less dis- charge, or cerebral disturbance. If permitted to proceed, it may produce absorption of the mastoid cells, tympanum, or petrous bone, and thus lead to very serious, if not fatal, consequences. Its softness and elasticity readily distinguish it from bony tumors of the meatus. The only remedy is thorough excision. The molluscous tumor of the meatus is very uncommon. It consists of a whitish sub- stance, lamelliform in its arrangement, and is essentially composed of scaly matter, of variable size and shape. It has its origin, apparently, in the dermoid tissue, from which it gradually encroaches upon the canal until it fills its entire caliber, causing more or less pain, buzzing, discharge, and other unpleasant symptoms. When the tumor is unusually bulky, it may occasion partial absorption of the osseous wall of the meatus; and Mr. Toynbee has described cases in which it ex- tended even into the cranial cavity. Fig. 189, copied from his work on the ear, affords an illus- tration of such a growth. A molluscous tumor of the meatus may be mistaken for a polyp, or a mass of unhealthy granulations consequent upon caries, necrosis, or hypertrophy of the osseous wall. Error will be most likely to arise when the growth is attended with profuse discharge. The tardy progress of the excrescence, and its whitish appearance, however, are generally sufficiently character- istic. If any doubt exist, the examination of a particle of the morbid mass under the micro- scope will at once reveal its true nature by the disclosure of its epithelial structure. The only effective remedy is removal of the growth with the scoop and forceps, aided by the free use of the syringe, charged with tepid water, Bepullulation is prevented by the cautious application of nitrate of silver. Dr. Burnett informs me that he has employed, with excellent results, finely powdered boracic acid in this condition of the external auditory canal. Malignant tumors are sometimes developed in this situation, commencing either in the soft structures, in the petrous portion of the temporal bone, or in the mastoid process. Whether certain forms of polyps or of polypoid excrescences, described in the preceding paragraphs, are capable of assuming this kind of action remains to be determined, but such a conclusion is certainly not unreasonable. However this may be, the malignant growth is, in general, easily recognized by the peculiarity of its color, which is always purple or livid, by the rapidity of its development, by its tendency to extend, not only outwardly, but laterally, in every direction, by its speedy reproduction after removal, by the almost insupportable fetor of the discharge, by the excessive pain, and, lastly, by the Fig. 189. Molluscous Tumor. CHAP. V. AFFECTIONS OF THE AUDITORY TUBE. 249 early involvement of the neighboring lymphatic glands. The constitution gradually becomes affected, and the patient at length sinks under all the symptoms of the cancerous cachexia, or he dies suddenly, and, perhaps, unexpectedly, from effusion upon the brain. The treatment is wholly palliative. Syphilitic affections, chiefly in the form of fissures and condylomatous excrescences, are liable to occur around the orifice of the meatus, causing more or less irritation and discharge. They are usually associated with syphilis in other parts of the body, and must be treated upon the same general principles. It is not improbable that disease here occasionally results from direct inoculation. 5. Inflammation—The most common variety of inflammation of the auditory canal is the simple, which usually begins in the skin and connective tissue, from which it often extends to the periosteum, and even to the superficial portion of the bone. The disease, in the severity of suffering which it induces, bears a very striking resemblance to paro- nychia. It is usually ushered in by a dull, aching sensation, which is soon converted into a violent throbbing pain, attended with a feeling of weight and obstruction, and various kinds of noises in the ear. The swelling is slow, but as it proceeds it often causes com- plete occlusion of the tube, and involves the parts around the ear, which are always exquisitely tender, and intolerant of the slightest pressure and motion. When the dis- ease is at its height, the patient is unable to masticate, and to lie on the affected side. Headache and constitutional disturbance generally attend, and there is, in most cases, a strong tendency to suppuration, the matter being, however, always small in quantity, but deep seated. The origin of this disease is not well understood. It is often witnessed in persons who are, apparently, in the most robust health. In general, however, it arises from cold, or a disordered state of the digestive organs from overfeeding, intemperance, and other causes. Occasionally it occurs as a sequel of measles, scarlatina, typhoid fever, or smallpox. When the inflammation attacks an individual already much debilitated by disease, it may prove dangerous by involvement of the brain and arachnoid membrane. When an ab- scess forms, the matter discharges itself either into the auditory canal, or it finds an outlet in the immediate vicinity of the ear, either just in front of the temporo-maxillary articu- lation, or over the root of the mastoid process. This disease occasionally assumes an erysipelatous type, or it may possess this character from the commencement. Its nature will be denoted by the peculiar discoloration of the skin, by the presence of minute vesicles, by the tendency of the morbid action to spread over the surrounding parts, and by the peculiar burning, itching, or stinging character of the pain. The treatment must be rigidly antiphlogistic. If the symptoms are urgent, and the patient is robust, it may be necessary to take blood from the arm, to purge him actively, and to subject him to the use of antimonial and saline preparations, with anodynes to allay pain and procure sleep. In general, however, these remedies may be dispensed with, as the object may readily be attained by the application of leeches to the anterior and pos- terior part of the ear, anodyne fomentations, light diet, and diaphoretics, especially if an early and free incision is made, which is often just as necessary here as in whitlow, or in an ordinary phlegmonous boil. The opening should be deep rather than extensive, reach- ing down to the bone, so as to afford free vent to the confined fluid. When the disease is slow in disappearing, or when abscess after abscess forms, a course of alterative and tonic medicine will be indicated, along with a proper regulation of the diet, and change of air. In the erysipelatous form of the affection, the treatment does not differ essentially from that necessary in the preceding case, only that the inflamed surface should be painted freely with dilute tincture of iodine, and that, if matter form, the incision should be somewhat more extensive. 6. Boils or Furuncles—Great suffering is occasionally entailed by boils occurring in and around the auditory canal, owing to the unyielding nature of the affected structures. The pain is often intense, and there is always exquisite tenderness in the surrounding parts, interfering more or less with mastication and deglutition. In the more severe attacks there is generally considerable constitutional disturbance, attended with want of appetite and sleep, and inability to attend to business. The amount of swelling varies, but is often sufficient to occlude the orifice of the meatus, and to cause partial deafness. The pain is generally of a severe, throbbing character, and not unfrequently extends over the greater portion of the affected side. In some instances, indeed, it is felt deeply in the head, especially in the direction of the mastoid process and the petrous portion of 250 DISEASES AND INJURIES OF THE EAR. chap. v. the temporal bone. The disease commonly takes its rise in the connective tissue beneath the skin, in connection with a hair follicle. Sometimes several boils coexist, or form in more or less rapid succession, and I have met with cases in which there was a well- marked furuncular diathesis, the tendency to the formation of boils continuing for many months, or even for several years. There is usually a distinct “ core” of connective tissue, intermixed with a small quantity of thick, yellow matter. The causes of these boils are generally referable to suppression of the cutaneous prepa- ration, to intemperance and high living, to disorder of the digestive apparatus, or to the derangement of some important secretion, as that of the liver or kidney. The treatment resolves itself chiefly into the application of leeches, tincture of iodine, blisters in front or behind the ear, and emollient cataplasms. The use of steam, medi- cated with laudanum and camphor, often greatly mitigates the pain and distress in the head. Tension should be relieved by an early and free incision, the surgeon not waiting for fluctuation. Constitutional treatment must not be neglected. The diet must be pro- perly regulated, and pain relieved by the liberal use of anodynes. Faulty secretions must be corrected, and change of air secured, when there is a tendency to a recurrence of the disease. Dr. Sexton, of New York, has found sulphide of calcium, one-tenth of a grain three and four times daily, of great assistance in preventing the occurrence of boils in the ear. 7. Herpetic Affections—The auditory passage is occasionally the seat of herpetic dis- ease, either as a primary affection, or as a propagation from the auricle, where it is by no means uncommon. It is characterized by the formation of numerous vesicles, generally more minute than the smallest pin-head, closely grouped together, if not confluent, and filled with a thin, whitish, or slightly yellowish fluid. The surface upon which the erup- tion rests is of a dusky-reddish appearance, and the seat of intolerable itching. The vesicles on breaking are replaced by little ulcers, chaps, or fissures, discharging a thin, sanious fluid, which may be so copious as to run out upon the ear, and even upon the patient’s pillow. The auditory canal is red, swollen, angry looking, tender, and, at times, even quite painful from the great extent of disease. The suffering is increased by expo- sure, the use of stimulating food, and disorder of the alimentary canal. The affection may last for years, and finally extend to the membrane of the tympanum. Besides the itching, which is always a prominent symptom, the patient is troubled with noises in the ears, and with partial deafness. To treat this affection successfully, particular attention must be paid to the state of the general health, which always exercises a remarkable influence upon its progress and con- tinuance. The secretions must be improved by a mild course of alteratives, the diet must be plain and non-stimulant, and the bowels must be moved from time to time with vege- table cathartics. If the patient is robust, antimonial and saline preparations will be of service; while in obstinate cases the use of iodide of potassium may be necessary. In weak, debilitated states of the system, the most appropriate internal remedies are tincture of chloride of iron and Fowler’s solution of arsenic, twenty-five drops of the former and six to eight of the latter being given thrice a day. The best local applications, at the commencement of the treatment, are leeches with warm water-dressing, and afterwards, when the morbid action has been somewhat moderated, weak solutions of bichloride of mercury, acetate of lead, or what I prefer to everything else, benzoated ointment of zinc, or zinc ointment, with the addition of five grains of chloral to the ounce. 8. Chronic Inflammation of the External Auditory Canal The skin, ceruminous glands, and subjacent tissues are liable to chronic inflammation either from the suppres- sion of the cutaneous perspiration, disorder of the digestive apparatus, the extension of some specific disease, irritation of the gums, as in teething, or the presence of a foreign body. Its characteristic is an inordinate secretion of cerumen, accompanied with a sense of fulness and uneasiness deep in the auditory tube, which is at the same time, perhaps, con- siderably swollen, although rarely as much as in the more common forms of inflammation. The discharge is of a pale-yellowish color, of a thin consistence, almost like water, and so abundant as to run out of the ear in considerable quantity. If it be allowed to remain, it closes up the passage, becoming thick and hard, of a dark-brownish, or blackish color, and firmly adherent to the walls of the tube. Ordinarily there is little or no impairment of the hearing, but there is nearly always more or less noise in the ear, especially when the disease extends to the membrane of the tympanum, when there is occasionally also considerable deafness. An active purgative with light diet, and a few leeches behind the ear, generally suffice DISEASES OF THE MEMBRANE OF THE TYMPANUM. 251 CHAP. V. to put a speedy stop to the morbid action. If the disease has been the result of cold, diaphoretics, as Dover’s powder or a combination of antimony and morphia, will be proper. To clear away the discharge, tepid water, containing a little soap, should be gently injected into the ear, followed by some mildly astringent lotion, as a very weak solution of nitrate of silver, acetate of lead, or sulphate of copper and tannic acid. 9. Hemorrhage—Hemorrhage of the ear, a rare occurrence, may be the result of ex- ternal injury, or of ulceration of a tolerably large vessel, and ntjay have its seat either in the auditory canal, in the cavity of the tympanum, or in the parts immediately around the petrous portion of the temporal bone. Cases have been noticed in which the bleeding was so large and unmanageable as to lead to the belief that it proceeded from the internal carotid artery, laid open by an extension of the morbid action from the ear. The blood, in these cases, gushed out of the meatus in immense quantities, and, although it could be temporarily controlled, it ultimately caused death by exhaustion. When it proceeds from, or passes through, the cavity of the tympanum, it also escapes at the Eustachian tube, from which it is either ejected by the mouth, or, as is more common, it descends into the stomach. In fractures of the base of the skull, involving the meninges and the petrous portion of the temporal bone, there is often a copious discharge from the ear, at first of pure blood, and afterwards of sanguineous serum. After injuries to the head, there may be a pinkish, watery discharge from the ear, but this is not positively indica- tive of fracture of the base of the skull and an escape of cerebrospinal fluid. The force of the blow may rupture the membrane of the tympanum, and the adjacent skin of the canal, from which the sero-sanguinolent fluid flows, giving rise to the suspicion that deeper injuries are present. When this flow is seen, the diagnosis and prognosis should be guarded, especially if the membrane of the tympanum is found ruptured. Sometimes the bleeding is vicarious of the menstrual flux. Aural hemorrhage is treated in the same manner as hemorrhage in other parts of the body; by attention to position, the exhibition of opium with acetate of lead and ergot, cold applications to the mastoid process and the back of the head, and the use of the tampon. When the blood issues from the fauces, the Eustachian tube should be plugged with the catheter, its extremity being surrounded by a bit of sponge to secure more accurate closure. SECT. Ill DISEASES OF THE MEMBRANE OF TIIE TYMPANUM. 1. Wovnds and Lacerations—The membrane of the tympanum is liable to various kinds of wounds, either as a result of violence directly applied, or as concomitants of fractures of the skull. In the latter case it is probably more frequently injured than is generally supposed. It is an interesting fact to know that, when the lesion is not too extensive, it is readily repaired by an effusion of plastic matter, the process employed by nature being the same as in the healing of wounds in other parts of the body. Independently of clinical observation, which long ago established the fact, the experiments of Valsalva are perfectly conclusive upon the subject, proving that wounds of this membrane are suscept- ible of cicatrization, even when they are accompanied by considerable loss of substance. This distinguished physician repeatedly perforated and even lacerated the membrane of the tympanum in dogs, which, after some time, he killed, when he found that the injury had been most thoroughly repaired in every instance. Similar experiments have been performed since the time of Valsalva by physiologists and surgeons, with precisely similar results. In the operation of excising a portion of the membrane for the cure of deafness, formerly so much in vogue, the great trouble has been to prevent the opening from closing. From all these facts, then, we may deduce the interesting conclusion that wounds of this membrane, even when attended with considerable loss of substance, are, in general, easily repaired. To promote this occurrence, in case of accident, the treatment should be strictly antiphlogistic, particular attention being paid to the position of the head, and free use being made of leeches behind the ear. Absolutely nothing should now be dropped or poured into the ear, since, on account of the perforation in the membrane of the tympa- num anything poured into the meatus will enter the tympanic cavity and inevitably inflame the mucous membrane lining it. Rupture of the membrane of the tympanum may be produced in several ways, as a fall upon the side of the head, a box on the ear, blowing of the nose, and the forcible intro- duction of a foreign body, as exhibited in the accompanying sketches, figs. 190, 191, 192, from Toynbee. I have met with several cases in which it was occasioned by the concussion of the air during the firing of a cannon. The occurrence is generally 252 DISEASES AND INJURIES OF THE EAR. CHAP. v. attended with a loud noise, not unlike that caused by the discharge of a pistol, some hemorrhage, and a good deal of pain. As the edges of the rent retain their contact, the lesion is soon repaired by the interposition of lymph, without any permanent impair- ment of the hearing. Fig. 190. Fig. 191. Fig. 192. A fissure in the Lower Part of the Tympanic Membrane from a Box on the Ear. A fissure in the Posterior Part of the Tympanic Membrane from Blow- ing the Nose. A flssurein the Tympanic Mem- brane caused by a Twig. 2. Inflammation—Inflammation of the membrane of the tympanum, or myringitis, may arise from various causes, as exposure to cold, external injury, or the presence of a foreign body. It is a frequent sequel of measles, scarlatina, and smallpox, and is often directly de- pendent for its origin upon a strumous state of the system. I plants and young children are most prone to its attacks, especially such as are naturally of a delicate constitution, or who have suffered from poverty and want. When this is the case, it is often induced by the most trifling causes, and followed by the most disastrous consequences, such as partial destruction of the membrane and partial or complete deafness; the inflamed membrane, inspected with the aid of a strong light and the instruments shown on page 237, will be found to exhibit a pale rose color, which, as the morbid action advances, is generally converted into a deeper hue. Small, straggling vessels are seen ramifying over the affected surface, and the part, instead of being thin and transparent, as in the natural state, is thick and opaque, from interstitial deposits. The inflammation often affects the adjoining parts, especially the bottom of the auditory tube, attended, when this is the case, with an increase of cerumen, soon followed by suppuration and a discharge of muco- purulent matter. Myringitis is characterized by the existence of more or less pain, deep-seated in the ear, and extending to the side of the head ; it is generally described by the patient as exceedingly sharp, aching, and distressing, and is always aggravated by loud noise, stooping, cough- ing, or sneezing, and by exposure of the part to the cold air. As the disease approaches the suppurative point, the pain generally becomes throbbing, and almost agonizing, de- priving the individual both of appetite and sleep. The parts around are now more or less tender, and the movements of the jaw add greatly to the local distress. The sense of hearing is usually considerably exalted ; loud, cracking, or ringing sounds are perceived, and there is often a feeling of fluttering as if an insect were flying about in the ear. The inflammation, if at all severe, is attended with high symptomatic disorder, and occasionally with delirium, when it may be concluded that the inflammation has involved the tympanic cavity. In the treatment of acute myringitis, under these circumstances, active antiphlogistic measures should be employed with the least possible delay, with the twofold object of saving structure and preventing cerebral involvement, the two great dangers in every severe attack of this kind. If the pulse is strong and full, the pain excessive, the mind delirious, and the skin hot and dry, blood must be taken freely from the arm, the operation being followed by the application of leeches over the mastoid process, a brisk purgative, the antimonial and saline mixture, the hot foot-bath, and a sufficiency of morphia to relieve suffering and induce sleep. Copious diaphoresis should be aimed at, and promoted by tepid drinks. The steam of hot water, directed upon the ear and the adjacent parts by means of a funnel inverted over a large pitcher, will often prove ex- ceedingly grateful, and afford more decided comfort than almost anything else. Its efficacy may be greatly enhanced by the addition of laudanum and powdered camphor, or camphor dissolved in alcohol. The application of dry heat will also be productive of great amelioration. The patient’s head should be constantly maintained in an elevated position, noise should be excluded from the apartment, and the surrounding temperature should be regulated with the thermometer, especially in cold weather. If cerebral in- volvement be threatened, leeching and counterirritation will be necessary. If suppuration CHAP. V. DISEASES OF THE MEMBRANE OF THE TYMPANUM. 253 cannot be prevented by this treatment, and the membrane of the tympanum be observed to bulge outward from the results of inflammation contained in the drum-cavity, para- centesis of the membrane should be performed at the posterior, inferior quadrant, by means of the knife represented in fig. 193. The operation, which must be done under the most perfect illumination of the parts by means of the speculum and forehead mirror, consists in stabbing gently the protruding membrane. Immediately a drop or two of fluid will exude from the wound. In the event of there being any discharge, the syringe and tepid water may be had recourse to, but it is impossible to be too careful in their use, otherwise they will be sure to aggravate the disease instead of diminishing it. As to any direct application, the only one at all admissible, as a general rule, consists of equal parts of laudanum and glycerine, or laudanum and water, slightly warmed, and introduced into the bottom of the ear, in immediate contact with the affected surface. Irritating lotions always prove prejudicial, and cannot be too much condemned. 3. Abscess and Gangrene Inflammation of the membrane of the tympanum probably terminates much more frequently in the formation of abscess than practitioners are aware; but, owing to the difficulty of examining the parts when thus affected, the occurrence commonly escapes detection. The pus is seated in the submucous connective tissue, and, although very small in quan- tity, generally leads to perforation of the membrane, and some- times to the discharge of the small bones of the ear, its formation being ordinarily preceded by rigors and delirium. The treatment is antiphlogistic. If the abscess is accessible, evacuation is effected with a cataract needle or paracentesis knife, and cica- trization promoted by the cautious application of nitrate of sil- ver upon the extremity of a probe. 4. Ulceration and Otorrhcea—Ulceration of the membrane of the tympanum may be an effect of ordinary inflammation, both acute and chronic, or of a strumous or syphilitic taint of the system. Hut usually perforation of the membrane of the tym- panum must be regarded as a symptom of disease of the tympanic or drum-cavity. The erosive action may display itself in the form of little, superficial abrasions, not larger, perhaps, than a small pin-head, and of a circular or oval shape; or in that of a deep and broad surface, with abrupt and well-defined edges, rapidly followed by perforation of the affected part, and a discharge of pus. The ulceration often proceeds until the whole membrane is destroyed, and all the adjacent parts, osseous as well as soft, are involved in the mischief. In such cases the morbid action sometimes extends to the substance of the temporal bone, and thence along to the brain and its meninges, leading to various effusions and the formation of abscesses, from which the patient seldom, if ever, recovers. Occasionally there is, in addition to these affections, facial paralysis, from involvement of the portio dura, in consequence of the propagation of the ulceration through the facial canal. Most cases of this disease that are not produced by mechanical causes are of a strumous or syphilitic nature. The subjects are generally young, delicate children, who are either the offspring of persons who have perished from phthisis or from some allied disease, or who are themselves destined to suffer in this way. The exciting cause of the complaint is either exposure to cold or an attack of measles, scarlatina, or some other eruptive dis- ease, the tendency of which is to impoverish the blood and exhaust the vital powers. The ulceration is frequently of a very insidious character, coming on without any pain during the convalescent stage of the cutaneous malady, and continuing, with, perhaps, little inter mission, for an almost interminable period. Cases of this kind are often met with which have lasted for five, ten, and even fifteen years. The discharge is generally of a thick, cream-like consistence, of a yellowish color, verging upon greenish, and so horribly fetid as to render the patient disagreeable both to himself and to those around him. Exposure to cold, derangement of the digestive organs, and neglect of cleanliness, always aggravate it. It is often attended with polyps or polypoid growths, and is liable, unless closely watched, to be followed by inflammation of the brain and its membranes. If, upon the Fig. 193. Paracentesis Knife. 254 DISEASES AND INJURIES OF THE EAR. CHAP v. supervention of acute symptoms, the discharge ceases, especially if accompanied by severe earache, or headache, or both, suspicion of grave complication, such as involvement of the mastoid cells and the meninges of the brain, should be aroused. When the ulceration, by whatever cause induced, is of long standing, or of considerable extent, deafness, more or less complete, is the inevitable consequence. All, therefore, that can be done in such a case is to endeavor to arrest the disease, upon which the per- foration depends, and happy is the surgeon who can succeed in his efforts ; for it may truly be asserted that there is no affection which is more unmanageable, or more difficult to be brought under the influence of remedies than chronic purulent inflammation of the middle ear. As to improvement of the hearing the practitioner, indeed, cannot be too guarded in his prognosis. He should do all he can, but promise nothing. In many cases, when the disease has not extended too deeply into the middle ear, and the constitution has not been greatly impaired, very good hearing is the result of careful and patient treatment. Persons laboring under the more aggravated forms of this disease occasionally perish from an extension of the morbid action to the petrous bone, or to this bone and the brain and its envelops. The danger is always greatest in very young children, in whom this bone consists almost entirely of diploe, or of a soft, spongy structure inlaid with veins. In some cases, secondary phlebitis arises, apparently from an extension of the disease along the cerebral sinuses and internal jugular veins. The parts most liable to suffer in this manner are the lungs, pleura, liver, and joints. The symptoms announcing these events are such as ordinarily usher in the occurrence of pyemia. The most prominent are rigors, or chilly sensations, alternating with flushes of heat, and rapid exhaustion of the vital powers, with excessive restlessness and a tendency to low muttering delirium, especially when there is serious involvement of the brain. In the latter case, there will also be violent cephalalgia, and agonizing pain in the affected side of the head. Involvement of the internal carotid artery is occasionally observed in the more severe forms of these affections, the more common alterations being inflammation of its tunics, and occlusion of its interior, by fibrinous concretions, followed, now and then, by perfora- tion and fatal hemorrhage, the blood escaping by the external meatus or by the Eusta- chian tube. A similar occurrence is occasionally met with in the jugular vein. A num- ber of cases have come under my observation of facial paralysis from inflammation and compression of the portio dura, caused by caries or necrosis of the petrous portion of the temporal bone. The treatment of ulceration of the membrane of the tympanum is too frequently con- ducted empirically. When the disease has been induced by the presence of a foreign body, or by the retention of pus from some morbid growth, or by disease of the cavity of the drum, the removal of the exciting cause will often of itself be sufficient to effect a cure ; but where no positive information exists respecting this point, our course must, necessarily, be one of uncertainty. A careful examination should always be made of the condition of the parts before we begin the treatment, by washing out the ear with tepid water thrown in gently with a large syringe. The prominent indications are, first, to allay fetor, and, secondly, to arrest the morbid action. The former is fulfilled by the free but cautious use of deodorizers, as chlorinated sodium or permanganate of potassium, injected into the ear twice or thrice in the twenty-four hours; the latter, by counterirritation, the topical application of nitrate of silver, chloride of zinc, or yellow-wash, and by attention to the state of the system. When the disease is of a strumous nature, or associated with debility, an alterant and tonic course will be indicated, consisting of iodide of iron and extract of cinchona, alter- nated with cod-liver oil, and combined with nutritious diet and exercise in the open air. The surface should be well protected, and sponged daily with tepid salt water, followed by dry friction. Too much attention cannot be bestowed upon cleanliness; for, apart from the offensive character of the discharge, the accumulation of pus in the ear must necessarily tend to keep up the morbid action, and to increase the mischief. Nitrate of silver, although undoubtedly one of the very best topical remedies, should not be em- ployed without the greatest caution. A solution of ten, fifteen, or even twenty grains, applied once a day, with a short, stiff camel-hair pencil, after the ear has been thor- oughly cleansed with tepid water, is a good average strength, generally well borne, and followed by rapid amendment. Many practitioners have found that the strength of the solution may be increased to from forty to one hundred grains to the fluidounce of water, without being productive of pain. The best way to apply this solution is by instillation with an ordinary medicine dropper. After it has been in contact with the diseased parts for a few moments, the head of the patient having been inclined towards the side opposite to CHAP. V. INFLAMMATION OF CAVITY OF TYMPANUM. 255 the one operated upon, the ear maybe syringed, and the solution of silver removed. The addition of a little table salt to the water used in syringing will prevent staining of the ear. A weak solution of chloride of zinc is also an excellent preparation. In many cases, I have derived marked benefit from the use of yellow-wash, in the proportion of one-eighth to half a grain of bichloride of mercury to the ounce of lime water. Lotions of nitrate of lead often promptly check the discharge. Glycerine and tannic acid, sulphate of copper, carbolic acid, and iodide of iron may be mentioned as among the better and more reliable subordinate articles. Solid nitrate of silver can never be advantageously employed in this affection. After the careful and judicious use of the remedies laid down, it will be observed that the discharge from the ear sensibly lessens, and that the ulcerated mucous membrane of the drum-cavity grows paler and smoother. The membrane of the tympanum becomes less infiltrated, the malleus and its short process are more distinctly seen, and the perforation grows smaller; when the discharge can be stopped entirely the perforation in the drum- head not infrequently closes. When the disease is due to a syphilitic taint of the system, it will be necessary, in addition to the local means here pointed out, to place the patient upon the use of iodide of potassium, either alone or in conjunction with bichloride of mercury, in small doses, continued sufficiently long to produce slight ptyalism. To the disease now described, the term otorrhceci is usually applied ; and practitioners, in prescribing for it, unfortunately too often forget that the concomitant discharge is merely a symptom of the affection, and not the disease itself. Another mistake that is often committed is the belief that the affection upon which the discharge depends will in time disappear spontaneously, or, to use a common expression, that the patient, especially if a child, will gradually outgrow it. Such an opinion is as absurd as it is culpable, and cannot be too severely censured. The poor patient, confiding in the judgment of his pro- fessional adviser, goes on from bad to worse, until, awakening from his dream, he finds that his ear is completely disorganized, and that he is irremediably deaf. Such cases are of constant occurrence ; and, while they are calculated to excite our sympathy for the sufferer, they cannot fail to rouse our indignation at the surgeon, who, either through ignorance, indolence, or supineness, neglects to make himself acquainted with the true nature and treatment of the disease. SECT. IV ACUTE INFLAMMATION OF TIIE CAVITY OF THE TYMPANUM. This disease, which has been variously designated by aural surgeons, is seated in the mucous membrane lining the middle ear, which is continuous, along the Eustachian tube, with that of the fauces. As it progresses, it may invade other structures, as the fibrous layer of the tympanum, and even the labyrinth ; or, beginning in these, it may extend to and involve the mucous tissue secondarily. Unfortunately, our knowledge of the maladies of these delicate parts of the organ of hearing is too limited to enable us to speak very positively upon the subject ; their deep situation, the difficulty of exposing them, and the infrequency of their fatality, being so many reasons of the imperfection of our informa- tion. Inflammation here is probably more common than is generally imagined, and it is not at all unlikely that some of the fatal cases of disease of the base of the brain, which are met with from time to time have their seat originally in the middle and internal ear. The causes of this disease are usually very obscure, although, in very many cases, it is directly traceable to the effects of cold, or suppression of the cutaneous perspiration. It may also be induced by external injury, by the presence of a foreign body, by irritating applications to the membrane of the tympanum, and by an extension of inflammation from the tonsils and fauces along the Eustachian tube. Children and young persons are its most common subjects, especially such as are of a strumous predisposition. Occasionally the disease is caused by a marked syphilitic taint of the system. The relation of inflammation of the cavity of the tympanum to the exanthematous dis- eases, especially measles and scarlatina, has been placed in a very striking light by the observations of Wilde, Troltsch, and other writers. A very considerable proportion of the cases of non-congenital muteism are due to the effects of these eruptive fevers. Of 1892 cases of acquired deafness, from all causes, occurring in Belgium, 21G arose from scarlatina, 80 from measles, and 28 from smallpox. The inflammation, under such circumstances, begins in the throat, from which it extends along the Eustachian tube to the middle ear, occasioning thickening of the lining membrane of the canal, and effusion into the cavity of the tympanum, not unfrequently followed by ulceration and perforation of the drum of 256 DISEASES AND INJURIES OF THE EAR. chap. v. the ear, copious fetid discharge from the auditory meatus, and more or less impairment, if not complete destruction, of the function of audition. The affection is ushered in by pain in the ear, which is speedily followed by fever, alternating with rigors. The pain is deep-seated, and, rapidly increasing, soon amounts to intense agony, being of a tearing, boring, dragging, or pulsatile character; it is aggra- vated by the slightest motion of the head, and darts about in different directions, as the temple, forehead, mastoid process, and teeth, which often ache most violently. Cepha- lalgia is generally present from the beginning, and is soon succeeded by delirium ; the patient is unable to remain for a moment in the same posture, and is harassed with all kinds of noises, while the sense of hearing is in the highest possible state of exaltation ; the countenance is flushed, the eyes are suffused, and there is a wildness of expression indicative of the most intense suffering. In the worst forms of the affection, the pain extends along the Eustachian tube into the throat; the whole; side of the head is exqui- sitely tender; the fever increases in intensity; coma at length sets in ; and the patient expires under all the symptoms of disease of the brain and its membranes. In some cases, there is facial paralysis, from involvement of the portio dura in the aqueduct of Fallopius. Upon dissection, matter is found in the cavity of the tympanum, and also, not unfrequently, over the petrous portion of the temporal bone, with effusion of serum into the arachnoid sac. In protracted cases, the temporal bone is carious, or partially necrosed, and separated from the dura mater by a distinct abscess. When the patient survives, the matter is sometimes suddenly discharged through the external ear, followed by partial relief of the frightful suffering. The mitigation thus produced, however, is often only temporary, death being caused afterwards either by exhaustion, or, as more generally hap- pens, by inflammation of the brain and its envelops. The period at which this event occurs varies from eight or ten days to several months. In the latter case, the patient is assailed by hectic irritation ; he becomes weak and emaciated; his countenance exhibits a sallow, cadaverous appearance; there is profuse discharge from the ear, or from the ear and the Eustachian tube ; and the mind is feeble, incoherent, or fatuous. In regard to the diagnosis of the disease there is hardly a symptom that is worthy of reliance. Perhaps the most important is the violence of the pain, the depth at which it is situated, its unremitting character, and its association with fever, rigors, and delirium. If the patient be a child, the head will be in constant motion, and the hand incessantly carried to the ear; an adult will express himself as being in great torture. The general excite- ment is higher than in external otitis, the ear is more intolerant of sound, and there is always marked delirium, usually beginning early, and lasting until the malady disappears or proves fatal. Another point of distinction of some value is that matter forms much later than in inflammation of the membrane of the tympanum, or of this structure and of the auditory canal, in which suppuration generally takes place in from twenty-four to forty-eight hours. Finally, there is more tenderness in the mastoid and temporal regions than in external otitis, and more pain in moving the head, sneezing, coughing, and mas- tication. The treatment of internal otitis must be prompt and vigorous; for, as the disease is one of great danger both to the part and the system, no time should be lost in timidity and indecision. The most trustworthy remedies are general and topical bleeding, as by leech- ing, active purgation, the free use of antimonial and saline preparations, the hot foot-bath, Dover’s powder, and anodynes in doses sufficient to relieve pain and promote sleep. The best direct application is the steam of hot water, strongly impregnated with laudanum, tincture of aconite, and powdered camphor, and conducted to the ear by means of an in- verted funnel, the head being well covered with a blanket during the operation. One great aim of the treatment should be to bring about early and copious diaphoresis, experi- ence having shown that nothing exerts so powerful an influence, after proper depletion has been practised, over the morbid action. Noise is carefully excluded from the apartment, and the body steadily maintained in the sernierect posture. If matter form in the middle ear, as denoted by the convex and opaque appearance of the membrane of the tympanum, a puncture should be made to serve as an outlet to the pent-up fluid, its escape along the Eustachian tube being generally prevented by adhesive inflammation. If prompt relief is not obtained in this way, a small opening should at once be made into the mastoid pro- cess, especially if there is reason to believe, from the inflamed, swollen, and tender con- dition of the overlying structures, that its areolar texture participates in the disease. When the affection assumes the chronic form, and the mastoid cells remain diseased, the surgeon has an important malady to treat, a subject which will be duly considered under a separate head. CHAP. V. DISEASES OF THE EUSTACHIAN TUBE. 257 SECT. V DISEASES OF TIIE EUSTACHIAN TUBE. The Eustachian tube, which establishes a direct communication between the middle ear and the fauces, is liable to various affections, which influence, to a greater or less ex- tent, the function of audition. These affections may be thus enumerated : 1. Congenital occlusion. 2. Inflammation. 3. Mechanical obstruction. 4. Stricture. In the investi- gation of these disorders the practitioner should never lose sight of the fact that most of them are caused simply by an extension of disease from the throat and nose. 1. Congenital occlusion of the Eustachian tube is probably more frequent than is gene- rally imagined. It is similar to the malformation which is met with in some of the other mucous outlets of the body, as the anus, urethra, and vagina, and may affect the entire canal, or be limited to a particular portion. In the latter case, the obstruction is caused either by a small membrane, not unlike a hymen, or by the presence of fibrous, fibro- cartilaginous, or cartilaginous tissue. However induced, it is generally, if not always, a cause of deaf-dumbness, and is beyond the reach of relief. 2. The Eustachian tube, being lined by a reflection of the mucous membrane of the fauces, is liable to inflammation and its various consequences, as thickening, ulceration, and even gangrene. Scrofulous children, affected with chronic disease of the tonsils, are particularly prone to suffer in this way. The inflammation of the fauces often continues for years, being constantly subject to exacerbations from the slightest exposure to cold, derangement of the digestive organs, and whatever has a tendency to excite and main- tain general debility. The membrane, from this habitual congestion, becomes gradually indurated and thickened from interstitial deposits, and thus ultimately encroaches very seriously upon the caliber of the tube. Similar effects are often produced in inflamma- tion of the throat and nose consequent upon some of the eruptive diseases, particularly measles, scarlatina, and smallpox. The morbid action thus awakened not unfrequently extends into the Eustachian tube, and thence along the tympanum, where, leading to various deposits and alterations of structure, it may be followed by the worst results. Ulceration of the Eustachian tube is observed chiefly in connection with constitutional syphilis, attended with destruction of the tonsils and the arches of the palate. Under such circumstances, the membranous portion of the canal may be entirely eroded, fol- lowed, during the healing process, by occlusion of the remainder of the passage. Gan- grene of the tube is extremely rare. Inflammation of the Eustachian tube may lead to a deposit of plastic matter, which, when the quantity is considerable, may cause permanent closure of the tube. Of sup- puration of this passage very little is known, but the probability is that it is much more common than is usually imagined. 3. Mechanical obstruction of the tube may arise from the presence of inspissated mu- cus, fibrin, blood, and earthy matter. Inordinate secretion of mucus is an occasional occurrence in this tube, chiefly as a con- sequence of chronic inflammation. When the fluid is very thick, or long retained, it may completely clog up the passage, and thus seriously impair hearing. Such an occurrence will be most likely to happen when the mucus is intermixed with plastic matter. A clot of blood, the result of hemorrhage in the middle ear, may be a source of obstruction. Finally, a substance resembling chalk—probably nothing but altered tubercular mat- ter—is sometimes found in the Eustachian tube, closing it either partially or completely, and thus acting as a cause of deafness. A foreign body introduced from without is occasionally met with in this canal, as when a substance, during attempts at extraction, is accidentally pushed into the middle ear, or when, from long retention, it causes perforative ulceration of the drum membrane. The most remarkable instance upon record is one related by Fleischmann, in which a small grain of barley was found projecting from the naso-pharyngeal orifice. The only incon- venience produced by it was an annoying noise in the corresponding ear. In a case re- corded by Masengeil a piece of oat straw passed from the mouth of a lady through the Eustachian tube into her middle ear, and finally in nine weeks through the membrane of the tympanum out of the external ear. 4. Stricture of the Eustachian canal is uncommon. It generally appears as a small, narrow band, stretched across the tube from one side to the other; or as a ring-like con- traction ; or, Avlien it involves the osseous part of the canal, as an exostosis, growing in- wardly and filling up the conduit. Sometimes the passage is nearly obliterated, from one extremity to the other, by a hypertrophied condition of the lining membrane. However constituted, the obstruction is usually permanent, although it may not be complete. 258 DISEASES AND INJURIES OF THE EAR. chap. v. The faucial orifice of the tube is sometimes occluded by the adhesion of the palate to the back and sides of the pharynx, as a consequence of syphilitic disease. Partial closure sometimes occurs in cleft palate, from the pressure of the soft parts. The diagnosis of the various affections of the Eustachian tube above described can best be established by means of the catheter, all other attempts at arriving at a knowl- edge of them being less direct and satisfactory. It was formerly imagined that the exist- ence of obstruction, from whatever cause arising, could readily be determined simply by inflation, during a forced expiration, by shutting the mouth and holding the nose ; it being asserted that if the air did not penetrate the tube, it was an evidence that it was closed. Nothing, however, can be more erroneous, for there are many persons who can- not, by any effort they can employ, distend this passage at all, however clear it may be. I have myself never been able to blow air into my left Eustachian tube, although my hearing is perfect, and the operation always promptly succeeds on the right side. Ca- theterism, then, is the most reliable means of diagnosis, and it is so much the more valua- ble, because, while it enables us to obtain important information respecting the nature of the disease, it is one of the best methods of cure. The operation of forcing air into the Eustachian tubes wdien the mouth and nostrils are closed is generally known as the ex- periment of Valsalva, from the fact that it was first distinctly described by that cele- brated pathologist. Although, as previously stated, it is uncertain as a means of diagno- sis, it is often of great service in freeing these passages from accumulations of mucus con- sequent upon acute and chronic inflammation. Politzer’s method of inflation will be described further on. Obstruction of the pharyngeal orifice of the Eustachian tube may generally, after a little practice, be easily detected by means of the index finger passed gently through the mouth in front of the tonsil, the right finger serving for the right side and the left for the left side. Any adhesions or cicatricial tissues that may exist may, with a little care, be broken up or destroyed in this way, provided they are not too firm or too old. Besides, a finger thus placed may be advantageously employed to guide the faucial extremity of the Eustachian catheter. In children such an operation is attended with many difficul- ties, and in the adult it is by no means always easy, especially if the patient has a small mouth, accompanied by a narrow intermaxillary space. Before the catheter is employed to inflate the Eustachian tube, thorough attempts should be made to accomplish the end by Politzer’s method of inflation, especially in children. Dr. Burnett never finds it necessary to use the Eustachian catheter in children under ten years of age, and he very rarely uses it excepting in adults. The existence of inflammation may be suspected when, along with inflammation of the fauces or nose, there are more or less pain in the ear, a sense of weight, pressure, or ful- ness, defective hearing, and excessive tinnitus, crackling, gurgling, roaring, or buzzing, increased by exposure to cold, recumbency, and loud talking. In speaking, the voice sounds in the patient’s ear as if a drum were beating in it. The noise is occasionally very loud and sudden, like a crack, apparently from the bursting of an air-bubble. The history of the case and a careful inspection of the throat often furnish important diagnos- tic information. Complete deafness of the affected ear does not necessarily follow complete obstruction of the Eustachian tube. The hearing is, of course, more or less impaired ; at times, how- ever, it is comparatively good ; and cases are met with, although they are uncommon, in which it is temporarily either very much improved or diminished. When the obstruction is of long standing, the tympanum generally participates in the morbid action. Toynbee found that, under such circumstances, the membrane is very concave, and of a dull, leaden hue, remarkably depressed inwards towards the stapes, or opaque, uneven, and irregular. Catheterism of the Eustachian tube is not as simple an operation as that of the bladder, and as it demands an unusual amount of practice, as well as a most accurate knowledge of the anatomy of the parts, it is evident that it can never come into general use. Besides, it is an operation which requires great delicacy on account of the exquisite sensibility of the nose, as well as of the surface immediately around the faucial mouth of the tube. For want of proper care in its performance, serious mischief may be produced. Different kinds of instruments are in vogue for exploring this canal ; some being straight, others curved; some flexible, others inflexible. The one which I have always been in the habit of using is represented in fig. 194. It is composed of silver or hard rubber, being six inches in length, and having a short curve at its distal extremity, with a very smooth, blunt orifice. It varies in diameter from to of an inch, according CHAP. V. DISEASES OF THE EUSTACHIAN TUBE. 259 to the age of the patient and the size of his nostril. In its general outline, it should be purely cylindrical, with the ring at its large extremity corresponding with the concavity of the curve at the smaller one; an arrangement which is found to be useful in the intro- Fig. 194. Catheter for the Eustachian Tube. duction of the instrument, as it indicates the direction of its point. In addition to the catheter, an auscultation-tube, or otoscope, fig. 195, and an air-bag, similar to that de- picted in fig. 198, are essential to thorough exploration. The patient being seated upon a chair with the head supported against the breast of an assistant, or a head-rest on the chair, or against the wall, the catheter is inserted into the nose, as in fig. 196, its con- cavity being directed downwards towards the floor of the nostril, along which it is con- veyed until it reaches the fauces. The point is now turned upwards and outwards, so that the ring of the instrument shall be in an oblique position, at an angle of 45,° while its body shall lie in close contact with the outer wall of the nasal fossa. All that is required now is to draw the catheter gently a little outward, when the beak will slide over the pos- terior lip into the faucial mouth of the tube. Here the instrument must lie, no endeavor to pass it into the calibre of the tube being admissible. The auscultation-tube, fig. 195, is then adjusted, by placing one end in the patient’s ear, and the other in the surgeon’s; when the con- ical end of the air-bag is inserted into the proxi- mal end of the catheter, and gently squeezed, as in fig. 197. If the adjustment has been accu- rate air will be heard to pass into the tube, and thence into the tympanic cavity, unless occlu- sion in some form has occurred in the Eusta- chian tube. The air as it rushes in will produce sounds varying with the degree of freedom in the caliber of the tube, the absence or presence of mucus, and the size of the catheter employed. Fig. 195. Auscultation-tube. Fig. 196. Insertion of the Eustachian Catheter. 260 DISEASES AND INJURIES OF THE EAR. chap. v. Thus, if the closure is partial, the air will readily find its way into the middle ear, very much as when inflation is attempted by shutting the mouth and nose ; whereas if it is complete no Fig. 197. Fixation of the Eustachian Catheter in Position, preparatory to Inflation. such effect will follow. The presence of mucus may generally be detected by the peculiar gurgling or rustling sound which the patient perceives as the air rushes past the accumu- lated fluid ; and soon after he will probably be conscious of a diminution of the disagreeable noises which previously disturbed him. If, on the other hand, the obstacle is of a solid nature, the sound produced by the inflation will be indistinct, or no sound will be heard. Stricture of the tube, from ordinary inflammation, may be suspected when the air, after having passed a certain distance, refuses to advance any farther, or passes in with great difficulty. It may be inferred that the obstruction is osseous, calcareous, or gristly, when the resistance is uncommonly great, and no air can be forced into the tympanum. The existence of mere deafness, or of various sounds, cannot, considered by itself, be re- garded as an evidence of closure of the Eustachian tube, as it is a concomitant of different affections. Catheterism of the Eustachian tube is an important means of treatment in affections, not only of the canal itself, but of the middle ear, whether arising from mere thickening of the investing membrane, or from an accumulation of mucus. In the former case, the mere contact of the instrument often produces an excellent sorbefacient effect, at the same time that it aids powerfully in the removal of the products of inflammation from the tube. The operation may be repeated, at first, once every other day, and afterwards at longer intervals. Three exhaustions of the hand air-bag will, in any case, be enough at one sitting. If the nasopharyngeal mucous membrane has been accidentally wounded during the introduction of the catheter, the inflation should not be repeated under twenty- four hours, lest it should give rise to emphysema of the fauces and the glottis. Obstruction of the Eustachian tube, from accumulations of mucus, is generally easily relieved by inflation of the canal, as originally suggested, in 1803, by I)r. Politzer, of Vienna, whose apparatus is represented in fig. 198. The method of inflation, which is shown in fig. 199, is founded upon the physiological fact that, at the moment of swallow- ing, the veil of the palate rises and draws the anterior wall of the Eustachian tube away from the posterior wall. The faucial mouth of the tube being thus opened and forced in- ward through the naris, the air, not being able to pass downward into the throat, will rush into the Eustachian tube, and thence into the tympanic cavity. In order to insure the act of deglutition, by the patient, at the moment desired by the surgeon, he is asked to take a sip of water, and hold it in his mouth until told to swallow it. There is no CHAP. V. NERVOUS DEAFNESS. 261 necessity of using the auscultation-tube in this operation. I much prefer, however, an ordinary gum female syringe, fur- nished with a suitable nose-plug and a central ball, as it greatly simplifies the operation, inasmuch as the tube is open at both ends. The plug being inserted to the distance of about half an inch into the nose, the mouth and nostrils are closed, and rapid efforts made at deglutition. It is not necessary, as is generally stated, to hold any water in the mouth to facilitate the process of inflation. Care must be taken not to blow too hard, otherwise rupture of the membrane of the tympanum may occur, as in a case recently under my observation. When more direct medication is required, the object may be attained by the injection of tepid water, slightly impreg- nated with some astringent article, as sulphate of zinc or Fig. 198. Fig. 199. Politzer’s method of opening the Eustachian Tube. Politzer’s Air-bag for Inflating the Middle Ear. acetate of lead. Great care must be taken that the solution is very weak, otherwise much harm may result. A better remedy than either of these is nitrate of silver, in the pro- portion of about an eighth of a grain to the ounce of water. Whatever substance is used, the injection should not be repeated oftener, on an average, than once every third or fourth day. Along with these means, special attention should be paid to the general health, the diet properly regulated, and the bowels maintained in a soluble condition. When the disease is obstinate, and fairly attributable to the effects of inflammation, benefit may be derived from slight and steadily continued ptyalism. Deafness, caused by permanent occlusion of the Eustachian tube, was formerly treated by perforation of the membrane of the tympanum. The operation, proposed early in the present century by Sir Astley Cooper, was at one time much in vogue, although it is now obsolete, as a means of curing deafness in chronic diseases of the tube, unless the deafness be due to retained secretions in the tympanic cavity. In such a condition a paracentesis may be followed by excellent results. The object was to drill a small opening into the drum, in order to admit air into the middle ear, the absence of which, as was alleged, was the principal cause of the want of hearing. Subsequently, as the aperture thus made was found to have a tendency soon to close, thereby frustrating the intention of the operation, an instrument was devised for cutting out a circular piece of the membrane. I had occasion, early in my professional life, to give this procedure a very fair trial in several instances, but as no benefit whatever resulted, I have not since repeated it; nor can I find any well authenticated case upon record in which it was of any permanent service. SECT. VI NERVOUS DEAFNESS. There is a form of deafness to which, for the want of a better expression, the term nervous is applied. The symptoms which characterize it have long been well understood, but of its pathology we are still in ignorance. The affection resembles, in many of its essential features, amaurosis or asthenopia. It was for a long time, attributed to paralysis of the auditory nerve, as amaurosis was attributed to paralysis of the optic nerve. That such an occurrence is possible is undeniable, but that much more importance has been ascribed to it than it is entitled to is equally true. Indeed, there is reason to believe that, in the DISEASES AND INJURIES OF THE EAR. CHAP. v. great majority of cases of what is called nervous deafness, the disease, instead of being caused by a want of power in the nerve of hearing, as a primary lesion, depends wholly upon inflammation. This has certainly been ascertained to be the fact in regard to amau- rosis, and that the same circumstance obtains in relation to nervous deafness is now gen- erally admitted. Too much stress cannot he laid upon this view, when we consider the influence which it must exert upon the treatment of this class of affections. Under the supposition that it was, from first to last, a purely nervous disease, the most erroneous practice was pursued, and this is, perhaps, one reason, among many others, why aural maladies have been so long a specialty in the hands of the empirics. Of the exciting causes of this form of deafness there is no very reliable information. In many of the cases that I have been consulted about, the disease appeared spontaneously, without the patient being able to assign any reason whatever for its occurrence. Occa- sionally I have known it to come on soon after an attack of typhoid fever, attended with an unusually tardy convalescence. Measles and scarlet fever are also sometimes followed by it. Several of the worst cases of nervous deafness that I have seen occurred, apparently, from bathing in cold water, after the body had been overheated by exercise. Profuse and long-continued diarrhoea, protracted hemorrhages, the inordinate use of purgatives, excessive smoking and chewing, masturbation, and abuse of sexual intercourse, have often been known to induce the affection. Another cause, and one, which, according to my experience, is more than commonly operative, is chronic dyspepsia, so rife among the people of this country. The disease generally begins in one ear, and, after continuing for some time, attacks the other; or it may be confined to one ear exclusively ; or, lastly, it may commence sim- ultaneously on both sides, and proceed uniformly or otherwise, until audition is completely lost. Sometimes it is produced very suddenly. Not long ago, I saw a child, four years old, who went to bed perfectly well in the evening, and woke up completely deaf in the morning. Great fright, and the concussion occasioned by the firing of a cannon or even a pistol have been known to deprive persons instantaneously of the faculty of hearing. Nervous deafness is sometimes hereditary, as in a case which came under my observa- tion in a young man, twenty-one years of age, who was partially deaf in his right ear, evidently from an affection of the auditory nerve ; the disease had been coming on gradually for eighteen months, and was attended with great buzzing, as well as other disagreeable noises, and occasional headache. lie had never had typhoid fever, measles, scarlatina, or smallpox. He was one of nine children. Ilis eldest brother, thirty-five years of age, was very deaf in both ears ; a sister, aged thirty, suffered in one. The father was deaf in both ears, and so was a paternal aunt. The paternal grandfather was likewise deaf. The mother heard well. A similar case has been reported to me by Dr. G. II. Patton, of Cin- cinnati, in which the deafness has manifested itself in four generations, chiefly in the male branches of the family. The first intimation which the patient usually has of his infirmity is, perhaps, derived from his friends, who, in their intercourse with him, are rendered conscious that he does not hear so well as formerly. They are obliged, in addressing him, to repeat their ques- tions or answers more frequently, and to speak in a louder tone and more emphatic man- ner. Along with this occurrence there are various noises in the ears, at first slight and occasional, but gradually becoming more and more intense and steady, until, in time, they constitute the great and absorbing symptom. Of the character of these noises it is difficult to convey any accurate idea. Most commonly, however, they are of a tinkling, ringing, roaring, or buzzing nature. Usually confined to the ears, they are sometimes perceived over the greater part of the head, and are liable to be aggravated by exposure, atmospheric vicissitudes, dyspepsia, constipation of the bowels, and, in short, by what- ever has a tendency to derange the general health, or to depress the vital powers. If oc- casionally slight amelioration occurs in the patient’s condition, it is always very transient, lasting seldom more than a few hours, or, at most, a few days. During this period the hearing is not only improved, but there is a considerable diminution of sound, and illusive hopes are entertained of speedy recovery. Presently, however, the symptoms recur in all their former intensity, and the disease goes on rapidly from bad to worse until the deaf- ness is complete. There are cases of this affection in which there is an entire abscence of noise. They generally come on very suddenly, in consequence often of some disorder of the brain, and are of the most hopeless character as it respects recovery. It is probable that this variety of the disease is due to paralysis of the auditory nerve. There is a singular form of deafness, originally described by Meniere, in 1861, and CHAP. V. NERVOUS DEAFNESS. 263 hence called by his name, in which a person, previously in good health, is suddenly seized with vertigo, accompanied by nausea and vomiting, with noises in the ears, on recover- ing from which one of these organs is generally found to be perfectly insensible to sound. Inspection of the tympanum reveals no disease in that structure, and the probability, therefore, is that the affection depends upon disorder of the labyrinth or of the base of the brain, or of both, attended with cerebral congestion, or, what is more probable, a slight effu- sion of blood. The deafness is incurable. The most successfuTtreatment for the relief of the vertigo is the liberal use of quinine, preceded by an active purgative. In obstinate cases iodide of potassium and mercury would be worthy of trial. Nervous deafness is seldom attended with any pain in the ear or in the surrounding parts. The patient, in addition to the noises already described, often complains of a sense of fulness in the organ, or a feeling as if the auditory canal had been stopped up with water; but, as to actual pain, he does not experience any, except occasionally as an inter- current and adventitious cii’cumstance. The general health is variable. In many cases it is impaired, perhaps very materially, at the moment of the attack ; but in some it is, apparently, as perfect and vigorous as it ever was. Some of the very worst examples of nervous deafness that I have ever witnessed occurred in persons of this description. The period which intervenes between the commencement of the first symptoms and the occur- rence of complete deafness varies from a few weeks to a number of years. Occasionally the individual is able to hear more or less all his life, especially if he uses an ear-trumpet. The ear, in nervous deafness, often retains its normal appearance most perfectly. The secretion of cerumen proceeds as before, and there is not the slightest evidence of disease in the membrane of the tympanum. Sometimes, however, there is a total absence of wax, and then the drum is not only unusually dry, but more or less opaque. Nervous deafness may be due to an affection of the auditory nerve, as it probably is in the unchangeable forms, or to a disease in the trophic nerves of the tympanic cavities, as is probably the case in those forms of nervous deafness in which the functions of the ear seem stronger or weaker, as the health of the patient varies. In the latter case the deafness can hardly be supposed to depend materially on disease of the auditory nerve. Among the numerous remedies that have been recommended for the relief of nervous deafness, there is not one which is worthy of great reliance in a curative point of view. I have myself so seldom derived any benefit from them that I have long been induced to look upon the disease as being generally incurable. Whatever advantage results is usually of a transient character, due, in great measure, if not wholly, to the effects which the treatment exerts upon the condition of the general health rather than to any improvement in the ear itself. The misfortune is that, in most cases, the affection is entirely neglected in its earlier stages, at a time when medication might, perhaps, be of service. The pa- tient, thinking that it is a matter of little moment, or that it will gradually vanish of its own accord, feels little inclined to apply for advice, until it is generally too late to do him any good. When the disease supervenes suddenly, and in its more decided forms, I be- lieve that no remedies, however judiciously employed, will be of any avail. All experi- ence goes to show that such cases are generally hopeless. Under opposite circumstances, however, it is always proper to institute as rational a course of proceeding as our limited powers of observation will admit. Looking upon the disease as being commonly of an inflammatory origin, and, therefore, as likely to produce structural disorder, preceded usually by functional derangement in the Eustachian tube and middle ear, it will generally be found that more or less catarrh of the former has impeded the natural ventilation of the tube and the tympanic cavity, and that this suspension of function in the sound-conduct- ing apparatus, can be overcome somewhat, at least, by the use of Politzer’s method of in- flation, or the catheterization of the Eustachian tube, air alone being used. If this method of treatment improve the hearing a little at the first examination by the surgeon, he may be encouraged to go on combating the naso-pharyngeal catarrh, or catarrh of the Eustachian tube, and inflating the tympanum every few days, for some weeks. When a point is reached where improvement in hearing is no longer detected, all further treatment is useless and should, of course, be suspended. If, on the other hand, there is evidence of general debility, as happens in the majority of such cases, the local treatment must be combined with tonics, as iron and quinine, a nutritious diet, the shower-bath, and daily exercise in the open air, with saline ablutions and dry frictions. When the structural lesion is fully established, no benefit need be anticipated from any treatment. In regard to direct applications of fluids or vapors, it is impossible to observe too much caution. When there is opacity of the membrane of the tympanum, the affected surface may be gently touched, once a day, with a little dilute mercurial ointment, or a solution of 264 DISEASES AND INJURIES OF THE EAR. chap. v. nitrate of silver, in tlie proportion of five to ten grains of the salt to the ounce of water. Another appropriate remedy is glycerine with a small quantity of strychnia and cam- phor or a few drops of acetic acid. Whatever substance be employed, care must be taken that it acts merely as a sorbef’acient, and not as an irritant; otherwise serious mis- chief may ensue. The treatment of nervous deafness by the introduction of the vapor of nitrous ether into the cavity of the tympanum, through the Eustachian tube, is now rarely,if ever, em- ployed, notwithstanding the high encomiums that were formerly lavished upon it. From personal experience with the remedy I was led, long ago, to regard it as one of the delu- sions of surgical practice; a conclusion fully verified by the later observations of others. Of faradization and galvanization, as means of relieving nervous deafness, nothing need be said here, as experience has shown that they are of no benefit. SECT. VII DEAFNESS FROM DISEASE OF TIIE TYMPANUM AND OTHER CAUSES. Besides this form of ear-disease, now described, there are others, some of which are transient and curable, others permanent and irremediable. In order to appreciate their character, it will be necessary briefly to inquire into their causes. These will be found to be both numerous and diversified. 1. Destruction of the membrane of the tympanum, whether occasioned by ulceration, a wound, or the contact of an acid or an alkali, must necessarily give rise to deafness. In- juries of the skull and brain are often followed by loss of hearing, sometimes partial, at other times complete. The effect is most liable to supervene upon injuries of the base . of the cranium, especially such as are attended with fractures of the petrous portion of the temporal bone and laceration of the meninges of the brain; but it may also take place when the lesion is seated upon the side and top of the skull, and when it is apparently of a more trivial character. A severe box upon the ear or temple is known to have caused permanent deafness, either by rupture of the membrane of the tympanum, or by con- cussion of the auditory nerve in the labyrinth. 2. Mere concussion of the membrane of the tympanum sometimes produces temporary deafness. Cases have come under my notice where it was caused by the discharge of a cannon, a gun, or even a pistol. Artillerymen are occasionally, in an instant, deprived of the faculty of hearing during the progress of a battle, or the tiring of a salute, from the sudden and violent agitation of the air. Under such circumstances, indeed, it is not uncommon to observe a considerable how of blood from the ear. 3. Caries and necrosis of the temporal bone are a frequent source of deafness. The same effect may be induced by the pressure of a tumor upon the nerve of the ear, the long retention of hardened wax, the pressure of a foreign body upon the membrane of the tympanum, the deposit of lymph or tubercular matter in the middle cavity of the ear, and occlusion of the Eustachian tube. 4. Violent sneezing and coughing have been known to produce temporary deafness. Of the possibility of such an occurrence there can be no question, as a number of well- authenticated cases of it are upon record. Forcible inflation of the Eustachian tube may lead to a similar result, the immediate cause in all these instances being not merely the rupture of the membrane of the tympanum but concussion of the terminal filament of the auditory nerve. 5. Another cause of deafness is frequent washing of the head in cold water, cutting off the hair very close in cold weather, or exposing the head, especially when the body is overheated, to currents of cold air. A chronic aural catarrh is thus induced. 6. The inordinate use of quinine has occasionally been followed by complete and irre- mediable deafness in a few hours. Of this occurrence numerous cases were formerly observed among the inhabitants of our Southern States, where this article was for a long time given in enormous doses. 7. Deafness may be produced by worms in the alimentary canal, the repulsion of cuta- neous disease, and the suppression of habitual discharges. Lauzani mentions the case of a woman who suffered from deafness during four successive pregnancies. Such attacks may be considered as reflex neuroses. 8. Loss of hearing may be occasioned by effusions at the base of the brain, whether the result of external injury, tuberculosis, or common inflammation, leading to compression of the cerebral tissues, or, directly, of the auditory nerve itself. 9. Deafness may depend upon malformation or disease of the internal ear. Cases occur in which there is no trace whatever of the vestibule, cochlea, and semicircular 265 CHAP. V. canals. Occasionally the labyrinth is composed of a single cavity, shut off entirely from the tympanum, as in the crustaeeous animals. Finally, the internal ear is sometimes occupied by scrofulous matter, serum, fibrin, or a substance resembling chalk. 10. The cause of deafness may reside in the cavity of the tympanum, which may be filled up with various kinds of materials, as mucus, lymph, pus, and blood, interfering with the transmission of sound. A substance resembling tubercle, and consisting of granules, epithelium, and oil globules, has been found in this portion of the ear, the occurrence be- ing most common in young subjects of a scrofulous predisposition. Finally, the cavity of the tympanum may be absent; or there may be an imperfect development of the small bones of the ear. 11. Deafness is sometimes, perhaps not unfrequently, produced by abnormal tension of the drum of the ear dependent upon the inordinate contraction of its tensor muscle. When this is the case, the lesion is almost invariably associated with various distressing noises in the ears, and also, in many cases, with giddiness and other unpleasant head symptoms. 12. Necrosis of the bony structures of the internal ear is necessarily followed by com- plete destruction of the function of audition. In the case from which the annexed cut, fig. 200, was copied, the necrosis involved the whole of the cochlea, vestibule, and semicircular canals, and gave rise to the most violent inflammation of the brain, with paralysis of the face, arm, and leg, and total deafness on one side. 13. There may be lesion of the auditory nerve, consisting either in imperfect development, interstitial deposits, induration, softening, paralysis, or compression by osseous and other matter. Deafness, seated in the nervous structures of the ear, is not very uncommon in hereditary syphilis. 14. Deafness may be occasioned by lesion of the mastoid process, the cells of which are lined by a reflection of the mucous membrane of the middle ear, and which are, there- fore, liable to the same kind of diseases. Inflammation, whether traumatic or idiopathic, may lead to various changes in the supplemental portion of the ear, all more or less pre- judicial to audition. It is also liable to malformations, obliteration, and scrofulous deposits. Diseases of the mastoid cells will be further considered in the succeeding section. 15. Deafness, partial or complete, may be caused by enlargement of the tonsils, by polyps of the nose, and by various affections of the fauces, leading to obstruction of the Eustachian tube, and to changes of structure in the middle ear. Cases have come under my observation in which inflammation, caused by a common cold, spread along the Eus- tachian tube from the Schneiderian membrane, without any participation of the lining membrane of the throat in the morbid action. 16. Finally, the cause of ear disease and deafness may reside in diseased teeth, gums, or jaws; a fact which has been placed in a very strong light by Dr. Samuel Sexton, of New York, in an exhaustive paper upon the subject in the American Journal of the Medi- cal Sciences for January, 1880. It is not necessary to enter into any formal account respecting the treatment of these various kinds of deafness. Their chief interest consists in their diversity, and the conse- quent necessity of inquiry into their character before an attempt at their removal is made by the use of remedies. Some of them, from their very nature, are incurable; others, for the same reason, hold out a prospect of relief by judicious treatment; and a few will disappear spontaneously, or simply by the operation of time. When the deafness depends upon the loss of the drum-membrane, the hearing may often be greatly improved by an artificial substitute, consisting of a little pellet of cot- ton-wool, either dry or moistened with glycerine, and inserted into the ear, in contact with the aperture at its bottom. Dr. C. II. llurnett has shown that the only useful kind of artificial drumhead is the cotton pellet of Yearsley. Other forms have been devised, and apparently have been of some service, although only in a very limited degree. Yearsley justly claimed for moistened cotton-wool, rolled into a moderately firm pellet, superiority over all other contrivances, because it is most easily applied, is simple, soft, and clean, retains its position longer, and causes no irritation, but, on the contrary, a feeling of support and comfort. It produces no noises in the ear during eating or talking, and, by protecting the drum cavity, tends to cure any slight discharge that may be present. The best results with the cotton pellet, as a restorer of the hearing, will be found in cases unattended with secretion. The latter must, therefore, always be checked before any useful trials can be made with this substance, inasmuch as this would be washed from DEAFNESS FROM DISEASE OF THE TYMPANUM. Fig. 200. Necrosis of the Inter- nal Ear. 266 its position over the perforation in the drum membrane by the outflowing matter from the cavity of the middle ear. It should be added that the application, removal, and renewal of the cotton pellet should be done only by a skilled surgeon, under perfect illumination of the auditory canal and membrane of the tympanum, by means of the forehead mirror. Being conveyed into position by slender forceps, very gentle pressure with a delicate probe will usually produce an improvement in hearing; if not, a very slight movement of the pellet, generally upwards and backwards, towards the incus-stapes joint, where the arti- ficial support is most needed, will often effect a very remarkable increase in audition. Dr. Burnett finds that, so far as his experience goes, nothing but the cotton pellet, as an artificial drum-membrane, ever produces any good, unless the paper-disc drumhead of Blake be excepted. All forms containing wire, hard rubber, and other material, while not rendering any aid to hearing, are absolutely injurious and dangerous, as tending to excite inflammation. In no case are artificial drums to be entrusted to patients for in- sertion. SECT. VIII AFFECTIONS OF THE MASTOII) CELLS. Disease of the mastoid cells occurs chiefly in young strumous subjects, from attacks of cold, measles, scarlatina, and smallpox ; but it may arise at any age as the result of an extension either of acute or chronic purulent inflammation from the tympanic cavity. Manifesting itself originally as an inflammation of the lining membrane, it may, in its progress, gradually extend to the osseous structures, on the one hand, causing caries, and even necrosis; and, on the other, to the brain and its envelops, eventuating in abscess of the former, and in thickening and effusions of the latter. In the milder varieties of the disease, which is much oftener chronic than acute, there is, generally, simply an opaque, thickening, and vascular state of the lining membrane, with an abnormal secre- tion of mucus, to which, when the inflammation is more severe, is frequently superadded a deposit of pus. In the latter case, especially when the matter does not find a ready out- let through the wall of the auditory canal or the tympanic membrane, suppuration is liable to occur in the lateral sinus, in the brain, and in the arachnoid and pia mater, the morbid action being propagated along the veins of the mastoid cells. In children, before the third year, the cerebrum is most prone to suffer from abscess from this cause, owing to the imperfectly developed condition of these cells, and their close proximity to this por- tion of the cerebral hemisphere ; but, at a later period, when these cavities are more fully formed, the mischief is generally seated in the cerebellum and its more immediate invest- ments. When the mastoid process becomes involved, the disease, which may ultimately extend to the petrous portion, if not, at times, also to the squa- mous, may manifest itself simply as caries, or as caries and ne- crosis, according to the nature and violence of the morbid action. In the adjoining cut, fig. 201, from Wilde, the whole of the mastoid process, together with a large piece of the petrous por- tion of the temporal bone, the posterior wall of the middle ear, and one of the semicircular canals, was removed from a child three years old. The matter which forms in disease of the mastoid cells, whether it be limited to these cells, or found also in the lateral sinus, cerebrum, cerebellum, pia mater, or arachnoid membrane, is either of the nature of ordinary pus, or, as most frequently happens, is strictly of a strumous character, and often very offensive. In the lateral sinus it is frequently associated with clotted blood. Collections of pus in the mastoid cells either destroy life by cerebral irritation, or by the induction of inflammation and abscess in the brain and its envelops ; or, if the patient survive, they may find a partial vent, by ulcerative action, through the auditory canal or tympanic membrane. More rarely, the fluid is discharged externally along an opening in the mastoid process. Death occasionally occurs, in this disease, from pyemia, as in the interesting cases related by Abercrombie, Watson, Wilde, Bruce, and others. The symptoms, treatment, and pathology of the affections of the mastoid cells have been most ably and thoroughly discussed during the last ten years by Dr. Sehwartze, of Halle, by Dr. A. II. Buck, of New York, and Dr. J. Orne Green, of Boston, while numerous papers of great value have been written on the subject by other aurists. The symptoms of inflammation of the mastoid cells are not always characteristic, as DISEASES AND INJURIES OF THE EAR. chap. v. Fig. 201. Necrosis of the Mastoid Pro- cess aod Petrous Portion of the Temporal Bone. CHAP. V. OTALGIA. 267 the disease is liable to be confounded with inflammation of the middle ear and of the auditory canal. In general, it will be found that the patient has been laboring for some time past under otalgia, and aural discharge, probably consequent upon some eruptive fever, and that he bears the marks of dilapidated health, a syphilitic taint, or strumous disease. The pain, which is often excessive, is referred to the mastoid process or occipital region, both of which are extremely tender on pressure ; the individual is feverish, thirsty, and restless ; there are buzzing noises in the ear; the head is dizzy and aches violently; and delirium usually sets in at an early stage, always followed, when matter forms, by rigors and coma, if not also by convulsions, especially if there be grave cerebral involve- ment. Signs of suppuration frequently appear in the auditory canal, even when the pus of the mastoid cells makes no effort to escape by that route or by the drum of the ear, both of which, however, invariably show signs of inflammation at an early period of the attack, the former being red and swollen, the latter injected and opaque. The treatment of inflammation of these cavities must be strictly antiphlogistic. Leeches with anodyne fomentations, light diet, irritating purgatives, and antimonial and saline pre- parations, together with morphia to assuage suffering and promote sleep, are the most reli- able remedies. Great relief always follows early and free incisions over the tender and inflamed surface, the knife being made to grate upon the bone. In chronic cases marked by a strumous taint, an issue in the nape of the neck, and the judicious use of quinine and iodide of iron, will be likely to prove beneficial. A gentle course of mercury, espe- cially in the form of the bichloride, should be tried when the disease is unusually obsti- nate. When the brain is endangered by an extension of the morbid action, the tympanic should be freely punctured, and the mastoid process promptly opened, to afford vent to the pent-up fluid, which is generally the direct cause of the cerebi’al mischief and of the carious or necrosed condition of the bone. Perforation of the mastoid process, originally suggested by Riolanus, in the seventeenth century, and first practised by Petit, in the eighteenth, may readily be performed with a common bone-perforator, a chisel and hammer, or a very small trephine, similar to that used in opening the maxillary sinus. A small aperture is generally quite sufficient to afford the necessary drainage and the introduction of the syringe for washing out the mastoid cells and middle ear, the fluid used for this purpose being tepid water with the addition of a few drops of chlorinated sodium, or a minute quantity of permanganate of potassium. The opening, when the operator has his choice, is usually made in a diseased portion of bone, or at the site of a fistulous orifice, the mere enlargement of which is sometimes quite sufficient. It should be remembered that there are no mastoid cells in early childhood. SECT. IX OTALGIA. Pain in the ear, otalgia, or earache, is of very frequent occurrence, especially in chil- dren and young persons, and may arise from a great variety of causes, as exposure to cold, inflammation of the membrane of the tympanum or of the auditory tube, gout and rheu- matism, disorder of the digestive organs, and affections of the teeth. Sometimes it is of a purely nervous or neuralgic character, coming and going in regular paroxysms, like neuralgic pain in other parts of the body. Children, especially such as are of a delicate constitution, are very subject to severe attacks of earache from exposure to cold. The suffering usually comes on in the evening, and is generally aggravated by recumbency, so that the patient is obliged to get up and walk the room, or, if lie is a child, has to be sup- ported in his nurse’s arms. Earache, often of a very distressing character, is a common attendant upon measles and scarlatina; and, under such circumstances, as well as in many others, the probability is that it is merely a symptom of ordinary inflammation of some of the structures of the ear. What corroborates this view is the fact that the mem- brane of the tympanum and auditory tube usually afford evidence of the morbid action, the former being red and injected, while the latter is exquisitely tender, and the seat of an inordinate secretion of cerumen. Neuralgia of the ear is most common in childhood, although it may occur at any period of life, and under circumstances apparently the most opposite. Its causes are various, being sometimes purely local, at other times constitutional, while in a third series of cases they are of a mixed character. During my residence in Kentucky, where neu- ralgia in all its forms is exceedingly common, I met with cases of this affection, which were unquestionably of a miasmatic origin. The paroxysms observed the same regularity as those of intermittent fever, recurring once in twenty-four hours, or once every other day, lasting for some time, and then gradually disappearing ; being generally preceded by DISEASES AND INJURIES OF THE EAR. chap. v. chilly sensations, or even by a severe rigor, followed by a copious sweat, and promptly relieved by the ordinary antiperiodic remedies. In the treatment of otalgia it is a matter of primary importance to obtain, if possible, a clear idea of the nature of the exciting cause, as upon a knowledge of this must depend the choice of our remedies. If the teeth be at fault, they must be extracted, or, at all events, put in order, before the subsidence of the local distress can reasonably be hoped for. When the attack has been provoked by exposure to cold, the most efficient remedies are hot foot-baths and Dover’s powder, along with hot drinks and warm applications to the ear. From three to twelve drops of laudanum either alone or with an equal number of drops of tincture of- the root of aconite, according to the age of the patient, should be introduced, tepid, into the affected organ, where it should be retained by means of raw cotton and a proper position of the head. When the distress is very violent, and the ordi- nary means fail, leeches should be applied behind the ear, and the bowels opened by a brisk cathartic, followed by an efficient anodyne diaphoretic. In the neuralgic form of the disease, the best remedy is quinine, either alone or in union with strychnia, arsenious acid, and morphia. Colchicum will be of service when the affection is dependent upon gout or rheumatism. SECT. X NOISES IN THE EARS. Among the more distressing affections of the ear are the various kinds of noises which so frequently accompany nervous deafness and other morbid states of this organ and its associated structures. These noises are so common in all classes and conditions of per- sons as to have always attracted special attention. The older writers described them under the expressive name of “tinnitus,” literally signifying a ringing or tinkling sound. In regard to the character of the sounds, nothing could be more strange and diversified. Thus, in one case, they resemble the ticking of a watch ; in another, the ringing of a bell; in a third, the buzzing of an insect; in a fourth, the chirping of a bird. Sometimes they are like the rustling of the wind among leaves, the pattering of rain, the roaring of a water fall, the motion of a saw-mill, the boiling of a tea-kettle, or the whistling of a steam-engine. Cases are met with in which they are of an explosive character, similar to the report of a pistol. Occasionally, again, they resemble the noise produced in filing. A throbbing, beating, or pulsatile sound synchronous with the contraction of the left ven- tricle of the heart, is sometimes noticed. In a case recorded by Roger, the noise was distinguished by auscultation, and readily arrested by pressure applied to the mastoid branch of the posterior auricular artery. Roth ears may be affected simultaneously or successively, or one may suffer, and the other be free. In general, the abnormal sounds, whatever their nature may be, are confined to the ears, but sometimes they extend over the whole head, causing the most disagreeable and distressing feeling. Fatigue, loss of sleep, exposure to cold, damp states of the atmosphere, and the depressing passions, have the effect of increasing them, and of aggravating the patient’s suffering, often inducing fits of the most dreadful despondency. Position also influences their intensity. Thus, they are often worse during recumbency than in sitting or standing, and conversely. Some persons suffer most at night, when the head lies on the pillow, and others when they are in an overheated room. Finally, they may be temporary or permanent, very slight or exceedingly annoying, according to the character of the exciting cause. The noises attendant upon confirmed nervous deafness generally continue, with, perhaps, an occasional transient improvement, during the remainder of life. The causes of these various sounds are not always appreciable. Indeed, in many cases, the closest scrutiny fails to detect their real nature, or the influences under which they are developed. From the fact that they so commonly attend nervous deafness, it has gene- rally been supposed that they are mainly, if not entirely, due to disease of the auditory nerve; but that they may also exist independently of such lesion is equally true. Most distressing buzzing, tinkling, or ringing usually accompanies obstruction of the meatus from the retention of indurated wax ; inflammation of the ear is invariably characterized by various abnormal sounds ; and similar effects are always produced by mechanical oc- clusion of the Eustachian tube, whether the result of thickening of its lining membrane, or of the presence of mucus, lymph, or blood. In a remarkable case, referred to in a pre- vious page, the most distressing noise in the ear was found, upon dissection, to have been occasioned by the lodgment of a small grain of barley in the faucial extremity of this tube. Very annoying tinnitus always accompanies inflammation, thickening, ulceration, and rupture of the tympanic membrane. Certain affections of the middle ear are occasionally CHAP. VI. DISEASES AND INJURIES OF FRONTAL SINUS. 269 accompanied by peculiar snapping noises, dependent, it is supposed, upon spasm of the palatal muscles, causing sudden expansion of the mouth of the Eustachian tube by draw- ing away the anterior wall from the posterior. Various disorders of the system, as anemia, dyspepsia, constipation of the bowels, and diseases of the brain, may give rise to abnormal sounds in the ears. The ringing noises of the ears in typhoid fever have long been familiar to the physician. The treatment of tinnitus is altogether empirical. The great point to be borne in mind is that the noise is merely a symptom, not a disease. Hence, the first step, in every case, is to ascertain, if possible, the nature of the exciting cause, and the second to remove it. Inflammation is combated, the inspissated wax or foreign body extracted, the catarrh relieved, the Eustachian tube cleaned out, and the general health, if at fault, amended. To lay down any other rules would be absurd. The distressing noises which so commonly accompany nervous deafness are usually utterly irremediable. Dr. Michael, of Hamburg, has reported a number of cases in which he derived marked benefit in the treatment of tinnitus dependent upon hypertrophy of the middle ear, and upon diseases of the labyrinth, from the inhalation of from one to five drops of nitrite of amyl. CHAPTER VI. DISEASES AND INJURIES OF THE FRONTAL SINUS. The affections of this cavity may be said to resemble, in their general characteristics, those of the maxillary sinus and of the nose. The most important are inflammation, abscess, fractures, foreign bodies, polyps, hydatids, and sarcoma ; but, owing to their great infrequency, their diagnosis is generally very difficult, and their treatment unsatisfactory. 1. Inflammation of the frontal sinus may be provoked by external injury, as a fall, or blow on the forehead ; but, in general, it is caused by the effects of tertiary syphilis, or by an extension of disease from the nose, by continuity of structure through the Schneiderian membrane. However induced, it is characterized by a sense of weight and fulness, and by a dull, heavy, aching pain along the eyebrow, accompanied, in most cases, by sneezing and a discharge of watery mucus from the nose, with lachrymation and suffusion of the eye, more or less cephalalgia, and other evidences of indisposition, such as attend the more severe forms of coryza. An unusual amount of mucus is no doubt poured out into the sinus, and, when the inflammation is at all severe, this, acting obstructingly, or not finding a ready outlet, may seriously aggravate the patient’s suffering. The treatment must be by leeching over the affected sinus, active purgation, and dia- phoretics ; aided, as the morbid action declines, by sternutatories, with a view to their revulsive effect upon the mucous membrane of the nose. 2. When the inflammation passes into abscess, the occurrence will be denoted by an increase of the local suffering, the pain assuming a throbbing, tensive, pulsatile character, and by excessive headache, delirium, and rigors, followed by high febrile disturbance. The forehead and eyebrow are swollen and tender, and, if the matter does not soon find an outlet, an erysipelatous blush will appear upon the surface, an almost unerring sign of the nature of the disease. If the case is misunderstood, or improperly treated, the morbid action may extend to the brain, or cause caries or necrosis of the walls of the sinus, as occasionally happens when the abscess is the result of tertiary syphilis. The pus may find an outlet through the nose, or through the anterior wall of the sinus, although such an event must necessarily be extremely uncommon. Occasionally, as when the quantity is unusually great, it passes into the other sinus, by breaking down the inter- vening septum. When it flows off by the nose, the patient is apprised of the fact by the use of his handkerchief. The treatment must be conducted according to the ordinary principles of practice. If the case is urgent, as indicated by the cerebral disturbance and the erysipelatous condi- tion of the forehead and eyebrow, the soft structures should be freely divided and a small 270 DISEASES ANI) INJURIES OF FRONTAL SINUS. CIIAP. VI. opening made, by means of a suitable trephine, into the most dependent part of the sinus, which may afterwards, if necessary, be injected with anodyne and detergent lotions to promote the cure. 3. Fractures of the walls of this cavity are uncommon. They may be caused by falls, blows, kicks, or gunshot injury, and may, therefore, be either simple, compound, or com- minuted. A curious phenomenon, occasionally witnessed in these accidents, is an em- physematous condition of the scalp, face, and eyelids, produced by an escape of air from the nose into the surrounding connective tissue. The injury, whatever may be its character, must be treated upon the same general principles as fractures in other parts of the skull. When the outer table is depressed, so as to occasion serious disfigurement, elevation must be attempted, either with the lever alone, or with this instrument and the trephine. Loose splinters and any foreign matter that may be present should, of course, be promptly and thoroughly removed. 4. The frontal sinus is occasionally the receptacle o\i foreign bodies, either formed within, or introduced from without; more generally the latter. Thus, Bartholin speaks of having met with earthy concretions, similar to those which are sometimes found in the nose. Several instances have been recorded in which the frontal sinus contained worms, doubtless derived from larvas originally deposited in the nasal cavity; and a few years ago a case occurred in Maryland in which a child, six or seven years of age, lost her life from the irritation caused by the development in this cavity of an immense number of spiders, the parent of which had been inhaled when the child was smelling a flow'er. The annals of surgery supply us with a number of examples of the lodgment of balls in this cavity in cases of gunshot wounds; and there are also several instances on record where the end of a knife-blade or scissors, broken off in its passage through the skull, was arrested in it. A case has been recorded by Mr. Fell, in which the iron bolt of a gun-barrel, burst in the act of being discharged, was so deeply imbedded in the frontal sinus that its presence re- mained undetected for many days; it was finally extracted, and a good recovery followed. The presence of a foreign body in this situation must necessarily be productive of pain, a sense of weight and fulness, and, probably, also, more or less tumefaction in the fore- head and eyebrow. No diagnostic value can, however, be attached to these symptoms. When the foreign body has been introduced from without, the nature of the case may easily be determined simply by its history. The proper remedy in these cases is, of course, extraction, a suitable opening being made into the anterior wall of the sinus by means of a trephine. The after-effects of a wound of the frontal sinus are sometimes troublesome. In a case reported by Dupuytren, the integument, after the cicatrization of the parts, was always elevated, when the patient blew his nose, into a little swelling near the temple, which gradually subsided again. It was, doubtless, owing to the passage of the air through an opening in the wall of the sinus, and was cured in a fortnight by compression with a small pad. 5. Poy/ps, of a gelatinous or fibrous structure, are sometimes developed in the frontal sinus, or extend into it from the nose, forcing apart its walls, and causing more or less pain and deformity, but affording no pathognomonic signs. In time, the overlying bone becomes softened and attenuated by the pressure of the tumor, crackling under the finger like parchment. Viallet and Rouger met with a case in which a polyp of the frontal sinus was associated with an exostosis of this cavity; and several instances have been recorded in which a tumor of this kind coexisted with a similar formation in the nose and maxil- lary sinus. Removal is effected with the knife and gouge, or knife and trephine, a crucial incision being made through the integument of the forehead so as to admit the surgeon’s finger and instruments. 0. Osseous tumors of the frontal sinus are occasionally met with, being most common between the twelfth and eighteenth years. They increase very slowly, and, as a rule, without pain, and evince a tendency to break through the anterior and orbital walls of the cavity. When they protude into the orbit they displace the eye forwards, downwards, and slightly outwards, and are liable to occasion inflammation of the different structures of that organ. In about one case in every four they also set up suppuration of the mucous lining of the sinus. Surgical intervention is attended with the risk of exciting purulent meningitis and abscess of the brain, as seven of the thirteen cases analyzed by Bornlmupt, of St. Petersburg, died from those lesions. 7. Langenbeck and Brunn have each recorded the particulars of a case of what they called hydatids of this sinus, but which, I suppose, were really only serous cysts. The tumor, during the progress of its developement, encroaches upon the forehead and roof of 271 CHAP. VII. AFFECTIONS OF THE NOSE. the orbit, pushing the eye forwards and downwards, and thus occasioning serious deformity. The diagnosis must necessarily be obscure. As the disease advances, however, the ante- rior wall of the sinus is rendered so thin as to yield under the pressure of the finger, and admit of the detection of fluctuation. In doubtful cases, important information might be elicited by the exploring needle. The proper remedy is excision. Robert Keate, in 1819, published, in the tenth volume of the London Medico-Chirur- gical Transactions, the particulars of a case of so-called hydatids of the frontal bone, in a girl eighteen years old, but the tumor seems to have been developed in the areolar tex- ture, and not in the sinus, which, however, became accidentally involved during the pro- gress of the disease. 8. Sarcoma of the frontal sinus is probably more common than is generally imagined, although I have myself seen only one case. The patient, a gentleman, upwards of sixty years of age, had been seized, twelve months previously, without any assignable cause, with what he supposed to be an attack of erysipelas of the forehead and face. On re- covering, he noticed an unusual fulness over the left eyebrow, attended with great hard- ness and excessive pain. The lids continued to swell, the left nostril, by degrees, became obstructed, and the seat of a thin, sanious discharge, more or less profuse, and, at times, quite fetid. At length several openings formed upon the most prominent part of the tumor, giving vent to thick, yellowish pus, and readily admitting of the passage of a probe into the nose. Upon enlarging these openings, the sinus was found to be occupied by a soft, fungous mass, the overlying bone being softened and disintegrated. The morbid growth presented all the characteristics, physically and microscopically, of round-celled sarcoma. The patient passed out of my hands in a few weeks, and died soon after com- pletely exhausted. CHAPTER VII. INJURIES AND DISEASES OF THE NOSE AND ITS CAVITIES. SECT. I AFFECTIONS OF TIIE NOSE. The nose is subject to certain congenital malformations, various kinds of injuries and diseases, as wounds, boils, syphilitic ulceration, morbid growths, hypertrophy, and various accidental deformities, some of which demand the interference of rhinoplasty for their relief. Fractures of the proper bones of the nose are described in volume first. 1. Congenital defects.—Congenital malformations of the nose are found in great variety, many as an effect of national peculiarities, and others as accompaniments of cyclocepha- lian monstrosities, so well described and delineated by Yrolik. Thus, the organ may exist simply in the form of a nozzle, ora knob,which is little more than a prolongation of the cutaneous tissue ; in other cases again there may be an imperfectly developed osseous nucleus with more or less defective soft structure. Deviation of the nose to one side is not uncommon; the bridge is often depressed in an unseemly manner, and the tip is sometimes turned up so as to give rise to a veritable deformity. In hare- lip and cleft of the hard palate, especially in the more aggravated forms, the shape, of the nostrils is always more or less seriously altered. A bifid nose is occa- sionally met with, as is shown in fig. 202, taken from a female child, six months old, a patient recently under my charge, in every other respect well formed. The organ, in its appearance, resembles that of a double bar- rel gun, the tubes being separated by a well-marked groove, the upper and middle portions of which were occupied by a cutaneous excrescence, resembling some- Fig. 202. Bifid Nose. 272 INJURIES AND DISEASES OF THE NOSE. CHAP. VII. what the comb of a young cock, except that it is not discolored. The nose is of extraordi- nary width ; the nostrils are of a circular shape and unobstructed, the breathing being perfectly natural; the eyes are set widely apart and are uncommonly small. In another case I found a rudimentary third naris on the right side in a child, three years of age, greatly distorted immediately below the proper nasal bone, with a small opening, from which there was nearly a constant discharge of mucus. Congenital occlusion of the nostrils is an occasional occurrence, but is much less fre- quent than that of the ear, anus, urethra, or vagina. The obstruction may be due simply to a continuation or extension of the common integument, or it may be caused, as is more generally the case, by skin and fibrous tissue. Some of these defects admit of relief, but the great majority are irremediable. To lay down any positive rules for the guidance of the surgeon in such cases would be impossible. In congenital occlusion, dependent upon an extension of the common integument, relief is sought by a cautious incision, and the subsequent use of the bougie to counteract the tendency to contract, which in such a condition is always great; when the obstruction is caused by skin and fibrous tissue, nothing short of excision will be of any service, and not much benefit will be likely to accrue even from that, if the material extend to any considerable distance into the nostril. 2. Wounds—Wounds of the nose, whether incised or lacerated, demand the nicest adaptation of their edges, and the most careful maintenance by wire sutures, introduced with a properly curved needle. Adhesive strips may be necessary to aid the approxima- tion. Any tendency of the parts to fall in towards the nose should be counteracted by filling the nostril with a roll of lint; few cases, however, will require such interference. 3. Furuncular Inflammation The nose, especially its tip, is liable to a form of boil, which, from the severity of the attendant pain and disfigurement, deserves special atten- tion. I have seen it most frequently in young and middle-aged subjects, of intemperate habits, but it is also met with in the old, particularly in huge feeders and in persons who neglect their bowels and take but little exercise in the open air. It begins either in the subcutaneous connective tissue or beneath the perichondrium, from which it gradually ex- tends to the skin and fibro-cartilage, and is characterized by violent, throbbing pain, a sense of excessive tension, great swelling, and a dusky, brownish, or livid appearance of the surface. In the more severe grades of the disease, the pain extends over the entire face, as high up as the forehead and temples, and there is more or less febrile disturbance with loss of appetite and sleep. Suppuration gradually sets in, and the matter finally dis- charges itself either through the skin or through the nose, not, however, without great aggravation of suffering owing to the peculiar firmness of the overlying structures. The dis- ease, which generally depends upon some constitutional cause, rarely, if ever, aborts, even with the aid of leeches, iodine, and active purgation. To allay suffering and prevent the occurrence of an unseemly scar, the best plan is to make an early puncture with a narrow-bladed tenotome, passed from the septum upwards in close contact with the ala of the nose. 4. Syphilitic Ulceration Syphilitic ulcers of the nose, commencing in the skin or mucous membrane, and gradually extending to the fibro-cartilaginous case, are sufficiently common, as a tertiary effect. They are generally associated with signs of syphilis in other parts of the body, and are liable, if neglected or improperly treated, to terminate in horrible deformity of the features. The most reliable diagnostic phenomena are, the his- tory of the case, the multiple character of the sores, the rapid progress of the disease, and the inflamed and indurated condition of the surrounding surface. The accompanying pain, usually very slight, is liable to nocturnal exacerbations. The most appropriate measures are the iodides, with bichloride of mercury, and dilute acid nitrate of mercury, until the ulcers begin to granulate, when the best dressing will be some mildly stimulat- ing ointment. 5. Epithelioma Carcinoma of the nose, chiefly of the epithelial character, occurs principally in elderly subjects, and, according to my experience, more frequently in women than in men. Arising either as a fissure, a tubercle, or a warty excrescence, it gradually proceeds from bad to worse, until at length an ulcer forms, the tendency of which is to spread in every direction, and to discharge a thin, ichorous, irritating fluid. The sore is indisposed to heal, and is the seat of more or less pain, smarting, burning, or itching. The disease often lasts for years, now stationary or slightly advancing, but sure in the end to commit serious ravages. Epithelioma of the nose should not be confounded with syphilis. The history of the case will generally, of itself, be sufficient to establish the diagnosis, superadded to the CHAP. VII. AFFECTIONS OF THE NOSE. 273 fact that the carcinomatous ulcer is nearly always single, while the syphilitic is commonly multiple. There is also, in the former affection, less discoloration in the adjacent surface. Fig. 203, affords a graphic illustration of an epithelial ulcer of the tip of the nose, in one of my patients, sixty years of age. It had commenced in a small wart-like excrescence two years previously, without any assignable cause, or apparent constitutional disorder. The treatment is the same as in epithelioma generally, the great remedy being early and free excision. 6. Discoloration A singular dis- coloration of the nose, known as rose acne, and vulgarly called the red nose, is sometimes observed, more especially in elderly subjects addicted to the pleasures of the bottle and of the table, although the young and temperate are by no means exempt from it. It is frequently, if indeed not generally, as- sociated with enlargement of the hair follicles and with hypertrophy of the skin, and appears to be essentially due to a habitually dilated and engorged condition of the capillary vessels, giving the part a somewhat tumid and livid, lilac, or purplish hue. Under pressure the blood slowly disappears, while un- der mental excitement the quantity naturally increases, and thus heightens the discoloration. The affection, which is usually confined to the tip and alae of the nose, is generally very obstinate, and, from its conspicuous character, a source of much annoyance. In the milder cases benefit may be derived from the use of Goulard’s extract, a weak solution of bichloride of mercury, dilute tincture of iodine, zinc ointment, and the occasional application of a few leeches. Depletion by puncture is sometimes serviceable. In the more intractable forms of the disease, I have found nothing so useful as extensive subcutaneous division of the affected vessels with a delicate tenotome. The drainage is copious ; the shrinkage rapid and decided. 7. Varicose Veins A varicose state of the veins of the nose is occasionally met with, chiefly in elderly subjects, in conjunction with a similar condition of the veins of the face. Their most common situation is the side of the nose. When very large and numerous, they impart a peculiar bluish, lilac, or livid appearance to the skin, which is, perhaps, at the same time, coarse, thick, and rugose, particularly in cases of long stand- ing, and in persons of intemperate habits. Occasional depletion of the engorged and dilated vessels by puncturing them with a bistoury will afford temporary relief. A per- manent cure is best effected by injections of subsulphate of iron, so as to produce a firm coagulum, upon the absorption of which the vessels gradually shrink to their normal size. It is not often, however, that any surgical interference will be necessary. 8. Ncevus Ntevus of the nose is generally, as in other regions, a congenital affection, of variable extent and shape, soft, compressible, expansible, and of a reddish, scarlet or purplish color, according to the predominance of the arterial or venous structure. Permitted to progress, it may, eventually, acquire a considerable size, and thus occa- sion serious disfigurement. The proper remedy is removal, either with the knife, or, what is commonly preferable, by strangulation with pins and ligatures. If Vienna paste be used, great care should be taken, lest its influence extend to the bones and cartilages. When the nmvus involves the nasal septum or the wings of the nose, the most suitable remedies are repeated injections of subsulphate of iron, the introduction of numerous ligatures, and the subcutaneous division of the abnormal structures with a delicate bis- toury. Ligation and excision will inevitably be followed by disfigurement. 9. Sebaceous Tumor The sebaceous tumor of the nose is uncommon ; it is of slow growth, and seldom attains any considerable bulk. The side and tip of the organ are equally liable to it. Its tardy development, small bulk, freedom from pain, and soft, com- Fig. 203. Epithelioma of the Tip of the Nose. 274 DISEASES AND INJURIES OF THE NOSE. CHAP. VII. preamble consistence are its chief diagnostic features. The proper remedy is extirpa- tion. 10. Lipomatous Tumor.—There is a curious affection of the nose—so curious gener- ally as to excite the risibility of the observer—to which the term lipoma is applied, from the fact that it essentially consists in an accumulation of the subcutaneous adi- pose substance, along with marked hyper- trophy of the integument. The drawing, fig. 204, borrowed from Liston, exhibits the disease in an extraordinary degree of development. The tumor has a lobulated appearance, or, more correctly speaking, it is composed of several distinct masses, having, seemingly, one common origin. The growth, which is always chronic and painless, is almost exclusively con- fined to elderly male subjects with a ruddy complexion and an active capillary circulation, addicted to the pleasures of the table and to alcoholic potations. 'The chief inconvenience which it pro- duces is of a mechanical character, ob- structing vision, compressing the nostrils, and interferin'; with eating and drink- ing. Occasionally the surface becomes very red and inflamed, and may, in time, even ulcerate. The sebaceous glands are sometimes much involved in the morbid action, being enlarged, obstructed, and transformed into distinct cysts. The only remedy for this disease, when it has attained any considerable development, is excision ; when small and of recent standing, removal may sometimes be effected by sorbefaeient applications, especially the tincture of iodine, a change of the patient’s habits, and the steady use of purgatives. When excision is determined upon, the sur- geon may expect to encounter a good deal of hemorrhage, owing to the enlargement of the cutaneous and other vessels, but this may usually be effectually controlled by liga- ture and compression. Care should be taken not to inflict any injury upon the cartilages of the nose, as the morbid mass is generally very firmly adherent to them. Sir William Blizzard met with an instance in which the patient died of hemorrhage after an operation for lipoma. 11. Fibrous Tumor.—The fibrous tumor, also of very rare occurrence, generally springs from the surface of the fibro-cartilage of the nose, lying immediately beneath the peri- chondrium, and exhibits the same structure as similar growths in other parts of the body. It is of a hard, compact consistence, unaccompanied by pain, change of color in the skin, or enlargement of the subcutaneous veins, seldom attains much bulk, and occasionally recurs after extirpation. 12. Hypertrophy of the Skin The skin of the tip of the nose is liable to hypertrophy, sometimes congenital, but more commonly acquired. The enlargement exists in various degrees, and may be so great as to occasion very unpleasant disfigurement. It is often associated with varicosity of the subcutaneous veins, and consists essentially in a thick- ened condition of the skin, without any material alteration of the other tissues. The only remedy is retrenchment of the affected structures. 13. Ndevoid Elephantiasis There is a variety of hypertrophy of the skin and connective tissue of the nose, in which these structures are not only greatly enlarged, but occupied by a cavernous material, interspersed with tortuous veins and arteries. In a case of this description, occurring in a female thirty-six years of age, a patient, at the College Clinic, in 1870, from whose nose I had removed a congenital naevus thirteen years previously, the organ was converted into a tumor, fig. 205, which measured seven inches in circumference, and four inches and a half in its vertical, by nearly six inches in its transverse, diameter. The skin, greatly thickened, nodulated, and inlaid with enlarged vessels, was so dense and firm as to grate under the knife. The connective tissue was of a hard, fibrous consistence, and highly vascular, while the cartilages, particularly the lower lateral, were involved in the general hypertrophy. Retrenchment was attended with troublesome Fig. 204. Lipoma of the Nose. CHAP. VII. AFFECTIONS OF THE NOSE. 275 hemorrhage, but the appearance of the nose was very greatly improved by the opera- tion. 14. Accidental Deformities Rhinoplasty.—The nose, from accident or disease, may be so impaired in its form and size as to require reconstruction by the aid of plastic sur- gery. The operation which is performed for this purpose is, accordingly, denominated rhinoplasty. The lesion for which, in civilized countries, interference is usually demanded, is constitutional syphilis, or the joint action of syphilis and mercury, which often destroys nearly every portion of the nose, except, per- haps, a small vestige of the bridge, causing thereby the most hideous deformity. The horror and distress of the case are greatly increased when the ravages extend to the frontal sinuses, the lachrymal passages, the upper lip, the ethmoid and spongy bones, and the soft and hard palate, in the latter event, throwing the nose and mouth into one immense cavern, an occurrence' which not only seriously affects the speech, but readily admits the passage of food and drink from the latter into the former. The deformities of the nose requiring plastic interference may very properly be arranged under the following heads:—1. Loss of the entire organ, bones as well as soft parts. 2. Destruction of the whole or greater portion of the cartilages, the bridge remaining intact. 3. Mutilation of the tip, as when a small piece is cut or bitten off, including a part of both wings. 4. Loss of one wing, either alone or together with the nasal column. 5. Perforation of the nose, either on the top or at the side ; in the latter case, with or without participation of the cheek. 6. Sinking of the organ from destruction of the cartilaginous septum of the nose, the soft structures being but little, if at all, affected. 7. Loss of the column. 8. Mutilation of the nose and upper lip, or the nose, lip, and cheek. For the repair of these various defects, some of the nicest processes of the art and science of surgery are required ; but, even with the very best skill that can be employed in their application, success is by no means always to be looked for; on the contrary, the surgeon will too often have occasion to lament the occurrence of some unexpected or un- avoidable event which frustrates his hopes, and disappoints the expectations of the patient. It is, therefore, of the greatest consequence, as stated in the general chapter on plastic surgery, that everything should be done beforehand calculated to insure a favorable result. If the operation is entered upon heedlessly, or without due preparation of the part and system, failure will almost be certain. The substance required for closing the chasm in the nose may be borrowed from the immediate vicinity of the organ, or from some distant part. In the Indian method, as the first proceeding is usually called, the flap is obtained either from the forehead, the cheek, the upper lip, or the nose itself, according to the exigencies of each particular case. In the other procedure, which bears the name of Tagliacozzi, in commemoration of its inventor, or “the Italian method,” from the country of his nativity, the operculum is taken from the arm. The operation, however, chiefly in consequence of the tedious and painful confinement of the head and limb, is now seldom employed, although instances occasionally arise in which it may be done with great advange. When an entire nose is to be reconstructed, the Indian method certainly deserves the preference, provided it is possible to obtain the requisite amount of substance from the forehead. Supposing that everything is favorable to the operation, the first step will be to measure off the shape and size of the flap. For this purpose, the defective part should be replaced with a wax mould, a piece of gutta-percha, or a lump of dough, representing as accurately as possible the outline and dimensions of the original organ. A piece of soft leather is then stretched over the artificial nose, to the shape of which it is cut with great care, including the column, or central portion. Another piece of leather, one-third larger than the former, is then fashioned, this addition being necessary to provide against Fig. 205. Nfevoid Elephantiasis of the Nose. 276 DISEASES AND INJURIES OF THE NOSE. CHAP. VII. shrinkage, which, in time, generally reaches fully this extent, if it does not exceed it. As a general rule, it may be stated that the flap should be from two inches and three-quar- ters to three inches in length, by two inches and a half in width at its widest part. In this length is included the column, which should be about one inch and a quarter in length, and from six to eight lines in width, according to the breadth of the nostrils. When the column is borrowed from the lip, the caudiform portion of the flap is of course omitted. The pedicle of the new nose must be from six to nine lines in width, and so long as not to displace the left eyebrow when it comes to be twisted upon itself, which, for the sake of convenience rather than anything else, is usually from left to right. The shape and size of the flap are to be caref ully mapped off, immediately before the opera- tion, with tincture of iodine, the preference being always given to the central portion of the forehead, unless there are contraindications, in which event it should be taken from one side. The shape of the flap, and the manner of forming it are shown in fig. 208. These preliminaries having been gone through, the patient, placed recumbent, with the head and shoulders gently elevated, is put under the influence of an anaesthetic, it being desirable that he should be as passive as possible during the operation. A roll of lint being now inserted into each nostril, to prevent the ingress of blood, an incision is made with a very sharp, narrow scalpel, along the iodinized track. The cut on the right side is extended down, close along the brow, to the root of the nose, while on the left side it reaches hardly as low as the level of the brow, being prolonged afterwards, if it should be deemed advisable. In performing this part of the operation, it is of the utmost im- portance not to interfere with the angular artery, as the vascular supply of the new nose will mainly depend upon its integrity. The structures are divided, at the first stroke of the instrument, down to the periosteum, which is left intact. The gap in the forehead being now sponged, and the bleeding arrested by ligature, its edges are immediately brought together by several points of the interrupted suture and adhesive strips, as little being permitted to remain open as possible. The next step of the operation consists in paring the edges of the mutilated organ, and removing such redundancies as may be in the way of the new material. The skin over the bridge of the nose should also be slightly revivified in order to facilitate adhesion between the contiguous surfaces. In the third step of the operation the parts are stitched together by the common inter- rupted suture ; or,what is preferable, by the tongue and groove suture of the late Professor Pancoast. In order, however, to do this properly, it is necessary that the edges of the flap should have been previously beveled off on the cuticular surface for about the eighth of an inch, as may readily be done in the act of forming it by running the knife along obliquely. The edges of the nose are beveled from without inwards, so as to form a groove for the reception of the tongue, an arrangement which thus brings together four raw surfaces. The connection is affected by passing a loop of thread with two needles, first through the inner lip of the groove, then through the base of the tongue, and lastly through the outer lip of the groove, all on the same level. The ends of the thread are Fig. 206. Fig. 207. Paucoast’s Tongue and Groove Suture. then tied over a thin roll of adhesive plaster, thereby forcing the tongue deep into the groove. The number of sutures on each side must vary from three to live, according to the extent of the wound. The annexed cuts will serve to convey a better idea of making this ingenious suture than any description, however elaborate. Fig. 206 exhibits the mode of introducing the thread, and lig. 207 the manner in which the tongue is received into the groove. All that now remains to be done is to fix the caudal portion of the flap, intended for the column, in its proper position, a procedure requiring great care and attention in order to secure its adhesion. For this purpose a deep transverse opening is made in the upper lip, at its junction with the natural septum of the nose, from three to five lines in length, AFFECTIONS OF THE NOSE. 277 CHAP. VII. into which the extremity of the strip, previously divested of cuticle, is firmly implanted, a few points of suture being emplo\Ad to keep them in place. The lint inserted into each nostril, prior to the operation, is now replaced by a fresh tent of the same material, inclosing a small rubber tube, to prevent the adhesion of the opposite surfaces, as well as to facilitate respiration. Narrow strips of isinglass plaster being stretched across the sides of the nose, to effect more uniform approximation, tin* dressing is completed by applying a layer of charpie, wet with oil, along the line of suture, to prevent the edges from becoming dry and shrivelled. The greatest care is used that, while the contact is complete, there shall be no undue tension anywhere. The diet is light and cooling, the temperature of the room is regulated by the thermometer, and the head is well elevated by pillows. An anodyne is given immediately after the operation, and the dressing is not disturbed until the end of the third day. New tents are now intro- duced into the nose, and any sutures that are loose removed ; otherwise they are not dis- turbed. When, as occasionally happens, the pedicle of the flap is redundant, giving the upper part of the nose, especially on the left side, a full, unseemly appearance, the defect may be remedied by the removal of an elliptical portion of the integument, care being taken not to perform the operation until the organ is fully capable of sustaining an independent existence. The adjoining sketches afford a good idea of the success which often attends rhinoplasty, when properly exebuted. Fig. 208 exhibits the appearance of the parts prior to the operation, and fig. 209 nearly twelve months afterwards. The operation was performed Fig. 208. Fig. 209. Rhinoplasty and its Results at the College Clinic, in 1856, with the aid of the tongue and groove suture, and the re- sult was, in every respect, most gratifying, the organ remaining up to the present moment large and well shaped. It is proper to add that the flap was very large, as it always should be, and that it united throughout by the first intention. In some of the more recent rhinoplastic operations, the periosteum of the forehead was included in the flap; and the results, in a few of the cases thus treated, are reported to have been most satisfactory, new hone having been formed in from six to eight weeks after the transplantation was effected. Whether the procedure, for the first practical application of which we are indebted to Professor von Langenbeck, really possesses any advantage over the ordinary methods, can only be determined by further experience, Observation has fully established the fact that the frontal bone suffers no material injury from the removal of its fibrous investment, as it is very freely supplied with blood from within. A very good nose may often be constructed by taking the necessary substance from the cheeks, especially if they are tolerably full and lax. A flap of integument, with the base looking upwards, is raised on each side of the nose, and stitched to its fellow along the 278 middle line. The two gaps heal by the granulating process, but their size may generally be materially diminished by drawing the edges together with wire suture. The Italian operation has undergone several modifications. As originally executed by Tagliacozzi, and afterwards by his immediate disciples, it was a most tedious and trying procedure, well calculated to put severely to the test the patience both of the subject and t he surgeon. The first step consisted in forming a suitable flap of integument at the inner and middle part of the left arm, over the flexor muscle, at least four inches in length by three and a half in width, its outline having previously been traced with ink. The longi- tudinal incisions being made, the integument was carefully raised in its entire extent, or as far as the two transverse lines, and a piece of soft linen, well oiled, passed beneath it, to prevent reunion. The wound, which in the modern process is closed by suture under the bridge, was left to suppurate, and, at the end of a fortnight, the flap, now thickened, hardened, and shrunk, by exposure, and covered with granulations on its posterior surface, was liberated at its superior extremity, which was then accurately stitched to the mutilated organ, the edges of which had been previously revivified for its reception. To prevent the sutures from giving way, the limb was brought up close to the head, and maintained in that position by an ingenious, but complex, apparatus, con- sisting of a cap and jacket, made of strong drilling ; the arrangement and mode of application of which may be easily understood from the sketch, fig. 210, copied from the original treatise of Tagliacozzi. Another fortnight having been permitted to elapse, to afford the parts time for uniting, the flap was de- tached from its connection with the arm, and, after being properly fashioned, accurately fixed in the posi- tion which it was destined to occupy. Tagliacozzi has left no statistics of his rhinoplastic operations, and we are, therefore, left in ignorance as it regards his success. From the great care, how- ever, with which he has described his process, and from the fact that he attended numerous patients from abroad, it is reasonable to conclude that his success was highly flattering. He was evidently a most in- genious and skilful surgeon, far in advance of his age ; and in the operation of reconstructing noses he dwells with great force and point upon the importance of having the adscititious parts of unusual dimensions, thus providing against the effects of shrinkage, one of the great obstacles to the formation of a good organ. Professor Graefe, of Berlin, modified the operation of Tagliacozzi, by attaching the flap at once to the mutilated nose, thus limiting the period of the constrained position of the head and limb to five or six days, this being generally found sufficient to insure ad- hesion between the parts. The actual value of this process, now usually known as the German method, has not been fully tested, but my opinion is that, while it answers very well in some cases, it is, on the whole, inferior to the original plan, since it lessens the chances of reunion, and admits of greater shrinkage after the operation. In the Italian procedure, the new material, from its exposed situation, acquires a more vigorous circula- tion, as well as a greater degree of solidity and thickness, thereby fitting it the better for the maintenance of its new relations. Dr. J. Mason Warren, adopting the German modification of the Italian method, oecasionally took his flap from the anterior surface of the forearm, about two inches above the wrist, and generally succeeded in effecting an admirable cure, the transplanted skin being separated on the fifth day. The idea of utilizing the fingers when the bones of the nose are destroyed seems to have originated with Mr. Tytler, and to have been first carried into effect by Mr. Hardie, of Manchester. In a case of horrible disfigurement of the nose, face, and eyelids in a man, twenty-five years of age, Professor Thomas T. Sabine, of New York, in 1875, mended the defects in the soft structures with integument taken from the surrounding parts, and finally closed the chasm in the bridge of the nose with the patient’s last phalanx of the middle finger, from which he had previously removed the nail, although not per- fectly, as it was subsequently partially reproduced. The hand, secured to the lace, was INJURIES AND DISEASES OF THE NOSE. CHAP. VII. Fig. 210. Tagliacozzi’s Apparatus. CHAP. VII. AFFECTIONS OF THE NASAL CAVITIES. 279 retained in place for several weeks, when, the circulation being thoroughly established, the finger was amputated at the middle of the first phalanx. A full account of this in- teresting operation, accompanied by several drawings, will be found in the Illustrated Quarterly of Medicine and Surgery for April, 1882. Small apertures, of an oval or circular form, the result of wounds, ulceration, or gan- grene, are met with on various parts of the nose, and may generally be readily closed by the transplantation of a suitable flap from the cheek, the forehead, or even the nose it- self, according to the circumstances of the case. A similar procedure will be required in partial destruction of the edge of the nose. When one of the wings is lost, it will generally be necessary to borrow the flap from the arm or forehead. When the nasal column is deficient, an admirable substitute may easily be obtained from the central portion of the upper lip, either by twisting the flap at its pedicle, or by everting the mucous membrane, the surface of which soon assumes the character of the cuticular tissue. The nose is sometimes unseemly depressed, or caved in, in consequence of the destruc- tion of its cartilaginous septum, without, perhaps, any injury of the skin, giving it more or less of an African expression. For such a defect, the only remedy is the construction of a new organ, all attempts to elevate the parts in a satisfactory manner proving useless for the want of proper support. These operations upon the nose do not always turn out so well as could be desired. Sometimes the result is spoiled by hemorrhage, coming on secondarily, perhaps several days after the parts have been adjusted, so as effectually to prevent the adhesive process. Occasionally the flap is assailed by erysipelas. Such an event is most likely to ensue in persons of unsound constitution, and in those whose systems have not been properly pre- pared for the undertaking. The most common cause, however, of all is the want of nour- ishment in the flap, in consequence of the small size or great paucity of its vessels, or of the partial arrest of the circulation from the pressure of the dressings. The best protection against such an occurrence is the retention of a pretty thick layer of connective and adipose tissues, in which the vessels can have full sway in the performance of their functions. The result is, generally, essentially influenced by the after-treatment. Even when the suc- cess is apparently most perfect, the effect may afterwards be marred by the recurrence of the original disease, by which the mutilation necessitating the undertaking was caused. Finally, the operation is not without danger, as is shown by the fact that it has some- times proved fatal. Dieffenbach, during one of his visits to Paris, lost two patients out of six, probably, as has been conjectured, because sufficient attention had not been paid to the preparation of the system and to the subsequent treatment. SECT. II AFFECTIONS OF THE NASAL CAVITIES. The nasal cavities are liable to malformations and to various accidents and diseases, of which the most important are hemorrhage, ulceration, polyps, hypertrophy of the mucous membrane, and foreign bodies. 1. Rhinoscopy For examining the anterior portion of the nasal cavity, a convenient Fig. 211. Fig. 212. Duplay’s Nasal Speculum. Fraukel’s Self-retaining Nasal Dilator. instrument is that of Duplay, delineated in fisr. 211. It consists of two branches, of which that corresponding with the nasal septum is lixed and somewhat flattened, while 280 INJURIES AND DISEASES OF THE NOSE. tha ether, intended to dilate the nostril, is movable, and regulated by a nut. A self-re- taining nasal dilator, devised by Dr. Frankel, of Berlin, fig. 212, is likewise a useful in- strument, especially when intranasal manipulation is required. The speculum of Metz, of Aix-la-Chapelle, consisting of two angular, polished, metallic portions, one of which is represented in fig. 213, is useful for lighting up those parts of the cavity which cannot c h a r. vii. Fig. 213. Metz's Nasal Speculum. be brought into view with the ordinary instrument. They may be employed together or separately, being heated, previously to their introduction, by plunging them into hot water, to prevent the condensation of moisture on their surfaces. The patient should be seated upon a chair, with the head thrown well back, in order that the light may readily penetrate the nares. If the sun is not sufficiently bright, the inspection may be con- ducted with the aid of artificial light. Inspection of the posterior nares, and the adjacent parts, may very satisfactorily be conducted with the mirror employed for laryngoscopic examinations, the reflecting surface being turned upward and forward. The mirror must be smaller, as a matter of course, ex- cept in subjects with a very capacious pharynx. It is usually requisite to keep the tongue depressed by some suitable contrivance. When it is, at the same time, necessary to have Fig. 214. Duplay’s Rhinoscope. one hand free, for the purpose of operating, or applying loeal remedies, the instrument of Duplay, fig. 214, which is a modification of that of Dr. Simrock, of New York, will some- times be found especially useful, as it combines with the mirror a hook for retracting the veil of the palate. Rhinoscopy was first practised by Bozzini, in 1807 ; but was almost forgotten, until it was revived by Czermak, who devised various useful instruments for its performance. 2. Cleansing and Medication of the Nasal Passages—For cleansing, disinfecting, and deodorizing the nose, the most eligible procedure is that of Dr. J. L. W. Thudichum, of London, founded upon the discovery of Professor Weber, of Halle, that when one side of the cavity is filled through one nostril with fluid by hy- drostatic pressure, while the patient breathes through the mouth, the soft palate so completely closes the nares as to force the fluid directly from one orifice into the other, without allowing any to descend into the pharynx. The apparatus for accomplishing this object, represented in fig. 215, consists of a glass vessel capable of bolding from one to two pints, which is open above, and connected at its lower part with an India-rubber tube three feet in length, and surmounted by a stop-cock and perforated nozzle. The patient, seated in front of a basin, with his head slightly bent over it, breathes entirely through the mouth, and refrains from swallowing. The nozzle being inserted into one of the nostrils, and held there by the patient, while the vessel is placed on a level with the Fig. 215. Nasal Douche. CHAP. VII. AFFECTIONS OF THE NASAL CAVITIES. 281 forehead, the stop-cock is opened, when, in a few seconds, a continuous and rapid stream will be seen to issue from the opposite cavity into the receiver below. Some little practice is necessary to insure the success of the operation, which is always more or less difficult in nervous females, children and young persons. A great outcry has been made in late years against the use of Thudichum’s instrument on the ground that the water is liable to be forced into the Eustachian tubes, and so cause inflammation, pain, and other trouble in the middle ear, followed, occasionally, by tetanus, convulsions, suppurative otitis, meningitis, and even abscess of the brain. These occur- rences have been much exaggerated, and are probably in most cases mere coincidences due to other causes. When the operation is performed in the manner here described, with warm water, as it always should be, and deglutition is avoided while the nasal passages and the pharynx are filled with fluid, no mishaps from this source will be likely to arise. When Thudichum’s apparatus cannot be obtained, an ordinary syringe, capable of hold- ing from four to six ounces, may be used. The nozzle should be well perforated, and in- serted some distance into the nostril. Injections of the upper portion of the pharynx and the nasal cavity, through the posterior nares, are much more difficult, but are sometimes requisite. Careful examination anteriorly and posteriorly presents the only method of determining with certainty whether all the accumulated sordes and collections of mucus have been detached from the nasal passages and the vault of the pharynx. The most unexceptionable articles for washing out and medicating the nasal cavities are tepid water, impregnated with a little common salt, and the various solutions men- tioned under the head of ulceration. Whatever substance be employed, care should be taken that it does not cause pain or irritation, otherwise it will be sure to create mis- chief. The injection should not, on an average, be repeated oftener than twice in the twenty-four hours; very frequently, indeed, one will suffice. The propulsion of medicated sprays, either warm or cold, may be advantageously em- ployed in the same class of affections as injections, with the same kind of medicinal agents. For this purpose, the handball apparatus will be more convenient than the steam atomizer. Unguents of different kinds, very greatly diluted, may sometimes be beneficially em- ployed for the nose, especially in ulceration of the cartilaginous septum, and of the anterior extremity of the turbinated bone. The application is best effected with a short, stiff, camel-hair pencil. The most efficacious salve, according to my experience, is the ointment of nitrate of mercury, diluted with eight to twelve times its weight of cosmoline. A combination of glycerine and tannic acid is also very serviceable. 3. Discharge of Serovs Fluid A discharge of serous fluid from fhe nostril is an occasional occurrence, to which attention was first called, in 1873, by Sir James Paget. The fluid, in the case reported by this distinguished surgeon, dropped from the left nostril, was of a clear, limpid appearance, and contained a small quantity of protein matter along with some of the earthy salts, and a slight trace of iron, its specific gravity varying from 1004 to 1010. Several ounces were occasionally discharged in the twenty-four hours, over a period of several months. The source of the fluid coidd not be determined, but was supposed to be the frontal sinus, the ethmoidal sinus, or the arachnoid sac. From its great quantity and long continuance one might infer it had been derived from the latter source ; but this opinion is contradicted by the fact that the fluid was totally different in its chemical composition from the cephalo-spinal liquid. A considerable discharge of serous fluid from one or both nostrils is an occasional occurrence in catarrh and gout, especially in elderly persons. No definite plan of treatment can be laid down in such an obscure affection. 4. Deviations of the Septum The most important malformation of the nose, surgically considered, relates to its septum. It consists of a kind of lateral curvature of the car- tilaginous portion of the septum, with or without hypertrophy of its anterior extremity. In consequence of this deviation, the corresponding cavity is diminished in size, and the opposite one proportionately enlarged. Cases occur in which the obstruction, thus pro- duced, amounts almost to complete occlusion, the patient being obliged to breathe nearly entirely through the unaffected nostril. The only remedy for this affection is excision of a portion of the offending septum, care being taken to avoid perforating it, which, how- ever, is not always possible. The best instrument for performing the operation is a narrow, probe-pointed bistoury, with which the necessary slicing is safely and expeditiously executed. When the obstruction is seated at the very orifice of the nostril, a tolerably extensive dissection may be required in order to effect the desired object. 5. Hemorrhage The mucous membrane of the nose, from its great vascularity, is a frequent seat of hemorrhage. The exciting cause may be external violence, as a blow, 282 DISEASES AND INJURIES OF THE NOSE. CHAP. VII. with or without fracture of the nasal bones, ulcers, and erosions, or mere plethora of the system, nature endeavoring to find a spontaneous outlet for the redundant fluid. Young persons, of both sexes, are particularly prone to this discharge about the period of puberty. Occasionally the flow is vicarious of the menstrual flux. It is apt to occur in subjects of the hemorrhagic diathesis. The amount of bleeding varies from a few drachms to a num- ber of ounces. In the latter case, and especially when the discharge is of frequent recur- rence, excessive debility, and even loss of life, may be the result. The blood generally proceeds from one nostril only; very rarely from both. In the milder cases, it probably emanates in great measure, if not entirely, from the inferior portion of the nasal septum. In the more ordinary forms of nasal hemorrhage, little or no treatment is usually neces- sary ; nor need anything be done when the discharge is vicarious of the menses. It is only, as a general rule, when the bleeding is profuse, or when, if slight, it recurs so fre- quently as to induce debility, that an attempt should be made to suppress it. The most suitable remedies, in addition to elevation of the head and shoulders, and perfect quietude of mind and body, are acetate of lead and morphia, tannate of iron, and fluid extract of ergot, given in liberal quantities, more or less frequently repeated, according to the urgency of the case. The heart’s action must be promptly tranquillized with morphia and aconite, or morphia and digitalis. Pounded ice should be applied to the nape of the neck ; and pieces of ice inserted into the nostrils often produce a very happy effect. Hot mustard foot-baths are frequently of great benefit, especially when there is coldness of the extremities. Dover’s powder, in large doses, should be prescribed when there is dry- ness of the skin. General bleeding is indicated only when the hemorrhage is connected with, or dependent upon, a plethoric state of the system. In obstinate cases, blisters applied to the back of the neck will be serviceable as counterirritants. Tincture of chloride of iron, with quinine, milk punch, and beef essence, will be needed to increase the quantity and quality of the blood when the hemorrhage has been unusually copious. An injection of a strong solution of subsulphate of iron sometimes promptly arrests the bleeding. Compression of the nostrils occasionally answers a good purpose, the fingers being retained until the blood is thoroughly coagulated, the head being strongly inclined forwards during the operation, and care taken that the patient do not blow his nose, lest 'the clots be prematurely detached, and the bleeding break forth afresh. Steady pressure upon the carotid arteries by a relay of assistants might occasionally be of service, and is worthy of trial. When these measures fail, or when as much blood has already been lost as the system can bear, direct interference by obstructive means is required. The patient being sup- ported upon the edge of his bed, in the semiereet posture, a double wire, very thin and flexible, and composed either of silver or iron, is passed along the floor of the nostril into the fauces, where it is seized with the finger introduced into the mouth. A strong, double ligature, tied over a piece of soft sponge, or a roll of cotton, charpie, or patent lint, is then secured to the loop, and drawn up into the nose by retracting the wire. The finger, being still in the mouth, assists in carrying the tampon round the palate and in adjust- ing it in the posterior naris. The wire is now detached, and the operation completed by tying the ends of the thread over another plug in front. Both outlets being thus effectu- ally occluded, the hemorrhage must necessarily cease as soon as the nasal cavity is tilled with blood, which thus serves to compress and control the bleeding vessels. The parts are not disturbed until the end of the second day, when the tampons are removed, and the nasal cavity washed out with some mildly astringent lotion, introduced with the syringe. When no wire is at hand, the plugging may be performed with a gum-elastic catheter, a piece of whalebone, or a stick of wood; in fact, with almost anything. The best con- trivance, however, of all, is that represented in fig. 216, and known at Belloq’s canula. It consists of a silver tube, nearly straight, about six inches long, containing a movable rod nearly of the same length, with a steel spring surmounted by a silver knob, with a hole in the centre for the attachment of the ligature which holds the posterior tampon. The instru- ment is one of the most perfect imaginable, and should find a place in every surgeon’s armamentarium. Fig. 217 exhibits the man- ner of applying it. Dr. Cohen prefers an eyed flexible probe, formed of silver wire, coated with vulcanized rubber. The probe, being threaded, is passed through the nasal passage and out by the Fig. 216. Belloq’s Canula. CHAP. VII. AFFECTIONS OF THE NASAL CAVITIES. mouth ; the thread following. The instrument is delicate enough for the smallest child, and can be passed as readily through the middle meatus as the lower one. Sometimes the hemorrhage may be promptly and effectually arrested by plugging the nostril with a piece of sheep’s intestine, filled with water, the fluid being introduced after the insertion of the tube, so as to make firm and equable pressure upon the bleeding surfaces. This treat- ment, originally suggested, I believe, by Mr. Green, of London, has the advantage of admitting of the fre- quent injection of cold water, until all disposition to hemorrhage has ceased. Garriel recommended, in 1850, with a similar view, a tube of caoutchouc, inserted into the nose, and filled by insufflation. By car- rying the tube back into the fauces, it will form an effectual obturator for the posterior naris. A similar contrivance, provided with a stop- cock, and admirably adapted to the object, has been introduced by Mr. Rosa, an English surgeon. I have seen five fatal cases of epi- staxis. In every one death was caused either by imperfect plugging of the nostrils, or because the operation was not performed until the patient had become exhausted by the hemorrhage. The plugs must not be retained too long, otherwise they will inevitably become sources of irritation and mischief, provoking the formation of matter, which soon becomes exces- sively offensive, tainting the atmosphere and poisoning the system. I have seen several cases where, from this cause, the patient lost his life, being seized with a slow form of fever or pyemia, attended with delirium, which nothing could arrest. To prevent such mishaps the plugs should be withdrawn at the end of forty-eight hours, and the nostrils well syringed with some mildly detergent and deodorizing lotion, when, if necessary, sub- stitution should be effected. When there is much discharge, a daily renewal of the dressings will be required. It is impossible to direct too earnest attention to this subject. The late Professor Colies, of Dublin, met with a case in which a plug in the posterior naris excited tetanus. The removal of the plug may generally be easily effected by means of a female catheter or grooved director, passed along the floor of the nostril, a pair of polyp-forceps being previously introduced into the mouth to seize the foreign body the moment it is detached. Such a precaution is eminently necessary, otherwise the plug, having lost its hold, might fall upon the epiglottis, and thus instantly produce suffocation. To meet this contingency, some practitioners adopt the precaution of attaching an additional thread to the tampon, for service in its removal; the portion projecting beyond the lips being secured, mean- while, around the ear. When the hemorrhage is dependent upon erosions or ulcers of the septum, it may gen- erally be promptly arrested by touching the spot with solid nitrate of silver, or by the application of styptic cotton. Plugging of the posterior nares is sometimes advantageously practised as a means of preventing the escape of blood into the throat and larynx in operations on the nasal cavi- ties, the maxillary sinus, and the superior jaw. The tampon should, of course, be removed as soon as the bleeding has ceased. 6. Abscess Two kinds of abscesses are liable to form in the nasal septum, the com- mon and the syphilitic, the latter being by far the more frequent. The former is generally the result of external violence, as a blow or a fall, and is of a strictly phlegmonous nature, running its course rapidly, the local and constitutional symptoms being characterized by more or less severity, and the matter being of a thick consistence and of a yellow-greenish color. The treatment is by leeching and early evacuation, along with light diet and gentle purgation. The syphilitic abscess generally occurs late in the tertiary stage of this affection, and Fig. 217. Plugging of the Nose. 284 INJURIES AND DISEASES OF THE NOSE. CHAP. VII. is usually tardy in its development, although occasionally it proceeds so rapidly as to give it the character of an acute disease. The matter is sanious, irritating, fetid, and more or less abundant. The abscess generally takes its rise in a gummy tubercle, in the connec- tive tissue beneath the mucous membrane, which is elevated in the form of a small blad- der, closely simulating a gelatinoid polyp. Its formation is usually attended with a thin, watery discharge from the nose, and trouble in breathing. Pain of a throbbing character is sometimes present. The coexistence of the abscess with syphilis in other parts of the body usually determines the diagnosis. Early evacuation and iodide of potassium con- stitute the most important remedies. In case the matter has perforated the septum, an effort must be made to heal the ulcer with nitrate of silver and other suitable local means. 7. Ulceration Ulcers of the nose, chiefly of a strumous or syphilitic nature, are suffi- ciently common, and from their rebellious character and fetid discharge, are often a source of great annoyance, both to the patient and practitioner. Seated originally in the mucous membrane, they gradually extend in depth, until, in many cases, they involve all the component structures, cartilage and bone, as well as fibrous tissue. The disease gene- rally commences high up in the nose, beyond the reach of the eye of the observer; but not unfrequently its first effects are displayed upon the inferior turbinated bone, or the nasal septum. In the strumous variety one side alone may suffer, whereas in the syphili- tic nearly always both are implicated. Both forms are often met with in early life, and hence it is by no means always easy to distinguish them from each other. Perhaps, the most important diagnostic characters are that, in syphilitic ulceration, there is, ordinarily, greater derangement of the general health, more extensive involvement of structure, and more abundant discharge, than in the strumous variety. Useful information may also, commonly, be derived from the history of the case and the temperament of the patient, although the latter is frequently of negative value, as scrofula and syphilis may coexist. The discharge attendant on this disease is noted for the intensity of its fetor, whence the term ozcena, by which it is generally designated. It is commonly of a thin, sanious nature, irritating, profuse, and easily aggravated by exposure to cold and other causes. During sleep it often descends into the fauces and the stomach, occasioning nausea and sometimes even vomiting. In the more aggravated forms of the affection large quantities of inspissated mucus pass off, or collecting in the nasal cavities, form thick, brownish in- crustations, which drop off* every fourth, fifth, or sixth' day, only to be succeeded by an- other crop. Portions of cartilage and bone, or even an entire bone, often die, and slough away. In syphilitic ulceration, more frequently than in the strumous, the ravages of the disease often extend to the proper bones of the nose and palate, and occasionally even to those of the face, eventuating in horrible and irremediable deformity. It is important that the horrible fetor which so frequently accompanies disease of the nose shall not be confounded with the bad breath caused by disordered conditions of the mouth, gums, teeth, and throat. Persons who labor habitually under chronic inflam- mation and enlargement of the tonsils, accompanied by irritation of the mucous mem- brane of the palate and fauces, are very liable to suffer in this manner. Carious teeth, ulceration of the gums, and disease of the jaws and of the maxillary sinus, give rise to similar effects. In the nasal cavities a bad form of oziena may be caused by the presence of a foreign body, and by the decomposition and protracted retention of the natural secretions. To avoid error as it respects the source of the fetor, the simplest plan is to make the patient alternately close and shut the mouth and nose during expiration. The treatment of ulceration and ozaena must be regulated by the nature of the exciting cause, which should therefore always, if possible, be ascertained beforehand. The more simple forms of the disease are managed on general principles, but it is otherwise when the disease is dependent upon a tainted state of the system. Here, a long course of treat- ment, involving the exercise of much patience on the part of the sufferer, and great skill on that of the surgeon, is usually necessary. When the strumous character of the dis- ease is well settled, the different preparations of iron, iodine, barium, and cod-liver oil are brought into requisition. If, on the contrary, it has been induced by syphilis, mer- cury and iodide of potassium should be employed, to an extent commensurate with the exigencies of the case. In general, there is no remedy which makes so rapid and decided an impression as local bleeding by means of a leech applied every fourth or fifth day directly to the inflamed surface. During the height of the morbid action, free purgation and antimonial and saline medicines may be demanded. Ordinarily, however, stimulants and tonics, and not depletory measures, are necessary, as is evident from the pallor of the countenance, and the emaciated frame. CHAP. VII . AFFECTIONS OF THE NASAL CAVITIES. 285 To allay fetor, and assist in establishing healthy action in the affected parts, various lotions are employed. The best are weak solutions of chlorinated sodium, permanganate of potassium, chloride of zinc, nitric acid, nitrate of silver, and sulphate of copper, thrown twice a day into the nostril with a large syringe, or, what is preferable, Thudichum’s apparatus, or the contrivance depicted in fig. 218, from Bryant, in which one end of the tube, attached to a weight, is sunk in a pitcher filled with water. The black and yel- low washes, as they are termed, so useful in certain forms of syphilitic ulcers in other parts of the body, are objectionable in this, on account of their liability to descend into the stomach, and thus lead to ptyalism. For many years past I have been in the habit of employing, with signal benefit, in both varieties of the disease under consideration, a solution of sulphate of copper and tannic acid, in the proportion of one- fourth of a grain of the former with three grains of the latter to the ounce of water. When there is much fetor, a small quantity of chlorinated sodium may advantageously be added to the other ingredients. In old, obstinate cases, a rapid cure may sometimes be effected by washing out the nostril freely, twice a day, with a solution of chloride of zinc, in the proportion of ten to fifteen drops to eight ounces of water. A weak solution of common salt is sometimes very bene- ficial, as half an ounce to the quart of water. When the diseased spot can be reached, as when it is seated in the an- terior and inferior part of the nose, nitrate of silver and sulphate of copper may be applied in substance, or the sore may be touched very lightly with dilute acid nitrate of mercury. Some of the milder unguents, as the citrine and calamine, often prove serviceable by softening the scabs, and promoting healthy granulation. When there is swelling, with pain or tender- ness in the nose, leeching will be serviceable. There can be no more serious error committed in the treatment of oziena than the employment of irritating lotions and unguents. The sensibility of the mucous membrane of the nose is naturally very great, and it is often not a little heightened in disease. Hence, the best plan is always to begin the treatment with a very weak application, the strength being gradually increased as the cure progresses, and as one article becomes inert another should be substituted. If there be any decided smarting, or a sense of pain and tension in the frontal sinus, the remedy will be more likely to be prejudicial than beneficial, and should immediately be weakened. 8. Necrosis Necrosis of the turbinated bones and also of the vomer is sufficiently common as an effect of tertiary syphilis. The disease may be limited, or it may involve the whole of one of these pieces. The symptoms are muco-purulent discharge, more or less abundant, excessive fetor, and a feeling of weight and soreness in the nostril. The treatment consists of deodorizing and slightly detergent injections, with removal of the dead bone as soon as it is found to be sufficiently detached. When the whole turbinated bone is necrosed, it may be necessary to break or divide it, in order to facilitate extraction. 9. Hypertrophy Hypertrophy of the mucous membrane of the nose is observed chiefly in children and young persons of a weakly, strumous constitution. Its most common site is the anterior extremity of the inferior turbinated bone : it consists of an enlarged and thickened state of the mucous tissues, dependent upon a process of hypernutrition, along with effusion of sero-plastic matter. The subjacent bone occasionally participates in the disease, becoming soft, porous, and expanded. Upon looking into the nostril with the aid of a strong light, the part presents the appearance of a small tumor, of a scarlet color, and of a spongy consistence, with numerous little vessels ramifying over its surface. It is generally of slow development, and the only inconvenience which it produces is its mechanical obstruction, which is sometimes so great as to lead to considerable embarrass- ment of breathing in the corresponding cavity. Both nostrils occasionally suffer, although Fig. 218. Nasal Douche. INJURIES AND DISEASES OF THE NOSE. CHAP. VII. seldom in an equal degree. The only affection with which it is liable to be confounded is polyp, but from this it is always easily distinguished by its site, scarlet color, and fixed- ness. The disease may continue, with perhaps little change, for years, and finally dis- appear spontaneously. The remedies best adapted to its cure are purgatives, and the different preparations of iodine, especially the iodide of iron, with a leech occasionally to the part, and the application, twice a week, of the solid nitrate of silver. Punctures and astringent lotions are sometimes beneficial. Posterior hypertrophy of the erectile tissue covering the lower turbinated bone may be detected by rhinoscopic inspection and by palpation with the finger hooked around the palate. When materially occluding nasal respiration, and rebellious to other means of relief, it may be retrenched by excising a portion with a wire snare passed through the inferior nasal meatus. 10. Calculi—Nasal calculi, technically termed rhinolites, are very infrequent; they are usually situated in the inferior meatus, are of an irregular shape, and vary from the volume of a pea to that of a pigeon’s egg. Their surface is rough, and they are of a black, gray, or brown color, their centre often consisting of some foreign body, as the root of a tooth, a bead, or a cherry-stone. Their composition is phosphate and carbonate of lime, cemented by animal matter. These calculi are usually solitary, but sometimes they are multiple, or form in each nostril. Their presence is productive of the usual symptoms of obstruction of the nose, with more or less discharge of a sanious and fetid character. When of considerable bulk, they may cause a good deal of pain and inflammation in the neighboring structures. Simple inspection of the nostril generally suffices to detect them ; when this fails, a probe is introduced, which, on coming in contact with the extraneous body, produces a characteristic click, not unlike what results from the contact of a sound with a vesicle calculus. Extraction is accomplished with a hook, bent probe, or polyp- forceps ; or, the attempt being unsuccessful, the concretion is pushed into the fauces, a finger being previously placed there to receive it. Sometimes expulsion is effected during a fit of sneezing. A body of this kind lies occasionally under the mucous membrane, and then requires the use of the knife for its liberation. 11. Foreign Bodies.—Various substances may find their way into the nasal cavities of children, being generally placed there as a matter of amusement. The most common of these are grains of corn, peas, beans, beads, pellets of paper, buttons, fruit-stones, rags, and pieces of ribbon. In a case recently under my charge, that of a little girl three years old, a patient at the College Clinic, the substance consisted of the foot and leg of a Chinese doll. If allowed to remain for any length of time, they always induce inflamma- tion, and sometimes even ulceration of the lining membrane, with more or less pain, and a sanious, fetid discharge. In a case reported by Dr. Hays, of this city, the substance, a glass button, was retained upwards of twenty years, keeping up constant irritation. Their ordinary site is the anterior portion of the nostril, between the turbinated bone and the nasal sepum, where they are often firmly impacted, and consequently difficult of spon- taneous extrusion. Should the child, or an inexperienced person, attempt extraction, as is too often the case, the foreign body will only be pushed farther in, and in this way it frequently passes entirely beyond the reach of the sight, being arrested, perhaps, high up in the cavity, or forced against the floor of the inferior meatus. Whatever the foreign body may be, it should always, for the reasons above mentioned, be extracted as speedily as possible. If the child is sufficiently old to cooperate with the surgeon, he is requested to take a pinch of snuff, and during the effort of sneezing which is sure to followr, expulsion is often promptly effected, especially if care be taken at the same time to occlude the sound nostril by means of the finger. If the substance obstructs the passage completely, it may often be promptly dislodged by insufflation. For this purpose the unaffected nostril is closed by external pressure, when the surgeon blows for- cibly with his own mouth into the mouth of the patient, the current of air thus established being sufficient to cause extrusion. In general, however, the removal of the foreign body is easily enough effected with a small, flexible, blunt, double hook, a probe bent at the end, or pieces of annealed wire, formed into a loop. The best instrument of all is the author’s ear-pick, delineated at p. 243. The patient being in a strong light with the head inclined somewhat backwards, the instrument is carried obliquely upwards, on a line with the ex- ternal nose, above and behind the foreign body, which is then extruded by a kind of jerking movement of the hand. The great fault usually committed by the surgeon, in his attempts at extraction, is that he inclines the instrument too horizontally, whereby he is sure to push the intruder farther into the nostril. In the American Journal of the Medical Sciences for April, 1860, Dr. W. S. King, of CHAP. VII. AFFECTIONS OF THE NASAL CAVITIES. 287 the Navy, gives an instance of the expulsion of a cherry-stone from the nose of a child during the action of an emetic, the mouth being tightly closed at the moment of emesis with a handkerchief. When the extraneous substance is out of sight, it may be necessary to wash it away with a stream of water thrown in with Thudichum’s tank, or to push it into the throat, and extract it through the mouth, as in a case communicated to me by Professor W. II. Pancoast. The patient, in stooping over a pincushion, accidentally ran a hairpin, two inches and a half in length, into the nose. The accident was followed by profuse bleeding, and, on expanding the nostril, it was barely possible to discern the point of the pin, which was immediately removed with a pair of forceps aided by the index finger. In a case mentioned to me by Dr. J. J. Moorman, the foreign body—a large bean, in- troduced a few days before and pushed far back into the nostril by the previous efforts at extraction—was propelled forwards within reach of the forceps, by closing the mouth with the hand, so as to make the patient, a child two years old, breathe entirely through the nose. Finally, it may be proper, in order to facilitate extraction, as when the patient is very fractious and unruly, to administer an anaesthetic; or, if this be objectionable, to secure his body with a stout apron, as in the operation for harelip. 12. Polyps The nose is a frequent seat of polyps, more so, in fact, than any other mucous cavity of the body. The only varieties met with in this situation are the gelati- noid and the fibrous, the former including growths composed of myxomatous tissue, or of delicate, succulent connective tissue, or of glandular tissue. The gelatinoid polyp, fig. 219, resembles, as its name imports, a mass of jelly, or, more closely still, a common oyster. It is of a soft, spongy consistence, moist, somewhat translucent, and of a white, grayish, greenish, or grayish-yellow color. Its surface, which is generally smooth, or smooth at one point and tabulated at another, is covered with cylindrical epithelium, and nearly always presents a few small, straggling vessels, which thus serve to impart to it a peculiar striated appearance. In its shape, the tumor is ordi- narily somewhat pyriform, its attachment being by a nar- row pedicle, while the broad, bulbous portion hangs down- wards and forwards into the nostril. It almost constantly takes its rise from the superior turbinated bone, surgically so called, and often exists in great numbers, although occa- sionally it is solitary. In a case under my charge a few years ago, I counted upwards of twenty separate tumors, from the size of a small pea up to that of a hazelnut. When carefully examined, the growth is usually observed to consist of a delicate fibrous tissue, the interspaces of which are occu- pied by a sero-albuminous fluid, much of which drains off on puncturing the investing membrane. Owing to this pecu- liarity of structure, the tumor is of a hygrometric character, expanding in damp, foggy weather, and shrinking in dry. It also generally exhibits a distinct adenoid structure, the mucous glands being greatly enlarged and increased in number. It is devoid of sensibility, breaks easily under pressure, and is most common in persons after the age of forty; occasionally it occurs at an early period of life, as in a case recently under my charge at the College Clinic, in which I removed a very large polyp from a girl only eight years old. It frequently exists simultaneously in both nos- trils. Its volume is usually diminutive. A polyp of this kind now and then contains fibro-cartilaginous concretions, or even osseous plates or nodules, as in a specimen in my private collection, extracted from the nose of an elderly gentleman. When a growth of this kind projects beyond the anterior naris, the exposed part shrivels, and assumes a red- dish, brownish, or purplish tint. The Jibrous polyp, of which the annexed cut, fig. 220, from a specimen in my collec- tion, exhibits a well-marked example, occurs at nearly every period of life ; I have seen it in children under fourteen years of age, in adults, and in old persons. More rare than the gelatinoid variety, it generally exists singly, is very prone to reappear after removal, and often displays a malignant tendency, when it will generally be found that it has assumed the type of fibrous sarcoma. It is ordinarily attached by a broad base to the superior turbinated bone, but occasionally it springs from the .septum, floor, or wall of the nose. In most of the cases that have fallen under my notice, it was situated in the posterior part of the nostril, so as to be distinctly perceptible in the throat. Both sides may suffer simul- Fig. 219. Ge’atinoid Polyp. 288 INJURIES ANI) DISEASES OF THE NOSE. CHAP. VII. taneously, but this is uncommon. The structure of the tumor is characteristic ; it is composed of fibres, of a white, glistening color, exceedingly firm and tough, closely knit together, and most intricately arranged. Interspersed among these fibres are numerous Fig. 220. Fibrous Polyp. vessels, both arterial anti venous, the walls of which are very brittle, anti, therefore, liable to give way under the most trivial accident. Owing to this circumstance, this form of the polyp is the seat of frequent, and, at times, profuse hemorrhages. For the same reason, it is always, in its recent state, of a dark red, purple, or modena color. Calcareous deposits occasionally occur in its substance, and now and then portions undergo the cartilaginous or osseous degeneration. Permitted to pursue its course, the tumor may acquire an enormous hulk, descending into the throat, protruding exter- nally, and pressing against the walls of the nasal and oral cavities in every direction. At this stage of the disease, the features are often frightfully distorted, presenting that pecu- liar appearance, seen in fig. 221, denominated “frog-face.” A fibrous polyp, the history ot which has been admirably eluci- dated by Flaubert, Michaux, Hu- guier, Nelaton, Robert, Maison- neuve, Giraldes, Masse, and other French surgeons, occasionally springs from the base of the skull, the petro-occipital suture, the inner surface of the great wing of the sphenoid bone, or even from the upper part of the spinal column, projecting as it advances into the nose and pharynx, and hence called the naso-pharyngeal polyp. It is of a very hard, dense texture, of a bluish, purplish, or livid color, and capable of acquiring a large bulk, its growth being rapid and uncon- trollable by medicine. When ex- tirpated, it is apt to return, although now and then the operation is fol- lowed by permanent relief. A few instances are recorded of a sponta- neous cure by sloughing. The tu- mor is usually attached by a broad base, closely identified with the periosteum of the part from which it springs. In its progress, it may extend down into the larynx, or, separating the muscles of tlie pha- rynx, pass into the zygomatic fossa Fig. 221. Frog-Face; the Polyps Causing much Deformity. AFFECTIONS OF THE NASAL CAVITIES. 289 CHAP. VII. and the face. Although the disease may occur at any period of life, it is by far most com- mon in young subjects, between the tifteenth and twenty-fifth years. It is met with mainly in male subjects. These tumors frequently exhibit, on minute examination, all the characteristic features of fibrous, or even pure spindle-celled, sarcoma, when their clinical history differs from that of the fibrous polyp in their more rapid growth, their softer consistence, their greater vascularity, and their disposition to perforate the skull. Examples of the latter occurrence have been recorded by Huguier, Deguise, Langenbeck, O. Weber, and other surgeons. The symptoms of polyp are chiefly of a mechanical character, as in obstructions of the nose from any other cause. The first intimation which the patient ordinarily has of the disease is a sense of fulness and weight in one of the nostrils; he feels as if there were some fleshy substance in it, interfering with the transmission of air, and, as a necessary con- sequence, lie makes frequent and abortive efforts to clear his nose, using his handkerchief, perhaps, every half hour. Gradually lie observes some discharge, at first of a mucous, then of a purulent, and finally of a sanious character, fetid, and profuse. The voice is generally nasal, indistinct, and even snuffling; the sleep is embarrassed, and attended with loud snoring, the head being thrown back as in enlargement of the tonsils; the nose is blown with difficulty, and, during every effort of the kind, most of the contents of the nostril are forcibly projected into the fauces ; the sense of smell is materially impaired ; and, eventually, as the growth spreads, the affected cavity is completely deprived of its functions. At this advanced stage of the disease, the patient is occasionally annoyed by lachrymation, partial deafness, and slight dizziness from the pressure of the tumor, respec- tively, upon the nasal duct, the Eustachian tube, and the jugular veins. The symptoms above enumeyated are, unfortunately., not characteristic; they may be, and often are, simulated by other affections. Thus, the person may labor under enlarge- ment of one of the turbinated bones, hypertrophy of the mucous membrane, malposition of the nasal septum, or malignant disease, either of the nose itself, or of the maxillary sinus; or, finally, there may be a foreign body in the nose, causing serious obstruction, and profuse, sanious, and fetid discharge. A remarkable case has been recorded by Cru- veilhier, in which a fibroma of the sheath of the second branch of the fifth pair of nerves made its way into the nostril through the sphenopalatine foramen, and was mistaken for a polyp. Attempts at evulsion were followed by death from meningitis. To make sure of the diagnosis, the polyp must be seen or felt. Protrusion at either opening of the nose at once decides the matter; but in the absence of this, a careful inspection is made with the speculum, in a strong light, with the head inclined backwards; a grooved director is used, if necessary, to move the tumor about, and determine its size, consistence, and point of attachment. If the tumor is covered with mucus, clearance is first effected by blowing the nose, or, this failing, by means of a pellet of cotton wrapped around the end of a probe. When the polyp lies far back, it may project into the fauces, and thus satisfac- torily reveal its character; should it not yet have descended, the index finger is intro- duced into the mouth, and carefully carried around the velum of the palate. There are several circumstances which generally serve to distinguish a gelatinoid from a fibrous polyp. In the first place, they differ essentially in their complexion ; the former being always white, like an oyster, a lump of mucus, or a mass of jelly, whereas the latter is of a deep red, purple, or modena color. Secondly, the gelatinoid polyp is generally smaller, and, consequently, its existence less marked in dry than in damp weather, which is not the case with the fibrous tumor, which is not affected by atmospheric vicissitudes of any kind. Thirdly, the discharge is always less profuse, less offensive, and less bloody in the gelatinoid than in the other form of the disease; and, finally, there is rarely any involvement of the general health in the former affection, while in the latter it seldom escapes, especially in the advanced stages. Moreover, the fibrous polyp usually grows much more rapidly than the other, and has a much greater tendency to encroach injuriously and disfiguringly upon the surrounding structures. In all cases of doubt the nares should be carefully inspected under reflected light from a Makenzie lamp and the aid of a rhinoscopic mirror. The turbinated bones, from the upper of which the more common varieties of polyps generally spring, are usually affected. In case, however, the growth is uncommonly large, it may, by its steady pressure, gradually soften their structure, and finally cause even partial absorption, as I have witnessed in several instances. In the harder polyps, and in polyps of a sarcomatous nature, attended with rapid development and great bulk, not only the spongy, but also the proper bones of the nose, and, indeed, the osseous walls of the nose, are occasionally deeply involved. 290 INJURIES ANI) DISEASES OF THE NOSE. CHAP. VII. Of the causes of nasal polyps nothing is known. The disease is often ascribed to the effects of external injury, the employment of snuff, the habit of picking the nose, and the irritation of decayed teeth; but it is very questionable whether it is ever induced in any of these ways. The most operative one, it has always seemed to me, is chronic catarrh. Males suffer from it much ofterier than females. Polyps may attain a large size in a few months; or, after having made some progress, remain stationary for an indefinite period. I have seen the gelatinoid tumor attain, in less than a year, the volume of a hen’s egg. Treatment—There is no doubt that a gelatinoid polyp of the nose is occasionally amen- able to local remedies; but the cures thus effected are uncommon, and cannot serve as rules of practice, even in ordinary cases. At one time a good deal of confidence was placed in the use of finely pulverized bloodroot, as a snuff, in the treatment of this affec- tion ; the insufflation of tannic acid has also been recommended ; and, in 1859, Dr. J. II. Reeder, of Illinois, published the particulars of two cases in which prompt cures were Fig. 222. obtained by strong injections of the tincture of chloride of iron, conjoined with the appli- cation of a piece of sponge moistened with a solution of this article to the cavity of the nose. Cures have also been effected by throwing from five to ten drops of pure acetic acid into the morbid growth. Such treatment is evidently adapted only to the softer varieties of nasal growths. Removal of the or- dinary nasal polyp is usually easily effected by torsion with the forceps. Very suitable instru- ments for this purpose are represented in the adjoining sketches, tig. 222. They are very light and slender, being seven inches and a half in length, and provided with large rings. The blades, which are nearly three inches long, are fenestrated, and grooved internally, with well- serrated margins. The great fault of the com- mon polyp-forceps is that they are too short and clumsy. When the tumor is situated in the upper and back part of the nose, a curved in- strument may sometimes be advantageously em- ployed. The mode of apptying the forceps is represented in fig. 223. The patient being seated upon a chair, in a strong light, with the head supported upon the breast of an assistant, the operator intro- duces the forceps as high as the origin of the tumor, which is then seized by expanding the blades over its pedicle, and twisted off by turn- ing the instrument several times very gently upon its axis. No pulling or traction is per- missible, lest injury should be inflicted upon the mucous membrane, or the turbinated bone be torn away. If the tirst attempt is unsuc- cessful, or if a part of the polyp is broken off, the instrument is reinserted, again and Polyp-forceps. Fig. 223. Mode of Extracting a Nasal Polyp. CHAP. VII. AFFECTIONS OF THE NASAL CAVITIES. 291 again, until the object is accomplished, not a particle of the grow th being left behind, it being desirable, if possible, to effect complete clearance at one sitting. When there are several tumors, they should all be dealt with in a similar manner. The blood which flows during the operation has a tendency to conceal the polyp, but it is easily dislodged by blowing the nose, the sound nostril being compressed, to render the effort more effec- tive. If riddance is impracticable in this wise, a stream of cold water, or of vinegar and water, is thrown up with a large syringe. It is rarely necessary to suspend the operation on account of hemorrhage ; the bleeding is usually slight, and nearly always ceases spon- taneously in a few minutes. When it threatens to be copious and persistent, plugging of the nose may be proper. When the tumor is situated far back in the nose, or hangs down into the fauces, it may occasionally be broken off with the index-finger, introduced into the mouth, and carried round the palate. In this way I promptly succeeded in removing, not long ago, a large gela- tinoid polyp from a youth of seventeen ; but such a procedure would be perfectly futile in a fibrous polyp, or even in a gelatinoid one with a broad base. In the case adverted to, the tumor had a very narrow footstalk, attached to the posterior extremity of the inferior spongy bone, and was, therefore, easily torn away. Nothing can be accomplished here with the forceps, however ingeniously curved and dexterously used, as there is no space for their application. When, therefore, the means just described are unavailing, removal must be effected with the double canula and a stout silver wire, represented in fig. 224. Fig. 224. Double Canula. The instrument, which is four inches and a half in length, is conveyed along the floor of the nostril as far as the fauces, when the loop of the wire is properly expanded, and passed by means of the index finger around the neck of the tumor, as near as possible to its origin. The ends of wire are then firmly but cautiously pulled, and secured to the shoulders of the canula. The annexed cut, fig. 225, exhibits the mode of applying the Fig. 225. Mode of Ligating a Xasal Polyp. instrument. The strangulation is seldom completed under three or four days, during which it is necessary to tighten the wire occasionally. When the polyp is nearly ready to drop off, the finger is introduced into the fauces, and the canula rotated on its axis, to 292 INJURIES AND DISEASES OF THE NOSE. CHAP. VII. promote tlie separation, lest, taking place during sleep, the tumor pass into the windpipe or oesophagus. In the gelatinoid form of the disease, the safest and most expeditious plan is to twist off the polyp the moment it is fairly embraced with the wire. The use of the wire loop drawn through a canula, modelled on the appliance of Gooch for the uterus or that of AVilde for the ear, has lately been gaining advocates both abroad and at home. I have occasionally succeeded in removing a fibrous polyp, when situated far back on the floor of the nose, or at the posterior naris, with an instrument shaped like a common chisel, about two lines in width, and bevelled off to a moderately sharp edge on one side of its extremity. The growth is easily scraped away from its connections, especially if counterpressure he applied to it with the index finger in the fauces. The operation, however, is liable to be attended with a good deal of bleeding, rendering it occasionally necessary to plug the nose. Some surgeons are very partial to the employment of the galvano-cautery as a means of effecting riddance of nasal polypi. Such an expedient is very proper when the morbid growths are very small and numerous, when they are adherent by a very thin and narrow base, or when they manifest an uncommon tendency to recurrence ; but it can never supersede the more ordinary means in the more ordinary forms of the affection. Besides, the use of the galvano-cautery is not without danger, from its liability to cause severe inflammation or erysipelas not only in the nose but also in the throat and especially in the Eustachian tube and ear. A very narrow naris, of course, acts as a barrier to its successful application. When the morbid sensibility of the mucous membrane of the nose is very great, as so often happens in chronic catarrh, a certain amount of preliminary treatment, consisting in the frequent tickling of the parts with a small camel-hair pencil, may be required before the galvano-cautery can be employed with advantage or safety. When the fibrous polyp is of extraordinary bulk, and quite inaccessible by the means now pointed out, its removal can be effected only by the knife, or the knife and saw. When the disease is carcinomatous, no operation should be attempted, not even with a view to temporary alleviation ; much blood will be likely to be lost, the manipulations will be tedious and painful, and the patient may die on the table. Under opposite circumstances, the operation is performed at all hazards, and with a prospect of a favorable issue. An incision, in the form of an inverted _]_, is made along the junction of the nasal and maxillary bones, commencing immediately below the lachrymal sac, and terminating a little below the level of the nostril, the flaps being dissected up, and held asunder. No particular treatment is required after the more common operations of this kind ; there is usually very little inflammation or discharge, and in a few days the patient, under ordinary care, is able to go about his business. To prevent relapse, a solution of nitrate of silver, zinc, copper, or alum may be injected once a day. In general, however, the practice may advantageously be dispensed with, as it is only when there is evidence of persistent morbid action that it is likely to prove beneficial. In the gelatinoid variety of the affection, where the tendency to regeneration is sometimes most remarkable, and also in the gregarious form of this disease, I have occasionally broken off'as much as one- half’ and even two-tldrds of the implicated spongy bone, believing that this procedure was greatly preferable to the frequent repetition of the ordinary operation. For the removal of naso-phctryngeal polyps two distinct operations may be practised ; one of which, originally proposed by Nelaton, consists in the division of the soft and hard palate, and the other, devised by Langenbeck, in the temporary depression of the upper jaw. Excision of the entire maxilla, first executed by Syme in 1832, and at one time recognized as a justifiable procedure, is no longer deemed advisable. The method of Nelaton is more especially applicable when the tumor is situated partly in the nose and partly in the pharynx, or when it springs from the middle of the base of the skull, the superior portion of the spine, or the internal surface of the pterygoid process, at the same time sending a prolongation into the pharynx. It is executed by dividing, first, the soft palate in its whole length, and then, by means of the saw and pliers, so much of the hard palate as may be necessary to afford complete access to the parts, the mucous membrane and periosteum having previously been raised from the bone. When the tumor is not very bulky, the operation may be limited to the soft palate, as advocated by Marine, of Avignon, in 1747, and modified by Maisonneuve, in 1859, by leaving the uvula intact. Through this opening, denominated the “palatine button hole,” the base of the growth is encircled by a loop of wire and removed by crushing. Depression of the jaw, as originally practised by Von Langenbeck, in 1859, is required CHAP. VIT. AFFECTIONS OF THE NASAL CAVITIES. 293 when the polyp springs from the petrous portion of the temporal bone, the petro-occipital suture, or the borders of the foramina lacera, thus rendering it inaccessible by the mouth. When the tumor is of unusual bulk, or when it has very firm and extensive attachments, it may be necessary to invade both bones, as in the remarkable case of Dr. Cheever, of Boston. In the operation, as performed by the Berlin Professor, a slightly crescentic incision with the convexity downwards is made from the ala of the nose along the lower border of the malar bone as far as the middle of the zygoma. A second incision, begin- ning at the centre of the root of the nose, is carried along the inferior margin of the orbit, across the frontal process of the malar bone, and joins the other at an obtuse angle. Leaving the integument intact, the periosteum is now divided along the tracks left by the knife, and the masseter muscle separated from its connection with the malar bone. With a narrow saw the jaw is cut through horizontally from behind forwards, the point of the instrument being guided by the finger introduced through the mouth into the pos- terior naris. The saw is then moved in the line of the upper incision as far as the lachry- mal bone. The flap of jaw, if so it may be termed, made by this procedure, is thus left merely adherent to the nasal bone, and to the ascending process of the maxillary bone, covered by its soft parts. The hard palate and the alveolar process also retain their integrity. The loosened jaw is now slowly pried upwards by an elevator inserted beneath the malar bone, and moved as on a hinge upon the sutures between it and the nasal and frontal bones. The tumor, thus rendered accessible, is then removed, when the jaw is restored to its natural position, the edges of the wound being united by suture. When Von Langenbeck’s last report of this operation was made in 1869, he had performed it altogether thirteen times, with ten complete cures and three deaths, the latter being cases in which the morbid growth had perforated the base of the skull, and in which re- moval was followed by meningitis. Osteoplastic resection, as this operation is now gen- erally called, has also been practised by other surgeons, as Esmarch, Wagner, Weber, Billroth, Simon, and Cheever. Dr. Cheever, who was the first to repeat Von Langenbeck’s operation in this country, has reported the particulars of two cases, in one of which he was compelled, on account of the great size and median situation of the tumor, to divide both jaws in order to obtain the requisite degree of access. The primary incision extended along each side of the nose in the direction of the natural wrinkle from near the inner canthusof the eye around the ala through the middle of the lip. The flaps being freely reflected as far upwards as- the malar prominences, and the body of the bone divided with a narrow saw from the tuberosity forwards on each side to the middle meatus of the nose, the nasal septum and vomer were cut with strong scissors. The two jaws, hinging merely on the pterygoid processes, were now depressed, thus exposing the tumor, the attachments of which to the sphenoid and ethmoid bones were severed with scissors and chisels. The jaws were then restored to their normal position and retained firmly by silver wire passed on each side through the malar bones. The operation, which reflects great credit upon Dr. Cheever, unfortunately proved fatal at the end of the fifth day from exhaustion, although the man had not lost much blood. Ollier, in a case of polyp weighing six ounces, effected removal through the upper meatus by turning down the nose over the upper lip by a fj-shaped incision, commencing over the bridge of the nose, and sawing through the organ obliquely from above down- wards. The root of the flap in this procedure is at the junction of the aloe and septum of the nose with the upper lip. When the tumor is very large, or situated unusually far back, Ollier suggests a second incision carried backwards from the meatus to meet the previous one, in order that, by lifting out a wedge from the jaw, more easy access may he obtained to the morbid growth. The operation of Ollier was successfully repeated by Cheever in 1878. None of these operations are followed by any serious mutilation, and as the flaps have an abundant arterial supply there is no danger, if proper attention be paid, during the after-treatment, of gangrene. The great risk after all of them is from erysipelas and septicemia. The bleeding is generally easily controlled. Free use should be made during the progress of the cure of chloralum and other means of cleanliness. A remark- able fact in connection with these procedures is that the palatine operations are more unsatisfactory than those in which ablation of the jaw is practised. Thus, of 25 cases of the former collected by Verneuil, 7 died, while of 11 examples of total resection only 1 proved fatal. In a case of naso-pharyngeal polyp with strong attachments to the borders of the pos- 294 DISEASES AND INJURIES OF THE NOSE. CH AP. VII . terior naris and the base of’ the skull in a young man under my charge, in 18G9, I suc- ceeded, after a good deal of effort, in wrenching off the tumor by means of a strong vol- sella passed through the inferior meatus, the inferior turbinated bone having previously been pushed aside to facilitate the necessary manipulations. The growth was of a very firm, fibrous character, fully the size of a pullet’s egg. Very little hemorrhage attended the operation, but there was so much oozing of blood the next day as to require the inser- tion of a tampon, wet with Monsel’s solution, behind the palate. Evulsion, however, is not free from danger. In a case recorded by Mr. Cooper Foster, it was attended with fracture of the cribriform plate of the frontal bone and followed by death, on the twelfth day, from general arachnitis and limited sloughing of the brain. Whatever process be adopted, the surgeon cannot fail to perceive the necessity of thor- ough work. With this view, after the main tumor has been removed, its base should be completely scraped away, along, if possible, with the mucous membrane and periosteum to which it was attached. To do less, would entail a speedy recurrence of the disease. 13. Exostosis Exostosis of the nasal cavity is a very uncommon occurrence. It probably, in most cases, originates in the antrum of Highmore, from which it gradually extends into the nasal cavity by causing absorption of the surrounding osseous structures, as the wall of the antrum, the vomer, and the spongy bone. However this may be, the growth may eventually acquire a very large bulk, completely obstructing the nasal cavity, and occasioning great deformity of the face. The principal symptoms are muco-purulent discharge, pain, and impediment in respiration. The diagnosis is established with the finger and probe. The structure of the tumor is generally of ivory-like consistence, in- terspersed with small cavities occupied with gelatinoid, fibrous, or cartilaginous matter. Removal is effected with the knife, saw, pliers, and chisel, either through the nose, or, if the mass is very bulky, through the face. In a case under the care of Dr. Cohen, of the Jefferson Medical College Hospital, an exostisis on the floor of the nasal cavity was very expeditiously ground off with the burr of the surgical engine, after exposure by incision of the overlying mucous membrane, and elevation of the periosteum, which was replaced at the close of the operation. Spontaneous detachment sometimes occurs, as in the re- markable cases reported by Legouest and Dr. Duka, of Bengal, in both of which, how- ever, notwithstanding this circumstance, dislodgement could not be effected until after the partial removal of the superior maxillary bone, so completely were the tumors im- pacted in the nasal cavity. In cases of this descrip- tion, it is very probable that the tumor is developed from the membranes rather than from the bones of the nasal cavity. 14. Chondroma The cartilaginous tumor of the nasal fossa is extremely uncommon : inthefevv instances in which it has hitherto been observed, it occurred in connection with the septum, or the septum and floor of the nose in young subjects. It has been observed in combination with sarcoma, as in the case recorded by Mr. Stanley; and in such an event the growth differs from true enchondroma in its rapid growth and its disposition to penetrate the skull through the ethmoid bone. As the cartilaginous tu- mor rarely attains a large size, it may be removed through the nostril with the gouge and chisel. 15. Malignant Tumors The nose is occasionally the seat of sarcoma, and soft, medullary, or glandular epithelioma ; sometimes by extension from the max- illary sinus, but more generally by direct develop- ment from the bones, periosteum, or glands of the mucous membrane ; chiefly in children and young persons ; marked by the usual local symptoms, and invariably tending to destruction. The tumor, which may spring from almost any part of the nasal cavity, is liable to be confounded with polyp; but from this it may commonly be readily distinguished by its broad attachment, by the remarkable rapidity of its growth, by its disposition to encroach upon the surrounding structures, and, in case of carcinoma, by the great abund- ance and foulness of the accompanying discharge, and by the early appearance of consti- Fig. 226. Carcinoma of the Nose. CHAP. VIII. EXAMINATION AND MEDICATION OF LARYNX. 295 tutional cachexia. The tumor is very friable, and often bleeds profusely from the slightest injury. The horrible disfigurement produced by this disease is well represented in fig. 226. The treatment is purely palliative, operative interference being entirely out of the ques- tion. By attention to cleanliness, a nourishing diet, and the use of opiates, the patient is rendered comparatively comfortable, and enabled to eke out his miserable existence. CHAPTER VIII. DISEASES AND INJURIES OF THE AIR-PASSAGES. The principal surgical affections of the air passages are, inflammation, oedema, croupous deposits, ulceration, morbid growths, epithelioma, spasm, stricture, and foreign bodies. Before I proceed to describe these lesions, it will be necessary to offer some remarks upon the proper mode of inspecting the air-passages with a view to their more ready detection. I EXAMINATION AND MEDICATION OF THE LARYNX. The investigation and treatment of the maladies of the larynx and trachea were, until recently, much embarrassed for the want of proper mechanical appliances by which the interior of these structures could be brought into view ; but the diffi- culty has, in a great measure, been overcome by the introduction of Garcia’s laryngoscope, by Dr. Czermak, of Pesth, who commenced his researches in 1857, and to whom is undoubtedly due the credit of being the first to practise laryngoscopy upon scientific principles, although a similar idea had previously occurred to Babington, Beau- mes, Liston, and others. The laryngoscope consists of a brilliant glass mirror, fig. 227, of a square, oval, or, preferably, a circular shape, mounted on a flexible but firm rod, which may be secured in a movable handle, and, on an average, about three-fourths of an inch in diameter by one line in thick- ness. Previously to its introduction it should be slightly heated, either by holding it over a flame, or by plunging it into hot water, to prevent the respired air from becoming condensed upon its surface, and so ren- dering it unfit for use. For lighting up the larynx and pharynx, in the absence of sufficient daylight, all that is necessary is an argand lamp, furnished with a concave glass mirror for reflection, about three inches in diameter, and with a small central aperture. In conducting the examination, by artificial light, the source of illumination is adjusted a little behind and to the right of the patient, so that the flame may be on a level with the roof of the mouth. The patient slightly advances his body, and throws the head a little back- wards, the mouth being well opened and the tongue depressed. The observer, seated directly opposite to him, uses his left hand to support his neck and chin, or to control his tongue, while with the right he holds the laryngoscopic mirror, at the same time looking through the perforation of the reflecting mirror. The light and the position of the observer and patient being thus properly regulated, as delineated in fig. 228, the former warms the instrument in the man- ner above indicated, and requests the latter to take alternately a deep inspiration and to utter the vowel sounds ah, eh. By this procedure the velum and uvula will be raised, allow- ing the easy introduction of the instrument, to which a proper inclination should then be given, so that the rays of light from the reflecting mirror may illuminate it; while the epiglottis will be elevated so as to expose the interior of the larynx. The speculum, by throw- ing the rays into and upon the larynx, reflects the reversed image of the parts to the eye of the observer. With a little care, any source of illumination may be utilized in an emergency, and in almost any position ; as, for example, from a chandelier or ordinary side bracket. A slight Fig. 227. Laryngoscopic Mirror. 296 DISEASES AND INJURIES OF AIR-PASSAGES. CHAP. VIII. knowledge of the ordinary optical laws will enable the operator to place his patient in the most favorable position. With a little perseverance, any one may soon learn to bring into view' tbe base of the tongue, the layrngeal surface of the epiglottis, the vocal cords, the ventricles of the larynx, and even the bifurcation of the trachea, on the one hand, or the Eustachian tubes, the posterior nares, and the pharyngeal vault when the reflecting surface of the mirror is turned upwards, for rhinoscopic use, on the other. It is advisable, however, to begin the study upon the excised human larynx, or to msike the examination upon one’s own per- Fig. 228. Mode of Conducting a Laryngoscopic Examination. son, in order that the observer may gain a sufficient amount of proficiency in the use of the instruments before applying them to a patient, as well as to accustom himself to the altered position of the parts, as, in the reflected image, they are seen reversed from before backwards, although in their proper position in relation to the right or left side of the body. Great care must be taken in introducing the mirror to avoid unnecessary contact of the fauces and pharynx, lest the act of swallowing or vomiting be provoked ; and in some subjects the parts will be found to be so irritable as to require some preliminary training, as in the operation for cleft palate, to render them tolerant of the presence of the specu- lum. For medicating the pharynx and even the larynx, the self-retaining tongue depres- sor of Dr. Henry Church, of New York, or the laryngoscopic mouth-piece of Dr. Elsberg, will sometimes be found very convenient, as it leaves one hand of the operator free to make the necessary applications. For the introduction of the treatment of affections of the air-passages by cauterization, we are mainly indebted to the labor and writings of the late Dr. Horace Green, of New York, although attention had previously been directed to the subject by Brettoneau, Sir Charles Bell, Trousseau, and other practitioners. The recommendation met with much opposition and even obloquy, and it is only within a comparatively recent period that its value has been fully established. Few surgeons, however, will pretend to be able to carry a mop down into the trachea, as Dr. Green alleged he had so often done. To cauterize even the interior of the larynx requires, according to my observation, no ordinary skill ; indeed, it is safe to affirm that this cannot be done without a great deal of experience and manual tact. The operation is particularly indicated in chronic affections of the larynx, whether simple, syphilitic, or tubercular, or dependent upon the presence of warty excrescences. It is also very efficacious in acute inflammation, especially in diph- theria and membranous croup. Aphonia, caused by disease of the larynx, is likewise a suitable case for its employment, and it is particularly valuable in the treatment of throat affections so common among clergymen, singers, and other classes of people ac- customed to the constant use of the voice. The article with which the cauterization is effected is the crystallized nitrate of silver, in the form of solution, in the proportion of twenty to forty grains to the ounce of water. CHAP. V 1 11 . EXAMINATION AND MEDICATION OF LARYNX. 297 When ulceration is present, or when the medicine has ceased to produce the desired effect, the strength of the solution may be considerably increased ; but for ordinary purposes this is unnecessary. Ingenious instruments for mopping the air-passages have been devised by Semeleder, Elsberg, Gibb, and others. Ordinarily, a probang, like that sketched in fig. 229, answers Fig. 229. Sponge-probang for the Larynx. sufficiently well. It consists of a thick whalebone rod furnished with a stout handle, and bent at an angle of nearly 45°, the curved extremity being surmounted by a camel-hair brush or small, roupd piece of sponge, of great softness and delicacy, and securely attached by means of a strong thread. The whole instrument is about ten inches in length. The sponge or brush being slightly moistened with the caustic solution, the patient, seated upon a chair, is requested to open his mouth as widely as possible, and to take a full in- spiration, followed by a gentle expiration, thus placing the parts in the best condition for the easy introduction of the instrument, and the prevention of spasmodic cough. While this is being done, the surgeon depresses the tongue, and carries the probang over the top of the epiglottis, and thence suddenly on, over the lower surface of that cover, downwards and forwards through the mouth of the larynx into the interior of that tube. A momentary contact is all that is necessary. The operation is generally followed by some cough, but this soon passes off, leaving the part and system comparatively comfortable. When the spasm is unusually violent, threatening suffocation, I have found the best remedy to be the inhalation of a little chloroform, which usually affords almost instantaneous relief. The operation in chronic diseases should not be repeated oftener than every third or fourth day; in acute, on the contrary, it may be required every eight, ten, or twelve hours. For making caustic and astringent applications in a strong solution to circumscribed localities in the interior of the larynx, or on the epiglottis, as, for example, to a small ulcer, a tiny fragment of soft surgical sponge, may be safely secured in a suitable sponge carrier, fig. 230, and be directed to the desired spot under guidance of the image in Fig. 230. Cohen’s Laryngeal Sponge Carrier. the laryngoscopic mirror. A delicate camel-hair pencil is sometimes employed for a similar purpose; but the sponge is preferable as a means of cleanliness, as it is thrown away after each application. For applying solid nitrate of silver to the larynx and epiglottis, the most simple and efficient instrument that I know of is a pointed probe like that of Dr. Lente, sketched in fig. 231, roughened at its point, which is to be dipped into the salt melted for the purpose in a test tube, or a special little platinum crucible. The caustic adheres firmly for many minutes. In the use of this substance great care must be exercised that it does not break 298 DISEASES AND INJURIES OF A I R-P A S S A G E S . CHAP. VIII. off and fall into the windpipe ; and it is, therefore, desirable that the probe should be freshly coated at the time the application is about to be made. Injections of nitrate of silver may be practised when the disease is situated in the trachea and bronchial tubes beyond the reach of the probang, the operation being per- formed with a small syringe, fitted to a narrow gum-elastic catheter, a little upwards of one foot in length, inserted into the interior of tiie larynx, and thence passed rapidly on Fig. 231. Lente's Porte-Caustique. into the windpipe, until only about two inches and a half of the tube project beyond the front teeth. The fluid must be thrown in as quickly as possible, lest the procedure pro- voke violent coughing, and thus prove abortive. The strength of the solution should vary from ten to twenty grains of the salt to the ounce of water, to be gradually increased with the tolerance of the parts, the quantity injected at any time not exceeding a drachm and a half, one-third, or less, of this being quite sufficient at the beginning of the treatment. The operation, which is often followed by severe spasm, and which requires unusual dex- terity for its successful execution, may be repeated every third, fourth, or fifth day, according to the exigencies of the case. When the object is merely to medicate the larynx, or the larynx and the upper part of the trachea, the operation may be performed with the instrument delineated in fig. 232. Fig. 232. Laryngeal Syringe. It consists of a silver or rubber tube, perforated at the end, and attached to a small glass or rubber syringe. It is charged in the usual manner, and then passed into the larynx or even between the lips of the glottis, the fluid being propelled into the air-passages in a number of tine jets. Medicated sprays are often employed in the treatment of diseases, both acute and chronic, of the air-passages, and they are doubtless highly beneficial. The articles gen- erally selected are nitrate of silver, alum, tannic acid, ayd tincture of chloride of iron, in solution, very weak at first, and gradually increased in strength, according to the toler- ance of the parts, in cases needing stimulation; and preparations of opium, alkalies, bro- mides, and other articles in cases needing sedation. When the fauces and air-passages are very irritable, or the patient is uncommonly timid or unmanageable, it will be well to institute a kind of preliminary treatment, con- sisting in the frequent application of the finger, and of various instruments, to the epi- glottis, tongue, and throat, so as to educate the parts for the approaching ordeal, as in the operation of staphylorrapliy. If the fauces are inflamed, they should at the same time be occasionally brushed with nitrate of silver. II CONGENITAL DEFECTS. Partial occlusion of the rima of the glottis sometimes exists as a congenital affection, as in the interesting cases observed by Dr. Elsberg and Dr. Zurhalle. In the former of these cases, that of a girl seventeen years of age, the vocal cords were covered or united by a thick, tough, fibro-elastic membrane, so arranged as to leave only a small opening at the posterior part of the larynx for the entrance of air. When the cords were forcibly stretched, the opening was irregularly circular, and hardly a quarter of an inch in dia- CHAP. VIII. LARYNGITIS. 299 meter. The ventricles of Morgagni were unusually wide and deep. The voice was feeble, hoarse, husky, and squeaky. Dr. Elsberg cut out a portion of the abnormal mem- brane, and succeeded in effecting a marked improvement in the condition of the vocal and respiratory functions. In the case of Dr. Zurhalle, a kind of double membrane ex- isted, one of which united the anterior two-thirds of the vocal cords, while the other was situated farther down in the tube, under cover of the upper. The voice, it is said, be- came natural after the division of the abnormal structures. In a case of this kind mentioned to me by Dr. Cohen, the supposed congenital web was destroyed in its central line by repeated touchings with the galvano-caustic point; and the patient, a young girl, increased rapidly in weight and sexual development as soon as a normal amount of at- mospheric air gained access to the lungs. It must not be forgotten that a similar web occurs after ulceration of the anterior por- tions of the vocal cords, from adhesion in cicatrization. This is chietly observed in syphilis. Adhesions of the vocal cords at this point also follow their division in the operation of thyrotomy. Ill LARYNGITIS. Inflammation of the larynx, or of the larynx and trachea, is an exceedingly common affection, the result usually of cold, external violence, or the inhalation of the steam of hot water, or the fumes of irritating gases. Not unfrequently it arises from the effects of the syphilitic poison. Acute laryngitis in the adult is not likely to be attended with fibrinous deposit as in the child, but it is liable to become complicated with oedema of the larynx or of the epiglottis. As usually encountered it is a superficial inflammation yield- ing promptly to rest and moderate antiphlogistic measures. In some instances the inflammatory action is severe, involving the mucous membi’ane and the submucous tissues, and requiring much more active medication and much more frequent supervision. It yields readily, as a rule, to absolute rest and to proper antiphlogistic systemic treatment, with sedative inhalations to reduce intralaryngeal pain and tumefaction. As generally met with, the disease is most common in young children, in whom it ordinarily assumes the form of croup, which occasionally manifests an endemic charac- ter, and is extremely liable to be followed by a deposit of plastic matter, accurately moulding itself to the interior of these canals, and closely adhering to their surface. In the more aggravated cases, the deposit extends, on the one hand, up into the throat, and on the other, down into the lungs, thus causing great, if not fatal, mechanical obstruction to respiration. In 120 cases ex- amined by Houssenot, it was confined to the larynx and trachea in 78, while in 42, or one-third, it passed into the larger bronchial tubes. Fig. 233 exhibits this deposit as it occurred in one of my specimens removed from a lad who died of croup. In that form of plastic deposit known as membranous croup, tracheotomy is occasionally employed ; generally, however, at so late a period of the disease as to be of no permanent benefit. This is especially true of the operations that have been performed in this country, the great majority of which have terminated fatally. Of 783 cases which occurred at the Hopital des Enfants at Paris, 191, or 25 per cent., are said to have been successful. The subjects in all these cases had been ill for several days, and were affected with great difficulty of inspiration. Guersant, who has furnished these statistics, performed this operation 156 times in private, and saved 28 children, or 1 in Of 141 cases analyzed by Martini, 66 were cured, and 75 died. As an offset against these results, it may be added that of 351 cases of tracheotomy, performed on account of this disease, by twenty-one French surgeons, including a number of the most distinguished operators of Paris, 312 terminated fatally, affording thus a ratio of 8 deaths to 1 recovery. One of these surgeons operated forty times, and lost every one of his patients. Dr. A. Jacobi, of New York, in 1868, published the results of 213 cases of tracheotomy, performed by himself, Voss, Krackowizer, and Yon Roth, of which 50, or per cent., recovered. In diphtheria, as in croup, tracheotomy is seldom a successful operation, and still it is, in my judgment, in many cases, a highly proper one. Even when it cannot save life, it Fig. 233. False Membrane of Croup. 300 DISEASES AND INJURIES OF AIIi-PASSAGES. CHAP. VIII. should often be performed to prevent impending asphyxia, and thus afford the patient the benefit of a more easy mode of death. The operation is usually more fatal in very young children than in those several years of age, not, perhaps, on account of any greater amount of blood-poisoning, but simply because it is generally so difficult to effect proper medica- tion. In the adult, this operation has rarely saved a diphtheritic subject, probably on account of the great amount of systemic infection which ensues before the comparatively larger larynx has become sufficiently occluded to demand surgical interference. The most favorable subjects for tracheotomy are those in whom the plastic deposit is mainly con- fined to the throat and larynx, without any serious disease of the trachea, lungs, and bronchial tubes. Whenever these structures are at all extensively implicated, no treat- ment, whether medical or surgical, will be likely to be of any permanent avail. Of 754 cases of diphtheria subjected to tracheotomy at the Children’s Hospital, at Berlin, between 1861 and 1876, 31.65 per cent, recovered. The greatest mortality occurred during the first two years of life ; and it is worthy of note that the percentage of recoveries varied greatly in different years, evidently dependent upon the mildness or virulence of the disease. When tracheotomy is performed for either of these affections, a double canula must be worn until the urgent symptoms have passed off, when it may be removed, and the wound allowed to heal. The instrument should be frequently cleaned, and care taken that the air of the patient’s apartment is not only kept moist but at a temperature of eighty-two to eighty-five degrees. Sometimes large masses of plastic matter are dis- charged through the wound or by the mouth. In the latter event, asphyxia may be caused by the lodgment of some of the substance in the glottis, or by its imperfect ex- pulsion from the larynx. The most common cause of death, after tracheotomy for croup, diphtheria, and ulcera- tion, is suffocation, or exhaustion from previous suffering, from congestion of the lungs, and inadequate supply of air. Occasionally the patient perishes from oedema of the glot- tis, ulceration of the mucous membrane of the larynx, erysipelas, pyemia, or hemorrhage. Sometimes a portion of false membrane is partially or completely detached in the act of coughing, and, obstructing the ingress of air, causes speedy asphyxia. In a case of croup under the charge of Dr. Wills, of London, the child died five days after tracheotomy from ulceration of the innominate artery. Copious hemorrhage sometimes occurs at the edges of the wound, from the inflamed and congested condition of the mucous membrane. The proper remedy, in such an event, is the ligature, if the blood proceeds from distinct ves- sels ; the actual cautery, if it oozes from numerous points. A number of examples of fatal hemorrhage from this cause have been reported. The presence of the canula, after trache- otomy, occasionally excites ulceration in the wound, and even suppuration in the struc- tures around the windpipe. Syphilitic laryngitis generally belongs to the tertiary group of syphilitic phenomena, a form of the affection which, as it is described in another part of the work, need, not be reconsidered here. The proper treatment is by the iodides in union with mercury, tonics, and stimulants. When great respiratory difficulty supervenes, the only hope for the patient is tracheotomy. Laryngitis is occasionally of a tubercular nature, and then nearly always passes into ulceration. Its coexistence with phthisis renders it nearly uniformly fatal. Gangrene of the larynx is exceedingly uncommon, and almost necessarily terminates fatally under any mode of treatment, however skilfully conducted. IV CHRONIC LARYNGITIS. Chronic laryngitis is a common affection liable to occur among all classes of persons, and at all periods of life, often coining on without any assignable cause, but generally due to repeated attacks of cold, to the inhalation of irritating particles of matter floating about in the atmosphere, to the presence of morbid growths, to tubercular deposits, and above all, to a syphilitic taint of the system. Occasionally it is the result of the acute form of the disease, especially after croup and diphtheria, while in many cases its origin is directly traceable to an extension of disease from the throat, or the throat and nose. W1 latever the operating cause may be, the disease, if long continued, invariably occasions, not only severe suffering, but great structural changes in the larynx. Among the more important of these changes, are thickening of the mucous membrane, with or without enlargement of its follicles, and ulcerative action, which often makes serious inroads upon the different constituents of the tube, removing large patches of the lining membrane, CHAP. VIII. CHRONIC LARYNGITIS. 301 destroying the vocal cords, and causing erosion, and even necrosis of some of the carti- lages, especially the thyroid and arytenoid. The epiglottis is also very prone to disease. The most important local symptoms of chronic laryngitis are, change in the condition of the voice, cough, and expectoration, and difficulty of breathing and deglutition, and pain, tenderness, or uneasy sensations at the seat of the disease. An alteration of the voice is generally an early symptom of the complaint, and manifests itself in various ways; most commonly, however, it is husky or raucous, and greatly lessened in power. As the disease advances, the patient becomes either completely aphonious, or he expresses him- self in scarcely audible whispers. These changes are sometimes intermittent, being, when this is the case, usually worse at night than in the day. A stridulous state of the voice is not uncommon. Cough is a constant attendant upon chronic laryngitis, and is generally a source of great distress, especially when, as so often happens, it is of a spasmodic nature, the par- oxysms recurring with greater or less frequency, and lasting, perhaps, until the patient is almost completely exhausted. In most cases, the cough is rough, hoarse, croupal, and more or less dry ; at other times, especially when there is ulceration of the mucous mem- brane, it is accompanied by more or less expectoration of mucous or puriform matter, which, upon being detached and expectorated is usually followed by great temporary relief. The breathing is little, if at all, effected in the earlier stages and milder forms of the disease, but as the morbid action progresses, dyspnoea becomes a prominent symptom, and so continues up to the time of relief or the death of the patient. The immediate cause of the trouble may be narrowing of the glottis, paralysis of the larynx, or great general de- bility. In the more severe cases, there are generally attacks of asthma, particularly severe at night, during which the head is thrown backwards, as in true orthopncea; the patient is unable to lie down, unless he is supported by pillows, the inspiration is strongly sibilant, and the expiration loud and prolonged. Death often occurs from asphyxia. Uneasy sensations referred to the larynx, are of frequent occurrence. Sometimes there is a good deal of pain, especially when there is extensive ulceration or marked involve- ment of some of the cartilages ; and in all confirmed cases there is more or less tenderness on pressure over the seat of the disease. Difficulty is occasionally experienced in swal- lowing, especially when there is partial distraction or great thickening of the epiglottis, and, under such circumstances, it is not uncommon for a portion of the food and drink to return by the nose. More or less pain in deglutition is almost invariably present during the latter stages of chronic laryngitis. As it respects the general symptoms of this disease, they present nothing peculiar; gradual emaciation and exhaustion, with hectic fever, being the most prominent. In its earlier stages and milder forms, the disease often admits of relief; but in many cases the prognosis is unfavorable from the start, and all that can be done is to palliate suffering. The diagnosis can only be determined with the aid of the laryngoscope. The symp- toms above described afford, it is true, valuable information in a general point of view in connection with the larynx; but the particular character of the disease giving rise to these phenomena cannot be ascertained in any other manner. In the treatment of chronic laryngitis, the first aim should be to ascertain, and, if pos- sible, to remove the exciting cause. Morbid growths must be removed by operation; thickening or ulcerated mucous membrane relieved by the use of nitrate of silver, intro- duced in the manner [minted out in a previous page. A syphilitic taint of the system is met with the exhibition of the iodides, either alone or in connection with mercury, and necrosed cartilage extracted as soon as it is sufficiently loose to admit of easy removal. Leeches, blisters, and iodine are among the best local remedies. The strength must be supported in the usual manner, cough and pain controlled with anodynes, and sleep secured with chloral, and other means. The temperature of the patient’s apartment should be regulated by the thermometer, and kept at 73° Fahr. Laryngotomy is, I am satisfied, too much neglected in the purely irritative forms of laryngitis, not dependent upon the presence of morbid growths. By making an artificial opening in the early stages of the disease, whether caused by thickening or ulceration of the mucous membrane, we place the muscles in a state of repose, and afford the affected structures a much better chance for repair, to say nothing of the comfort which the operation is sure to secure from the spasmodic cough and dyspncea, which is so distressing, even in the milder forms of the disease. Abscess of the larynx is occasionally observed in very young children, as in two cases 302 reported by the late Dr. John S. Parry, of this city, in one of which the age was nine weeks, and in the other four months and a half. The principal symptoms were frightful dyspnoea, lividity of the face, dysphagia, and stridor, heard at a considerable distance from the patient. From retropharyngeal abscess, the disease is distinguished by the absence of swelling in the throat, and from oedema of the glottis by the facility with which the epiglottis may he felt and moved. As the accumulation of pus advances, the larynx forms a marked projection on front, or front and side, at the point of least resistance, and more or less distinct fluctuation is perceived, clearly denotive of the presence of fluid. The matter, which seldom exceeds two drachms in quantity, may discharge itself into the larynx ; but commonly it travels towards the skin, where, if not speedily evacuated, it finally finds an outlet. If allowed to burrow, it may invade the laryngeal cartilages and cause other serious mischief. Intralaryngeal abscess is not unusual in perichondritis, from whatever cause arising. It is sometimes produced in other affections. Its presence is recognized in the laryngo- scopic mirror as a tumid swelling, more or less conical in contour, and sometimes with distinct evidence of pointing. The local symptoms are those of obstruction. It may he discharged, if necessary, by incision with a properly curved instrument similar to the knife represented in fig. 235. V (EDEMA. The larynx is liable to oedema; sometimes as an epiphenomenon of acute laryngitis, simple or specific. The parts which are most commonly affected are the aryteno- epiglottic folds, and the epiglottis, the edges and under surface of which are usually thickened and pulpy. The lips of the glottis itself are involved only in exceptional instances. The disease, considered by many as of an erysipelatous nature, consists in an effusion of serum, or serum and lymph, in the submucous connective tissue, leading to mechanical obstruction of the tube, and serious impedi- ment in the respiratory functions. The swelling is devoid of vascularity, pits on pressure, and is generally most prominent around the margins of the larynx, which are often elevated into white, glossy, pendulous bags, not unlike those of the epidermis after the application of a blister. Small purulent deposits are sometimes seen in it, while its surface is occasionally incrusted with patches of lymph. The swelling is of a pale straw color, reddish, mottled, or greenish, and disappears almost completely when incised or punctured. The base of the tongue, pharynx, tonsils, uvula, and palate ordinarily participate in the morbid action, as is evinced by their inflamed condition. The mucous mem- brane of the larynx is heightened in color, and the lym- phatic glands in the immediate vicinity of the tube are often enlarged, infiltrated, and softened. The adjoining cut, fig. 234, from a specimen in my collection, affords a good illus- tration of this disease. (Edema of the larynx is usually insidious in its origin, and rapid in its progress, often terminating fatally in a few days. It is more common in men than in women, and is rarely observed before the age of puberty. In children, it is sometimes induced by the inhalation of steam, or by drink- ing hot water from the spout of a tea-kettle. It often comes on suddenly, during the pro- gress of different complaints, as scarlatina, measles, smallpox, tonsillitis, erysipelas, and typhoid fever. The disease is marked by embarrassment of breathing, fits of coughing, change of voice, and threatened suffocation. Most commonly, the first indication is soreness of the throat, with a sense of constriction in the upper part of the larynx, as if there were a foreign body impacted in it. The voice is hoarse, sharp, hissing, or croupish ; the cough is dry, sonorous, and convulsive ; deglutition is painful ; and the act of inspiration is performed with great difficulty and distress, while expiration is, at least at first, easy and unembar- rassed. The obstruction to the breathing seems to depend, not so much upon the dimin- ished capacity of the larynx, as upon the manner in which the tumid and infiltrated lips of the organ are drawn in, valve-like, by the air, as it rushes from the mouth into the DISEASES AND INJURIES OF A I R-P A SS A G E S . CHAP. VIII. Fig. 234. CEdema of the Larynx. lungs. The dyspnoea steadily increases ; the expiratory act becomes impeded, as well as as that of inspiration; every respiratory muscle is called into play; the head is retro- verted ; the shoulders are elevated ; the countenance is anxious and livid, from the imper- fect aeration of the blood ; and the poor patient, harassed with frequent paroxysms of suf- focation, at length dies exhausted. High fever is always present in the later stages of the malady. The distinctive signs of oedema of the larynx are, the difficulty of drawing the air into the lungs; the almost total absence of pain in the larynx; a feeling of fulness in the upper part of the pharynx, conveying the idea of the existence of an extraneous sub- stance; soreness in the throat, and impediment in deglutition, often so great as to render it almost impossible to swallow either fluids or solids. In many cases, especially in females, in whom the distance between the lips and the affected parts is, in general, con- siderably less than in men, the end of the index finger may easily be brought in contact with the elevated epiglottis and the swollen lips of the larynx. In young, restive sub- jects, it may be necessary, in conducting the exploration, to depress the tongue with a spoon, and to separate the jaws with a piece of wood. Subglottic oedema, which is ex- ceedingly rare, can only be diagnosticated laryngoscopically. The rational symptoms are those of stenosis of the trachea. The effusion is usually fibrinous. Too much attention cannot be bestowed upon the diagnosis of oedema of the larynx, the nature of which is, unfortunately, too often overlooked. There are few practitioners who cannot recall to mind cases of this kind, and who have not had reason to regret their want of early discrimination, while life was still within the reach of remedies. An error of this description is the more to be lamented, because it is always fatal to the poor suf- ferer, who is sure to be suffocated by the mechanical obstruction which the swollen parts offer to the ingress of the air. The period at which death occurs from this cause varies from forty-eight hours to three, four, or five days. The treatment of oedema of the larynx consists of purgatives, emetics, and anodyne dia- phoretics, with leeches to the throat, followed by fomentations, and by blisters to the nape of the neck. General bleeding can only be required when the patient is young and ple- thoric. When the symptoms are urgent, the affected parts must be freely scarified, to afford vent to the effused fluids, the cause of the whole respiratory difficulty. For this pur- pose, the long probe-pointed bistoury of Dr. Buck, fig. 235, with a short double-edged blade, bent at an angle of 45°, is carried into the larynx, and moved about in such a manner as to divide the tumid and infiltrated structures at different points of their extent. The operation, which should be performed while the patient’s head is thrown back, and firmly held by an assistant, the tongue being carefully depressed, and the jaws widely separated, is followed by hardly any bleeding, and is to be repeated at longer or shorter intervals, according to the amount of relief afforded. The above treatment may often be advantageously aided by nitrate of silver, a solution of which, in the proportion of twenty grains to the ounce of water, should be applied freely, not only to the larynx, but also to the surrounding parts, which, as before stated, are generally seriously involved in the inflammation. If these means fail, and the obstruc- tion to the respiration steadily advances, the only resource is tracheotomy, an operation which has often succeeded in such cases, under circumstances apparently the most despe- rate. In an instance under my care in 1855, although great relief followed the operation, the patient, a female, fifty years of age, died on the third day, from inflammation of the lungs. The ingress of air is promoted by a silver tube, or by means of hooks, as after tracheotomy for the removal of foreign bodies. The atmosphere of the patient’s apart- ment must be kept constantly moist, and not lower than 72° Fahr. Of 168 cases of this disease analyzed by Sestier, 127 died. In 132, the ordinary treat- ment was adopted, with a loss of 104. Of 36 cases subjected to bronchotomy, 13 recov- ered, and 23 perished. Scarification has afforded by far the most cures. Subglottic oedema, being usually fibrinous, would not yield to puncture, were it access- ible, which is unlikely. Threatening stenosis would, therefore, indicate a necessity for tracheotomy below the seat of occlusion. CHAP. VIII. (EDEMA. 303 Fig. 235. Knife for (Edema of the Larynx. 304 DISEASES AND INJURIES OF AIR-PASSAGES. CHAP. VIII. VI ERYSIPELAS. The larynx is occasionally attacked by erysipelas, although very rarely as a primary disease; in general, it is merely an extension of the affection from the face, tongue, and throat. In 1844, ’45, and ’4G, when erysipelas prevailed extensively as an epidemic in this country, many cases came under my observation in which it invaded the air-passages. In that form of the affection known under the name of “ black-tongue,” the morbid action usually began in the throat and fauces, or simultaneously in those parts and upon the scalp and face, as a red, glossy swelling, exceedingly painful, pitting under pressure, and attended with the most hideous deformity of the features. The inflammation rapidly ex- tended to the larynx, the lymphatic glands, and the structures generally of the neck, and even the upper portion of the chest. The tongue was dry, excessively enlarged, of a dark livid hue, and incapable of protrusion ; the uvula, tonsils, and arches of the palate were deeply discolored, rigid, and (edematous ; the submucous connective tissue of the larynx and trachea was extensively infiltrated with serum, or serum and lymph ; the lungs were in- flamed ; the bronchial lymphatic glands were softened; and the thoracic cavities often contained a considerable quantity of serum and pus. If the patient survived any length of time, profuse suppuration, and sometimes even extensive sloughing, occurred ; abscesses formed in the neck and other parts of the body ; and ulcers, of different shapes and sizes, appeared in the throat. The parotid glands sometimes suffered very severely. The general symptoms, in the more common forms of erysipelas of the larynx, are either of a low, typhoid character, or they soon assume that type ; the pulse is weak, small, and frequent; the respiration is hurried and stridulous, inspiration being especially difficult; the stomach is oppressed by nausea, or nausea and vomiting; the bowels are constipated, the skin is hot and dry, the urine is high-colored and scanty, and there is excessive thirst, with great restlessness and anxiety. Delirium often sets in at an early period of the attack. The mucous membrane of the throat is of a red, scarlet, or crimson hue, and the glottis, as seen with the laryngoscope, is in an oedematous condition. The danger in this disease is generally imminent, most of the cases terminating fatally within the first four or five days, the immediate cause of death being asphyxia or exhaus- tion. Those who survive have always a tedious convalescence. The diagnosis rests mainly upon the history of the case, the peculiar character of the discoloration of the mucous membrane of the throat, the great swelling of the neck, the difficulty of respiration, and the coexistence of erysipelas upon the external surface. The discrimination will be very difficult, if not impossible, when the disease is confined mainly to the fauces and larynx. The treatment must generally be of a tonic and supporting character, even in its very incipiency. If the patient be young and robust, leeches may very properly be applied to the neck, over the region of the larynx, followed by a large blister; but the use of the lancet is usually wholly inadmissible. Emetics are often serviceable, especially when the throat and windpipe are clogged with mucus ; and the bowels should be gently evacu- ated with a mild mercurial purgative. The most suitable tonics are quinine and iron with milk punch, and anodynes to allay pain and cough. If symptoms of asphyxia arise, relief should be attempted by scarification of the infiltrated structures ; or, if the vital powers are not too far exhausted, tracheotomy may be performed. Abscesses of the neck, tongue, pharynx, and tonsils should be promptly opened, to abridge suffering and prevent suffocation. VII ULCERATION. Ulcers of the larynx, of a common, tubercular, syphilitic, or mercurial origin, are not unfrequently met with. Commencing usually in the muciparous follicles, or in little abscesses beneath the lining membrane, they are irregularly circular in their shape, super- ficial, from one to two lines in diameter, and surrounded by thin, grayish edges. The mucous membrane in their immediate vicinity is generally softened and abnormally red, but now and then it appears to be entirely sound. The ulcers, although they may occur in any situation, are most common in the vocal cords, the ventricular bands, the base of the arytenoid cartilages, the ventricles of Morgagni, and the epiglottis, the latter of which is particularly liable to suffer in tertiary syphilis. Ordinarily small and shallow, they sometimes occupy a large surface, or extend to a great depth, exhibiting a frightful appear- ance, and destroying, in their progress, muscles, ligaments, cartilages, and everything else that comes in their way. CHAP. VIII. ULCERATION. The symptoms of ulceration of the larynx vary according to the nature, seat, and ex- tent of the lesion. The syphilitic form, fig. 236, from Jones and Sieveking, is generally the most severe, but the tubercular is also not unfrequently attended with much pain and distress. When the vocal cords, the ventricles, or arytenoid cartilages are involved, there will be a sense of heat and pricking in the larynx, hacking cough, a husky, wheezing, or whistling state of the voice, and difficulty of breathing, along with purulent and bloody expectoration. As the disease progresses, the voice is re- duced to a mere whisper, or becomes completely extinct, severe pain is experienced in the affected parts, hectic fever supervenes, and the patient finally dies from exhaustion of the vital powers, effusion into the lungs, or constitutional irritation. The suffering is greatly aggravated when the epiglottis is seriously implicated; for there is then not only dyspmea, with cough and change of voice, but every at- tempt at deglutition is attended with great distress, if not with a feeling of instant suffocation. In the more advanced stages of the malady, whatever may be its character or situation, the difficulty of swallowing is often so extreme that life is essentially abridged by starvation, the patient being sometimes unable for days together to take even liquids. Ulceration of the larynx is always a dangerous disease. If the more common forms are occasionally recovered from, the more aggravated nearly always prove fatal. This is particularly true of the syphilitic and tubercular varieties, very few cases of which, especially in their more advanced stages, are ever cured under any treatment. The latter is, as a general rule, even more dangerous than the former. It is, too, particularly liable to eventuate in stenosis or stricture from vicious cicatrization of the ulcerated surfaces and the organization of fibroplastic deposits in the tissues surrounding the ulcers. Serious involvement of the muscles, ligaments, and cartilages is always denotive of great danger, whatever may be the nature of the exciting cause of the lesion. Ulceration of the epiglottis, usually the result of tertiary syphilis, may also be caused by the contact of irritating substances, as hot water, the alkalies, or corrosive sublimate, as in a case from which the annexed cut, fig. 237, was taken, and in which death followed in nine days from swallowing a large dose of this poison. The dis- section revealed, besides ulceration of the epiglottis and surrounding parts, the existence of pneumonia, ulceration of the stomach, and inflammation of the entire intestinal track. The drawing is from Jones and Sieveking. It must be obvious that the treatment of a dis- ease, depending upon so many and such various causes, and the diagnosis of which is so obscure, cannot be conducted with much prospect of per- manent relief. Indeed, experience has shown that temporary amelioration alone is usually to be looked for. When there is reason to believe that the lesion is owing to a syphilitic taint, mercury, iodide of potassium, nitromuriatic acid, and kindred articles, must be employed. In ulceration, consequent upon tubercular deposits, little or nothing is to be ex- pected from internal remedies, beyond the beneficial influence which they may exert upon the general health. In all cases, whatever may be the origin of the malady, permanent quietude of the affected organ is indispensable. Hence, the patient must refrain from all conversation, and even, as far as practicable, from deglutition. Local suffering may often be subdued for a few hours at a time, by the careful propulsion upon the sore parts of morphia powder, a third of a grain at a time. When there is much general pain, soreness, or Fig. 236. Ulceration of tlie Larynx. Fig. 237. Ulceration of the Epiglottis. DISEASES AND INJURIES OF A I R-P A SS A G E S. tenderness in the parts, a few leeches may occasionally be applied to the front of the larynx, or the nape of the neck may be rendered raw with a blister. The best local remedy, however, is a solution of nitrate of silver, in the proportion of twenty to thirty grains of the salt to the ounce of water, with which the ulcerated surface should be gently but efficiently touched, through the natural passage under laryngoscopic inspection, or through an artificial opening in the larynx or trachea as may be indicated, every third, fourth, or fifth day, according to the tolerance of the parts. If suffocation be threatened, tracheotomy must be performed, and a tube worn not only to facilitate respiration, but to save life. VIII.—STRICTURE. Stricture of the larynx or of the windpipe, fig. 238, may be induced by a deposit of fibrin in the mucous and submucous connective tissues, or, as is more frequently the case, by the contraction consequent upon a wound, the healing of a huge ulcer, or the death and exfoliation of a portion of one of its cartilages. A bad form of coarctation sometimes arises as an effect of syphilis. Great diminution of the tube may be caused by the pres- sure of an enlarged thyroid gland. The symptoms are those of im- peded respiration, gradually increasing, and surely tending to the de- struction of the patient. The diagnosis is established by the history of the case, and by a careful laryngoscopic inspection, aided, if need be, by exploration of the tube with the probang. Relief may be at- tempted, although with hardly any prospect of success, by systematic dilatation with the bougie, passed from the mouth, or from below up- wards, through an opening in the trachea. Attempts at dilatation are not justifiable until cessation of the diseased process which has produced the stenosis. The treatment is conducted on the same principles as in stricture of the urethra, oesophagus, and other mu- cous outlets. When the parts are very irritable, cauterization pre- cedes the dilatation ; and when the latter operation is impracticable, on account of the intractableness of the patient, control is effected by anaesthesia. In desperate cases the trachea is laid open, and a silver tube worn. By such a procedure, a patient may sometimes live in comparative comfort for many years; and dilatation from the mouth be practised without danger to his existence. IX TUMORS OR MORBID GROWTHS. Morbid growths of the larynx, formerly described as polyps and warty excrescences, may be arranged, according to their anatomical characters, under the following heads : papillary, fibrous, sarcomatous, myxomatous, adenomatous, cystic, chondromatous, lipomatous, and angiomatous, the supposed frequency of their occurrence being very much in the order here enumerated. The papillary tumor is more common than all the others together. Thus, of 100 cases observed by Dr. Morell Mackenzie, of London, G7 were of this description, and Dr. Cohen, of this city, met with 49 papillomas out of 60 morbid growths ; results which tally very closely with the experience of other specialists. Compound growths, consisting of a combination of neoplastic elements, are not uncommon, the mixed structures being often so nearly balanced in quantity as to render it difficult, if not im- possible, to determine which predominates. Of the carcinomatous growths of the larynx the epithelial is the most common. The soft glandular variety is met with only in about one-fifth of all instances. In regard to their form, tumors of the larynx exhibit great diversity ; most commonly, however, they are globular, ovoidal, conical, or pyriform, and either perfectly smooth, or, as in the case of the papillary varieties, rough, granulated, or fissured upon the surface like a cauliflower, mulberry, or wart. Of a pale-rose, pink, red, or grayish color, they vary in consistence, according to their structure, from soft, gelatinous matter to dense fibrous tissue. Their volume ranges between that of a mustard seed and an English walnut. As it respects their mode of attachment, they are either sessile or pedunculated ; more frequently the former. Their favorite seat is the interior of the larynx, at or near the vocal cords. Sometimes they are situated in the ventricles of Morgagni, at the root of the epiglottis, or at the border of the mouth of the larynx ; and cases occur in which nearly the whole tube is involved. The surface corresponding with the arytenoid cartil- CHAP. VIII Fig. 238. Double Stricture of the Windpipe. TUMORS OR MORBID GROWTHS. 307 CHAP. VIII. ages enjoys a remarkable immunity from morbid growths of every description ; although the interarytenoid commissure is not an infrequent seat. The papillary form of tumor is well illustrated by the annexed sketch, fig. 289 ; while fig. 240, from a drawing of a specimen in my collection, exhibits a fibrous growth, found in a man thirty-eight years of age, who finally died of tubercular phthisis, in a state of Fig. 239. Fig. 240. Papillary Growths of the Larynx in the Situation of the Vocal Cords. Polypoid Fibroma of the Larynx. profound marasmus. The tumor was about the size of a filbert, and hung down into the lower part of the larynx by a narrow footstalk. Morbid growths of the larynx are most common between the ages of forty and fifty; they are often met with in infancy and childhood; and cases occur in which they are either congenital, or arise soon after birth. Men are much more liable to them than women. Of 287 cases, referred to by Mackenzie, 197 belonged to the male sex. Causit has collected 42 cases of laryngeal tumors occurring in early life, of which two-thirds were noticed in boys. What influence, if any, occupation exerts upon the production of these growths has not been determined. It is, however, generally believed that the con- stant use of the voice, as in speaking and singing, especially during slight attacks of superficial laryngitis, is a predisposing cause. Frequent attacks of cold, the inhalation of irritating vapors and particles of matter, chronic thickening of the mucous membrane of the larynx, and a strumous taint of the system probably act in a similar manner. Warty excrescences, or papillary tumors, are often directly traceable to the effects of the syphil- itic poison. The existence of these tumors is indicated by a sense of constriction in the larynx, alteration of the voice, croupy cough, occasional and gradually increasing dyspnoea, and more or less violent attacks of suffocation, especially when the morbid growth changes its position by cough or laughter, so as to encroach upon the glottis. There is seldom any pain. Dysphagia may be present when the tumor is unusually large, or when it is at- tached to the epiglottis. An alteration of the voice is one of the most constant symptoms. In old, chronic cases there is frequently either complete aphonia, or the patient is unable to speak above a mere whisper. The dyspnoea, seldom present to any extent in the earlier stages of the disease, gradually increases in intensity and frequency with the development of the tumor, and is generally of a paroxysmal character, worse at night than in the day- time, and liable to be aggravated by cold and change of posture. When cough is present, which, however, is seldom the case, it is usually dry and hacking, and often accompanied by a hoarse, croupy, or stridulous condition of the voice. Inspiration is generally more difficult than expiration ; and, as the growth increases in bulk, the patient is often sud- denly seized with a sense of suffocation, especially on lying down. Occasionally a laryngeal growth will cease to increase in size after having acquired a 308 DISEASES AND INJURIES OF AIR-PASSAGES. certain bulk, varying from that of a mustard seed to that of a large pea. Hence, if there be no dyspnoea, and improvement of the voice is not essential to the patient, operative interference is by no means always imperative. The diagnosis of laryngeal tumors can only be satisfactorily determined with the aid of the laryngoscope. Occasionally a portion of the tumor, or, much more rarely, the entire mass, is detached and ejected, thus, of course, dispelling all doubt respecting the nature of the disease. Among the more reliable rational symptoms are, the altered state of the voice, accompanied by a peculiarly harsh inspiration at the commencement of every few words of a phrase, and the violent attacks of dyspnoea, generally coming on suddenly and unexpectedly. When the growth is very pendulous, or attached by a long, narrow pedicle, it sometimes produces a flapping, valvular sound, as it moves about during respi- ration or change of posture. This symptom may often be induced at will by rapid movements of respiration. When the tumor is situated above the vocal cords, the voice will be likely to be noisy and stridulous; whereas, when the cords themselves are affected, aphonia will be present. Simple ocular inspection is sometimes sufficient to detect the morbid growth ; only, however, when it is situated high up, or when it is connected with the epiglottis. Under similar circumstances a digital exploration may occasionally be advantageously made, as it may serve to determine the consistence and mode of attach- ment of the tumor. To ascertain the size and position of the growth a laryngoscopic examination, repeated # perhaps several times on different days, is essentially necessary, more especially if the parts are very irritable, or the patient does not properly cooperate with the surgeon. In trying to determine the nature of the tumor the chief points to be attended to are, its color, its consistence, and the appearance of its surface. Unfortunately, however, if we exclude the papillary and fibrous tumors, little light is to be obtained from such a mode of investigation, and even these do not always furnish very satisfactory data as it respects their precise characters. The papilloma is generally distinguished by its pink or reddish hue, its mamillary, fimbriated, or wart-like surface, its sessile base,its small size, the rapidity of its growth, and its great frequency in young subjects. The fibroma, which is next in the order of frequency after the papilloma, has a smooth and somewhat wavy surface, and is of a red color, round, oval, or pyriform in shape, and notably pedunculated, the latter forming one of its most characteristic features. Fatty, myxomatous, adenomatous, vas- cular, and sarcomatous growths of the larynx do not furnish any diagnostic signs. The cystic tumor has a white, jelly-like appearance, not unlike a ranula, and is of a soft con- sistence, hemispherical in form, and encircled by a hypersemic condition of the adjacent surface. The consistence of the growth may sometimes be determined by careful palpation with a properly curved probe. The distinction between benign and malignant growths of the larynx is generally easy, the differentiation being based mainly upon the history of the case and the fact that the latter have generally a much broader attachment than the former. Moreover, after the disease has made considerable progress, the surface of the tumor will usually be found to be more or less ulcerated. Growths, originally benign, are sometimes tortured into malignancy by incautious manipulation too frequently repeated. Gummy tumors are most common on the posterior wall of the larynx, within the first three months after the occurrence of the primary sore, and they generally present themselves as slightly raised prominences, of a whitish or pale, yellowish color, strikingly contrasting with the red and injected mucous surface in their immediate vicinity. The coexistence of syphilitic disease in other parts of the body will assist the diagnosis. Eversion of the mucous membrane of the ventricle of the larynx or actual prolapse of the laryngeal sac itself, fig. 241,from Cohen, has been mentioned by Mackenzie,of London, Moxon, Waldenburg, Elsberg, Lefferts, Cohen, and [Mackenzie,of Baltimore, as an occasional source of error of diagnosis. The oc- currence, however, is extremely rare, and a careful examination, especially if accompanied by an attempt to replace the everted sac temporarily by the aid of a properly bent probe, will gener- ally readily dispel any doubt that may exist upon the subject. Treatment The only remedy for laryngeal growths is re- moval by operation. If left to themselves the majority of them will almost inevitably prove fatal. Of 42 cases of laryngeal tumors, tabulated by Dr. Gurdon Buck, only one was relieved by spontaneous expulsion. [Most patients perish from suffocation. Caustics, as nitrate CHAP. VIII. Fig. 241. Prolapse of Laryngeal Sac. CHAP. VIII. TUMORS OR MORBID GROWTHS. 309 of silver, chromic acid, and acid nitrate of mercury, are of no use in destroying them. The great objection to their application is that, if they are sufficiently strong to be effec- tive, they provoke spasm of the glottis and more or less severe inflammation in the sur- rounding structures, thus doing harm instead of good. Galvanic cauterization, first practised in this class of affections by Professor Middel- dorpf, has occasionally yielded good results. It has been particularly extolled by Volto- lini, and Reichel, of Breslau, who, with others, have reported a number of cases said to have been permanently relieved by it. The procedure, however, can never come into general use, as it is not only painful but difficult and tedious, requiring frequent repetition as well as cumbersome apparatus, and great skill for its successful application. Extirpation of a morbid growth of the larynx may be effected either through the mouth, or by the oral method, as it may be termed, or by opening the windpipe, either through the thyroid cartilage, the thyro-hyoid membrane, or the crico-thyroid membrane. In the oral method, the chances of the success of the operation will be greatly increased by the previous training of the patient, so as to accustom him to keep his mouth open, to protrude his tongue, and to tolerate the manipulations and the contact of the instruments, which should always be warmed, otherwise they may cause spasm. In some instances, the opera- tion is surprisingly easy, owing to the tolerance of the parts induced by the very presence of the morbid growth ; and in others it is virtually impracticable. Sessile growths are usually removable in fragments only, necessitating repeated manipulation. No anaesthetic should be given, as it would only serve to embarrass the procedure and might even prove dangerous. The patient’s head should be nearly perpendicular, and rest against the back of a high chair instead of being supported by an assistant, who would only be in the way of the operator. He should hold the tongue himself with his thumb and fingers, a soft napkin being interposed to prevent slipping. Chloroform may be used when the larynx is opened, for the same reason as in the operation for the removal of a foreign body from the air-passages. The after-treatment must be conducted with unusual care, by leeches and blisters, with a properly regulated temperature and other measures, the great danger after an operation, especially one involving penetration of the larynx, being from inflam- mation of the respiratory organs. Repullulation must be opposed with nitrate of silver, chromic acid, or sulphate of copper, cautiously applied. When the tumor projects above the larynx, or when it is attached to the epiglottis, it may generally be torn away or twisted off with the curved forceps; or, instead of this, it may be snipped otf with a pair of curved scissors, or cut off’ with a long, slender knife, as was done by Dr. Horace Green, of New York, in 1852. When the tumor is more deeply seated, success will often attend the use of specially constructed forceps, particularly in the hands of a skilful operator. Two of the most useful of the many forceps devised for the purpose are illustrated in figs. 242 and 243; the former being spoon-shaped, with Fig. 242. Fig. 243. Mackenzie’s Cutting Laryngeal Forceps. Mackenzie’s Rectangular Laryngeal Forceps. sharpened edges, for cutting out portions of sessile growths. Small growths have occa- sionally been removed by means of a wire noose, constructed upon the principle of a double silver canula. One of the most ingenious contrivances of this kind is that devised by Sir Duncan Gibb, represented in fig. 244. It consists of a slender square bar, with a ring for the thumb at one end, and at the other a curved stem, grooved on its convex sur- face to within half an inch of the point, which is perforated by two small apertures. A crosspiece slides on the bar, and serves as a support for the fore and middle fingers. A fine steel wire is passed through the holes at the extremity of the instrument, and formed into a loop, with which the tumor is caught and detached, its situation having previously 310 DISEASES AND INJURIES OF AI R-R A SS A G E S . chap. vm. been determined witli the laryngoscope. The manoeuvre of securing the polyp is difficult of execution. On a similar principle, a circular knife-blade (fig. 24;>), acting like Fahnstock’s tonsillo- tome, has been devised by Dr. Stoerck, of Vienna, and others, which, as I am assured, is Fig. 244. Gibb’s Laryngeal icraseur. one of the most valuable appliances for encircling and excising small growths from the lateral walls of the larynx or from the glottis itself, without incurring any danger of wounding healthy structures. Stoerck’s handle may be supplied with forceps, wire loop, or other attachments, at present in use. Fig. 245. Stoerck’s Laryngeal Guillotine, with Universal Handle. Soft growths in the larynx of children, or soft growths high up in the larynx of the adult, can sometimes be scraped off with the finger nail. Voltolini and others have recently reported success in similar cases, by rubbing the growths off with a sponge probang. It is almost needless to insist that all these manoeuvres should be practised either under direct laryngoscopic inspection, or only after due knowledge, laryngoscopically acquired, of the exact position of the growth. Intralaryngeal operations are occasionally attended with such severe and unexpected results as to require subsequent tracheotomy, from injury done to the sound tissues ; a con- tingency which, rare as it is, must not be lost sight of by the surgeon. In a remarkable case of cystic tumor on the inferior surface of the epiglottis, in a boy eleven years old, Mr. Durham afforded prompt and permanent relief by a free incision through the mouth with a sharp-pointed bistoury. When such a growth occupies the in- terior of the larynx, it can only be approached by external excision. Thyrotomy is indicated, if not imperatively demanded, when, the tumor being impris- oned in the larynx, and all other means of relief having failed, the patient is threatened with asphyxia. The operation, originally proposed by Desault towards the close of the last century, was performed for the first time in 1833, by Brauers, of Louvain ; Ehrmann, of Strasbourg, repeated it in 1844; and, in 1851, it was performed for the first time in this country, by the late Dr. Gurdon Buck, of New York. The incision is carried along the CHAP. VI II. CARCINOMA. 311 middle, from the thyroid cartilage, the division of which is effected with a short, stout, sharp-pointed knife ; or, in the event of ossification, with a Key’s saw, care being taken that the separation is completed before the mucous membrane is penetrated, otherwise the blood, passing into the larynx, will, by exciting severe coughing, greatly embarrass the procedure. If sufficient room is not obtained in this way, the crico-thyroid membrane, and even a portion of the thyro-hyoid, may be divided horizontally, so as to allow the wings of the cartilage to be held properly apart, suitable retractors being at hand for this purpose. A strong reflected light being now thrown into the opening, the tumor is seized with a volsella, or pair of forceps, and snipped off with curved scissors, the base being well touched immediately after with solid nitrate of silver t6 promote cicatrization, and prevent repullulation. The operation is completed by drawing the wings of the thyroid cartilage together, and applying a few narrow strips of adhesive plaster across the neck in the situation of the external wound. The coughing, invariably following this operation, renders the use of sutures in the cartilage an unnecessary additional source of irritation. They are allowable in the skin, but are not always requisite. Of 48 cases of thyrotomy, tabulated by Dr. Mackenzie, 8.33 per cent, terminated fatally ; and as the operation is a dangerous one, from the liability of the blood to descend into the lungs, it should always be preceded by tracheotomy, if the larynx be much oc- cluded by the growth, a tube being worn in the opening until the wound in the thyroid cartilage is united. The objections to this operation are, the risk of injuring the vocal cords and the occurrence of tracheitis, bronchitis, and pneumonitis, as immediate effects, and the remote risk of serious disease of the laryngeal cartilages, and of the mucous mem- brane of the larynx. Besides, experience has shown that the operation does not insure immunity from repullulation. Extraction of morbid growths of the larynx has occasionally been effected through the thyro-hyoid membrane, performed according to the plan originally proposed by Malgaigne, consisting of a transverse incision carried along the lower border of the hyoid bone, through the skin, the fascia, and the inner half of the sterno-hyoid muscles. The proce- dure, although sufficiently easy of execution, can rarely be required, as, in the very class of cases to which it is applicable, removal can usually be effected through the fauces. Its advantage over thyrotomy is that it does not interfere with the vocal cords, but, on the other hand, there is danger, if the incision be carried high up, of wounding the epiglottis. Removal of laryngeal growths by crico-thyrotomy, originally suggested by Czermak, has been practised successfully by Burow, Mackenzie, Cohen, and others. The procedure is only to be recommended when there are small growths upon the edges or lower surfaces of the vocal cords, which cannot be removed through the mouth ; and when it is of great moment to avoid the adhesion of the vocal cords anteriorly, and the consequent perma- nent impairment of voice, which is the almost inevitable result of a thyrotomy. It is the least dangerous, by far, of the external operations. It is performed in the same manner as in ordinary laryngotomy, but the opening is made much larger and a canula is usually worn for a few days before an attempt is made to effect evulsion, it being desirable that all the tenderness and tendency to hemorrhage should have subsided. In some instances the evulsion of the growths or their destruction by the electric cautery can be practised immediately upon making the opening. The canula should be worn until the interior has healed. X CARCINOMA. Carcinoma of the larynx may originate in the tube itself, as a primary affection, or it may simply be an extension of the disease from the neighboring structures, as the tongue, fauces, palate, or tonsils. The most common form in which it presents itself is the epi- thelial. Occasionally the disease is entirely limited to the epiglottis, as in the remarkable example recorded by Sir Astley Cooper, in which an encephaloid growth, the size of a hen’s egg, sprung from the under surface of this valve-like body. It was removed twice with the finger, and finally caused fatal hemorrhage. A somewhat similar case has been related by Aronsshon. Epithelioma usually occurs in the form of an excrescence, of a rosaceous or florid color, of a tolerably firm consistence, and of varying dimensions, from that of a hazelnut up to that of a pigeon’s egg. The disease, in whatever form it may occur, is most common in elderly subjects, is rather tardy in its progress, and is generally so obscure in its character as to be detected with difficulty during life. The most promi- nent symptoms are dyspnoea, aphonia, pain in the laryngeal region, and difficulty of deg- lutition. In most cases, the diagnosis can only be satisfactorily determined with the aid of the laryngoscope and of the microscope. 312 DISEASES AND INJURIES OF A I R-PASS AGES . Palliative treatment only is indicated. Tracheotomy may be performed when the patient, otherwise in tolerably good health, is threatened with suffocation. When the growth occupies the epiglottis, or the mouth of the larynx, portions of it may advantage- ously, as a measure of temporary relief, be torn away with the finger or forceps. Speedy repullulation must, of course, follow, and the attendant hemorrhage might be so abundant as to destroy life. With what success extirpation of the larynx had been practised for the cure of this disease will appear in a future page. xi SPASM. Spasm of the larynx, or of the larynx and trachea, may be produced by a great variety of causes, some of them directly connected with the air passages, and others indirectly, con- sisting, perhaps, in some disease of the brain or spinal cord, painful dentition, or .some functional disorder of the oesophagus, stomach, bowels, or uterus. Violent dyspnoea occa- sionally results from an aneurism of the arch of the aorta, or from a tumor in the upper part of the chest, compressing and interfering with the recurrent nerves. Persons are sometimes instantly suffocated from the ingress of a foreign body into the windpipe, or from its lodgment upon the rima of the glottis. In such a case, the respi- ration may be permanently arrested in a moment, as effectually as from the administration of prussic acid, or a severe blow upon the head. Inebriated persons occasionally die in the same manner during attempts at vomiting. In the exhausted condition of the system, consequent upon the inordinate use of ardent spirits, the contents of the stomach are lazily ejected, thus allowing some of the ingesta, as they proceed upwards, to lodge against the rima of the glottis, or even to descend into the windpipe. Diseases of the epiglottis, disqualifying it for the due performance of its functions, remarkably predispose to this occurrence. The effect of the passage of a drop of water into the larynx is familiar to every one. All fluids, however mild, are capable, when introduced into the tube, of exciting dyspnoea, and the most violent, spasmodic, and suffocative cough : but the impression is evanescent, for the reason that the accident does not produce mechanical obstruction to respiration. The moment the spasm subsides, the breathing is reestablished. All solid articles, on the contrary, whatever may be their character, will, by entering the windpipe, or resting against the mouth of the larynx, endanger life by suffocation. A person laboring under delirium tremens, and confined so as to be unable to move, may, in an effort at vomiting, instantaneously perish from the introduction of food into the air-passages. Suffocation is occasionally produced by the sudden ingress of blood into the windpipe, as during operations upon the mouth and throat, and even during the per- formance of tracheotomy itself. Violent, and, indeed, fatal effects are occasionally produced by the impaction of foreign bodies in the pharynx and oesophagus. In most cases, the bad effects are caused by the spasm which the extraneous substance induces in the muscles of the larynx ; but occa- sionally it proceeds from sheer mechanical obstruction. In the treatment of spasmodic affections of the air-passages, careful inquiry should be made into the nature of the exciting cause, for it is only by doing this that the practi- tioner may hope to devise a rational plan of cure. The general health, if at fault, must be amended, the secretions corrected, and all sources of irritation, local and general, re- moved. As means of immediate or temporary relief, the most suitable remedies are anti- spasmodics, particularly chloroform, morphia, chloral, and valerian, with anodyne fomen- tations to the neck, or, what is generally more efficacious, cloths wrung out of iced water. If the case is urgent, threatening suffocation, the only resource is laryngotomy. No operation of this kind should, of course, be performed when the dyspnoea depends upon hysteria, dentition, or any other temporary ailment. In spasm from aneurism of the arch of the aorta, surgical interference would, in my opinion, be very proper. XII PARALYSIS. Paralysis of the larynx occurs in three varieties of form, traumatic, deuteropathic, and idiopathic, the first being not unfrequently associated with lesion of the trachea. Idiopathic paralysis of the glottis generally depends upon debility of the adductor muscles of the vocal cords, induced by impairment of the nervous system, undue exertion of the voice, or the effects of inflammation, immediate or remote as may be. In many cases, especially of bilateral paralysis, the affection seems to be of a purely hysterical nature, CHAP. VIII. CHAP. VIII. PARALYSIS. consisting in a want of consonance between the brain and the laryngeal muscles, and not in what may strictly be regarded as a want of power in the vocal organs, the disease being analogous to what is known as hysterical retention of the urine, a disorder rather of the mind than of the bladder. The paralysis may be transient, intermittent, or perma- nent, partial or complete ; and, as it is always associated with loss of voice, it is generally described as “ phonic paralysis.” The permanent form is commonly due to organic dis- ease of the laryngeal or pneumogastric nerves, caused by inflammatory deposits, or by the compi’ession of some neighboring tumor, as an aneurism, an enlarged lympathic gland, or some morbid growth. Less frequently, it is due to disease in the cerebrum. Unilateral paralysis is almost always indicative of pressure upon some portion of the nerve tract. Whatever the cause may be, it will be found, when the tube is examined with the laryngoscope, that the vocal cords, during the effort of speaking, remain more or less widely separated; or that, even, as sometimes happens, if they approach each other rather closely, they are so completely relaxed as to render them unfit for the discharge of their functions as organs of phonation. They resemble, in fact, in this condition, the loose strings of a violin. In the hysterical form of the affection, the patient is frequently unable to speak, except in the merest whisper. Occasionally even this is impossible, from associated debility of the diaphragmatic muscles impairing the force of the ex- panding current. In another class of cases, again, the voice, after having been entirely absent for weeks, and even months, sometimes suddenly returns, to be, perhaps, again lost in a few hours, as suddenly and unexpectedly as it came. Such attacks are most common in nervous, excitable women, the subjects of dyspepsia, anemia, disorder of the menstrual functions, displacement of the uterus, or of a badly regulated temper. There is one form of paralysis of the muscles of the larynx which interests the surgeon especially. This lesion does not impair the voice ; but it prevents efficient inspiration. I allude to bilateral paralysis of the posterior crico-arytenoid muscles, the dilator muscles of the glottis. When these muscles are paralyzed dyspnoea necessarily ensues, eventually threatening suffocation; and in most instances of this kind, tracheotomy is imperatively demanded. It must be borne in mind that intralaryngeal manipulations with the electric current or other agents are not as inoccuous here as in the opposite form of paralysis of the glottis where the production of spasm would be of benefit as terminating the paralysis. Tracheotomy once performed, and the patient accustomed to the tube, topical measures for relief may be resorted to with impunity, and the result of systemic medication be awaited without anxiety. In most of the cases reported, the paralysis resisted all treatment, and the tube had to be worn permanently. Syphilitic disease, tobacco poisoning, and plumbic toxemia are among the causes to which this form of paralysis is attributed. Paralysis of the epiglottis is occasionally encountered, most frequently as a sequence of diphtheria; and may require tracheotomy with temporary use of the canula, the paralysis usually subsiding spontaneously as the general nervous system undergoes reinvigoration. Paralysis of the vocal cords, especially when unilateral, must be discriminated from im- mobility due to true or false ankylosis of the crico-arytenoid articulation as may occur in tuberculous, syphilitic, and carcinomatous affections. Traumatic paralysis of the larynx, or of the larynx and trachea, may be attended with such urgent symptoms as to require immediate recourse to bronchotomy, in order to rescue the patient from impending suffocation. When the suffering is less violent, the more ordinary measures, especially anodynes in full doses, will generally suffice to afford relief. In the idiopathic form of the disease, the cure must be essentially based upon the correction of the antecedent evil, tonics, exercise, and cold bathing, with the local use of nitrate of silver, electricity, and stimulating sprays being the most reliable agents. In phonic paralysis, dependent upon a hysterical condition of the system, I have repeatedly succeeded in restoring the voice permanently by a single application of a weak solution of nitrate of silver to the mouth of the larynx. A sudden, powerful, mental impression will sometimes produce a similar effect. In some of these cases, relief may be afforded, as suggested by Dr. H. K. Oliver, of Boston, by carefully compressing, several times a day, the wings of the thyroid cartilage, at their upper and back part, with the thumb and index finger; the object of the manipulation being the approximation and stretching of the vocal cords, thereby rendering them more tense and better adapted to the exercise of their proper functions. The success of these efforts will be materially promoted if the patient be instructed to pronounce certain vowel sounds while they are being made. Blisters, and other harsh measures, seldom, if ever, do any good in such cases. 314 DISEASES AND INJURIES OF AIR-PASSAGES. CHAP. VIII. XIII FISTULES. Fistule of the windpipe is occasionally congenital, as in the eases recorded by Luschka, Riecke, Jenny, and in several observed by myself; most generally, however, it is caused by wounds refusing to heal, in consequence of the overlapping of their edges, or the pres- ence of some extraneous substance, as a piece of necrosed fibro-cartilage. Its size varies, of course, in different cases; usually it is very diminutive, perhaps hardly as large as an ordinary [tin’s head. Its edges have a red, raw appearance, and there is usually a small quantity of mucous discharge, at once indicative of the nature of the lesion. When a fis- tule of the trachea has continued for a long time, the tube above the opening is very apt to be contracted, thus interfering materially with the cure of the case. The treatment consists in paring the edges of the opening, both in the tube and in the integument, and in approximating them by several points of the interrupted suture. The milder cases occasionally yield to gentle cauterization with the solid nitrate of silver. XIV INCURVATION OF TIIE EPIGLOTTIS. In this affection, the free margin of the epiglottis is curled backwards in the form of a scroll, which, by encroaching upon the mouth of the larynx, keeps up constant irritation and tickling cough, with a disposition to clear the throat of mucus, hoarseness, partial aphonia, and paroxysms of suffocation. It presents itself in various degrees, is usually caused by ulceration, either simple or specific, is most common in middle-aged and elderly persons, and is frequently associated with chronic inflammation of the larynx, tonsils, and fauces. The diagnosis is readily determined by the finger and the laryngo- scope. In a case recently under my charge, in a woman, fifty years old, the suffering was most distressing, although the disease had existed only for about four months. The general health was much impaired from the loss of sleep, consequent upon the violent and inces- sant cough and the constant desire to clear the throat of mucus, which was secreted in large quantities. Cauterization of the laryngeal surface of the epiglottis with nitrate of silver, or, what I prefer, a weak solution of acid nitrate of mercury, repeated every fourth or fifth day, is the proper remedy for this complaint. The general health should be amended; and when there is reason to suspect a syphilitic taint of the system, some of the iodides in union with bichloride of mercury should be given. If the incurvation cannot be thus relieved, and the case assumes a threatening character, the offending portion of the epiglottis should be sliced off with the hook and probe-pointed bistoury, although such a procedure will rarely be necessary. The epiglottis is occasionally remarkably shrivelled and contracted, or singularly atten- uated and elongated, its form being altered in such a manner as to resemble the outline of a battledoor, the narrow extremity being at the mouth of the larynx. The lesion usually coexists with ulceration, and is most frequently met with in phthisical and syphilitic sub- jects. Sometimes the epiglottis is congenitally cleft at the centre, so as to give it a bifid appearance, a condition analogous to harelip and fissure of the palate, with which it is generally associated. An abnormally large epiglottis may occasionally become suddenly impacted in the pharynx, and thus obstruct respiration, producing temporary asphyxia, the muscular relaxation from which releases the imprisoned valve and gives immediate relief. XV TRACHEOCELE. This affection essentially consists in a protrusion of the lining membrane of the trachea at one of its intercartilaginous spaces, and generally presents itself as a small tumor, of a rounded, globular, or ovoidal shape, varying in size from that of a bean to that of a pigeon’s egg. It is of soft, gaseous consistence and easily effaced by pressure, but is re- produced the moment the pressure is removed. Its site is sometimes in front of the trachea but most frequently at the sides and generally immediately under the skin. Its contents consist solely of air and mucus, except when it is inflamed, when, in addition, it may contain pus. Its causes are various. In most cases it is congenital, due to a defi- cient development of the fibrous structure between two of the rings of the trachea. In other cases its origin is directly traceable to violent efforts of coughing or sneezing, or to the straining attendant upon parturition. Several cases have been recorded in which it was produced in the act of vomiting. The diagnosis is easily determined by the soft, gaseous feel of the swelling, and by its prompt and complete disappearance under press- CHAP. VIII. INJURIES. 315 ure. A distinct impulse is imparted to the finger on coughing. An escape of air always follows the insertion of a delicate needle. Tracheocele produces no inconvenience, except what results from the disfigurement which it occasions. No treatment is generally required. When, however, the tumor manifests a disposition to increase, more or less steadily, systematic compression should be employed to restrain its progress. Operative interference is out of the question. In some cases, as when the tumor is very small, a spontaneous cure takes place. XVI INJURIES. a. Wounds—Wounds of the windpipe, although in themselves not partiqularly dan- gerous, nearly always become so, on account of the entrance of blood, thereby threatening suffocation, and of the remarkable susceptibility of the lungs, after such lesions, to inflam- mation. (Edema is also liable to supervene, especially when the injury is situated high up in the larynx. Another effect that not unfrequentlv follows such accidents is a loss of sensibility of the glottis, in consequence of which, as stated by Mr. Erichsen, who has paid particular attention to the subject, it no longer closes spasmodically on the application of ordinary stimulants, as food and drink, but permits them to pass it, thereby inducing violent cough and serious respiratory difficulty, even although the pharynx and (esophagus retain their integrity. These, then, are the great sources of peril in cases of this descrip- tion, and, therefore, too much vigilance cannot be exercised in guarding against their oc- currence. When the tube is completely divided, the danger is, of course, imminent, death usually following in a short time by suffocation from the ingress of blood. In a case communicated to me by Dr. James D. Maxwell, of Indiana, a child, twelve years of age, lived fifteen days in this condition. The windpipe had been completely severed between the cricoid and thyroid cartilages. The oesophagus had also been freely divided. The immediate cause of death was broncho-pneumonic inflammation. Separation of the epi- glottis is also generally fatal; if the detachment is partial, the flap may become entangled in the glottis; if complete, death will be likely to occur from inanition or inflammation. Larrey and others, however, have mentioned cases in which the epiglottis was shot com- pletely away, and yet the patients made a good recovery. A wound of the thyroid cartilage, penetrating the larynx, is generally a serious acci- dent, as it may be complicated with copious hemorrhage into the windpipe, or be fol- lowed by violent inflammation. The danger of such a lesion will be particularly great if the opening extend into the vocal cords, as oedema of the larynx will then be almost sure to arise, and occasion fatal suffocation. The arytenoid cartilages are sometimes implicated, as in the interesting case recorded by Sir Charles Bell. A man, who had cut his throat, suffered from repeated attacks of frightful dyspnoea, accompanied with a peculiar flapping sound in the top of the wind- pipe, for which no rational explanation could be offered. lie finally died in a fit of suf- focation, when it was ascertained that one of the arytenoid cartilages had been divided, the fragment hanging by a piece of mucous membrane, so as to vibrate in the chink of the glottis, like a pea in a catcall. A somewhat similar case has been narrated by Mr. William Stokes, of Dublin, in which both the cricoid and one of the arytenoid cartilages were broken. Gunshot wounds of the windpipe must be regarded as serious accidents, since 35, or 42.68 per cent., of the 82 cases recorded by Dr. Otis perished. There is reason to believe that this tube possesses the faculty of deflecting bullets. Thus, in a case which I attended with Dr. Hooper, a man was struck by a pistol ball directly over the middle line of the neck, about two inches above the sternum,'and yet there was no symptom whatever de- notive of perforation of the trachea, or of serious lesion of any kind. Total asphyxia in injuries of the larynx and trachea is occasionally produced by great narrowing of their caliber by copious extravasation of blood in the submucous connective tissue. Such an occurrence is most likely to happen at the mouth of the larynx, where the connective tissue is very lax and abundant. Suffocation may also arise from compres- sion of the larynx and trachea by blood effused around these tubes. The treatment of wounds of the windpipe should be conducted by suture and position, along with strict surveillance over the lungs. Although surgeons generally are averse to the employment of the suture for such a purpose, I cannot share their fears in regard to its alleged injurious effects. It is the abuse, and not the proper use, of the remedy that does the mischief. The treatment in wounds of the larynx and trachea is always per- fectly safe if approximation be postponed until all danger of internal bleeding has ceased, 316 DISEASES AND INJURIES OF AIR-P A SS A G E S . as it usually will in five or six hours. The needle, a very delicate one, armed with silver wire, should be passed simply through the fibrous covering of the trachea, without, of course, including any portion of its rings. The external wound is closed in the usual manner. If any of the cervical muscles are divided, their extremities should be tacked together with the needle and thread. When the larynx is opened, the sutures are car- ried through the perichondrium, or even through the edges of the cartilages themselves. When the epiglottis is nearly severed, the best plan will be to cut off the flap, lest, falling into the glottis, it should cause suffocation. The dressing is completed by placing the head in an easy, comfortable position, with a slight inclination forwards, and confining it there by means of a tightly fitting head-bandage, the extremities of which are secured to a broad roller encircling the upper part of the chest. The head must not be drawn too far forwards, otherwise the edges of the wound, both in the windpipe and in the soft parts, may overlap. In a case, recently communicated to me by Dr. W. R. Van Ilook, of Illinois, in which the larynx was completely severed by a razor between the cricoid and thyroid cartilages, along with a portion of the oesophagus, the parts thus treated united perfectly in less than one month. No sutures were inserted into the oesophagus. The head was confined to the chin, and cough allayed by morphia. The advantages of the suture in wounds of the windpipe are, first, a more rapid cure, and, consequently, less danger of hemorrhage and inflammation ; secondly, greater facility of administering food and drink; and, lastly, much less risk of the occurrence of stric- ture and fistule. If emphysema or internal bleeding arise after the parts have been ap- proximated, it would be easy to open the wound, to a small extent in front, both in the integument and in the windpipe, and even to introduce a canula, until all danger from these causes has subsided. The after-treatment is strictly antiphlogistic. The tongue is frequently moistened with iced water; food and drink are, if necessary, conveyed into the stomach by means of a suitable tube, passed through the mouth ; and the bowels are moved by enemas. In very bad cases, involving serious lesion of the pharynx or oesophagus, life must be sus- tained by beef essence, brandy, and other means, introduced by the rectum. Cough is allayed, and sleep induced, by morphia and other means. The head and shoulders are elevated, and the dressings are disturbed as little as possible, the sutures being retained as long as they may seem to do good. Pulmonic and bronchial involvement are met by the usual means. The temperature of the patient’s apartment is regulated by the thermometer, and constantly kept at 80° Fahr. The admission of cold air, especially through the w'ound, cannot tail to be pernicious, from its tendency to awaken cough and inflammation of the respiratory organs. The patient must be watched with the greatest possible assiduity. If lie is suicidally inclined, he must be put in the straight jacket, otherwise he will be sure to tear away the dressings, and open the wound, if he do not inflict other mischief. Danger may arise during the treatment of laryngeal wounds from the formation of exuberant granulations, which, extending into the interior of the tube, may so encroach upon it as to cause excessive dyspnoea, if not fatal obstruction. The proper remedy is the removal of the redundant material with the scissors, and afterwards effectually cauteri- zing the raw surfaces with nitrate of silver. If this treatment fail, recourse must be had to tracheotomy, the incision being kept open until thorough cicatrization is effected. (3. Lacerations—Laceration of the windpipe is occasionally met with, generally as the result of a blow, kick, or fall upon the neck, without any external wound, and is always a dangerous accident, imperilling life by paralysis of the air-passages, spasm of the glottis, or suffocation from emphysema. Of 13 cases, collected by Dr. Fischer, of Hanover, in 7 of which the trachea alone was involved, only 2 recovored, the tube having been opened in one. The remaining 6, which were complicated with fracture of the laryngeal cartilages or the hyoid bone, perished. In a case observed by Dr. John L. Atlee, the patient, a boy, aged four years, perished from emphysema in less than fifteen minutes after the receipt of the injury, produced by striking his neck forcibly against a door- scraper. The air, under such circumstances, escapes from the wounded parts into the connective tissue of the cervical region, from which it spreads more or less rapidly over the head, trunk, and even the upper extremities, followed by frightful dyspnoea, and, if succor be not promptly afforded, by death. These injuries may affect both the larynx and the trachea, the former apparently more frequently than the latter. Laceration of the trachea alone may be caused by a sudden and violent effort at inspiration after the integrity of the tube has been impaired by atro- CHAP. VIII. CHAP. VITI. INJURIES. 317 phy and ulceration, as in an instance reported to me by Dr. Thomas Marshall, of Ken- tucky. Coughing has been known to produce a similar accident, as in a case observed by Bredschneider in a child, twenty-one months of age, affected with bronchitis. The occurrence was denoted by emphysema of the neck and chest, and the tube was found to be ruptured to the extent of six lines below the first ring. The proper remedy in these injuries is obviously tracheotomy, performed without a moment’s delay, especially if there be a rapid escape of air into the surrounding struc- tures. In fact, in case of extreme urgency, the operation should be attempted even if the patient is in the act of dying, or has actually ceased to breathe. The wound should be kept open with a suitable tube, the head maintained in a fixed position, and every effort made to allay spasm and prevent the occurrence of severe inflammation. The skin must be treely punctured, if there be extensive emphysema. Tracheotomy is not a new operation in this class of injuries. Habicot performed it successfully, in 1594, upon a man whose thyroid cartilage had been struck by a bullet, causing such an amount of dyspnoea as to threaten sutfocation. Liston resorted to it in 1823, and since that time it has occasionally been employed by others. y. Contusions—Contusion of the windpipe, especially of the larynx, is sometimes fol- lowed by very unpleasant symptoms. Such an accident, in fact, may prove suddenly fatal from closure of the rima of the glottis, in consequence of spasm Of the laryngeal muscles ; or of effusion of blood into the loose connective tissue. The exciting cause is generally a blow or fall upon the neck ; and the proper remedy, in case of urgency, is laryngotomy, performed without a moment’s delay, a tube being re- tained in the wound until thorough relief is obtained. When the symptoms are less se- vere, the chief reliance should be upon antipldogistics, as leeches, blisters, purgatives, and tartar emetic in union with morphia. If the patient remain aphonious for a long time, recourse should be had to mercury, in alterative and frequently-repeated doses, with stimulating embrocations to the neck. 6. Fractures of the Larynx The cartilages of the larynx may be broken by external violence, as a fall or a blow, the kick of a horse, or the pressure of the thumb and fingers. The accident is most common in elderly subjects, after partial ossification of these bodies, and the one which is most liable to suffer is the thyroid. Of 27 cases analyzed by Dr. William Hunt, of this city, including one observed by himself, only 5 were in children. The fracture may be simple, comminuted, or complicated. The only reliable diagnostic symptoms are crepitation, displacement of the fragments, and preternatural mobility. The ordinary accompaniments are difficulty of articulation, breathing, and deglutition, loss of voice, cough, hemorrhage, and emphysema, from an escape of air into the surround- ing connective tissue. The discrimination may be rendered very difficult, if not imprac- ticable, by great tumefaction of the neck. Most of the cases of this accident prove fatal either soon after its occurrence from suf- focation, or more or less remotely from the effects of inflammation. Of the 27 cases analyzed by Dr. Hunt, 17 died. In 8 laryngotomy was performed, with 2 deaths, and 6 recoveries. More extended observations show even a greater mortality. Thus, of 02 cases collected by Henoque and Durham, 50 died, and 12 got well, tracheotomy having been performed in eight. In every instance, 21 in number, in which the cricoid cartilage was fractured, the result was fatal. Fracture of the laryngeal cartilages, unless attended with serious displacement, requires little else than the ordinary antiphlogistic measures, with perfect quietude of the head, neck, and tongue. When the symptoms are urgent, threatening suffocation, tracheotomy should be performed with the least possible delay. The larynx may be opened when there is extensive separation of the fragments, as such a procedure would afford greater facilities for effecting replacement; but ordinarily tracheotomy deserves the preference. If the orifice is sufficiently large, there will be no need of a tube. In a case, reported in I860, by Professor Maclean, of Kingston, Canada, tracheotomy was rendered necessary, and was successfully performed, on account of oedema of the glottis consequent upon a comminuted fracture of the thyroid cartilage, attended with excessive apncea, dysphagia, and emphy- sema of the neck. £. Scalds of the Larynx Scalds of the larynx may be caused by the inhalation of steam or the contact of hot fluids, the subjects of the accident being usually very young children. Intense pain, restlessness, and difficulty of swallowing, followed by impeded respiration dependent upon oedema of the glottis, and broncho-pulmonary congestion are the characteristic symptoms of the occurrence. The mouth, tongue, and fauces are red, as well as here and there vesicated, and evidences of the effects of hot fluid also frequently DISEASES AND INJURIES OF A I R - P A SS A G E S . CHAP. VIII. exist upon the cheeks. The epiglottis is hard, round, and contracted, as if it had been scorched. In the worst forms of the accident, the voice is croupy, sonorous rales are heard over the chest, the countenance is of a purplish hue, the pulse is rapid and feeble, the surface is cold and damp, the eyes are rolled up, the pupils are dilated, and the patient is semicomatose. If prompt relief be not obtained, death ensues from spasm of the larynx, or from the joint influence of spasm and inflammation, the latter often extending to the bronchial tubes and to the substance of the lungs. The kind of treatment must depend upon the violence and extent of the injury. The milder cases will generally readily yield to ordinary antiphlogistic measures, as an active purgative, a gentle emetic to expel the redundant mucous secretion, and leeches to the neck, or the upper part of the sternum. When the symptoms are urgent, tracheotomy should be performed, as it is frequently the only chance of prolonging or saving life, although the result is generally unfavorable, as is shown by the statistics of Mr. Durham, in which, out of 28 cases, only 5 recovered. Professor Bevan, of Dublin, has met with four cases of scalds of the larynx all success- fully treated by emetics, leeches to the upper part of the sternum, and calomel, in doses of one to two grains every half hour, until free bilious evacuations were produced. XVII FOREIGN BODIES. The air-passages are liable to the intrusion of a great variety of substances, referable to four distinct classes, vegetable, animal, mineral, and mixed, the latter comprising such as are partly vegetable and partly animal, partly animal and partly mineral, or partly mineral and partly vegetable. Of these different substances, those which most commonly enter the air-passages, at least in this country, are grains of corn, beans, melon-seeds, pebbles, and cherry-stones. Bits of meat, bone, and gristle are also frequent intruders. Pieces of coin, pins, buttons, and similar articles are extremely liable to be entrapped in the windpipe, in consequence, apparently, of the foolish habit, so common everywhere, of holding such substances heedlessly in the mouth. I am acquainted with a number of cases, one of which fell under my own observation, in which the foreign body was a cocklebur, represented in tig. 246. Substances of extraordinary size sometimes pass into the air-tubes. Thus, in the case of a child between three and four years of age, commu- nicated to me by Dr. Foote, of Indiana, the foreign body, a brass pen-holder, was three Fig. 216. Fig. 247. inches and a half in length by three lines in diameter. It had descended into the left bronchial tube, where it was found after death, nine months after the accident, surrounded by thick matter. Several instances have been reported of the accidental inhalation of ears of rye, wheat, barley, or grass, as in fig. 247. Dr. J. C. Reeve, of Ohio, in 1869, extracted by tracheotomy, from a little girl, a shawl-pin, fig. 248, upwards of three inches Cocklebur. Ear of Grass. Fig. 248. Shawl-pin. in length. Worms, especially the lumbricoid variety, have been known to creep into the windpipe ; and at least one man lias lost his life from the introduction of’ a leech into the sinus of the larynx. Gautier has reported a case of death from the inhalation of a small fish. In my Treatise on Foreign Bodies in the Air-Passages, published in 1854, a number CHAP. VIII. FOREIGN BODIES. 319 of cases are mentioned in which teeth, both natural and artificial, were inhaled. In several of the cases, the artificial teeth were connected together by metal, as in fig. 249. In this instance, the substance was retained for thirteen years, and was found, on dis- section, in the right thoracic cavity, into which it had passed by ulceration. Mr. Nunn attended a man who drew a puff-dart, represented in fig. 250, into his windpipe. Occa- Fig. 249. Fig. 250. sionally, the entrapped substance has been a bullet, as in two instances, reported to me, respectively, by Dr. Maxwell, of Indiana, and by Dr. Stitt, of Kentucky. A case occurred in this city, in 1867, in which a man, twenty-three years of age, lost his life from the inhalation of a cork during the extraction of a molar tooth while under the in- fluence of nitrous oxide gas. The cork had been placed between the jaws, and was found by Dr. Shapleigh after death, which happened within less than two hours after the acci- dent, in the lower extremity of the trachea. The specimen is in my cabinet. Dr. Under- hill has reported a case in which the foreign body consisted of the copper tip of an umbrella ; and Dr. G. Buck one of a hard rubber tube, upwards of two inches and a half in length by six lines in diameter. Fragments of false membrane accidentally detached in the act of coughing, sometimes act as foreign substances, interfering with the ingress of air, and, if not speedily removed, causing asphyxia. Two, three, and even four foreign substances sometimes enter the air-tubes, either simultaneously or successively. Dr. Sipe, of Missouri, has communicated to me the par- ticulars of the case of a child, who, when the larynx was opened, ejected not less than a dozen fragments of parched corn. Dr. Mount, of Cincinnati, met with an instance, in an infant five weeks old, who, after the operation of laryngotracheotomy, expelled four pieces of unburnt coffee, three immediately, and the other and largest one the next day. Sometimes the substances are of a dissimilar character. Thus, in a case observed by Professor Van Buren, the child, upon the windpipe being opened, coughed up a water- melon seed and the shank of a plum. Situation The foreign body may be arrested in different portions of the windpipe, or it may remain loose, and move up and down the canal during the expulsion and intro- duction of the air. Occasionally, it is stopped at the very entrance of the larynx ; but more frequently, by far, it passes into the interior of the tube, and lodges in one of its ventricles. It is not often arrested in the trachea, or, if arrested, it does not long remain there. Instead of this, after having passed the larynx, it generally, either at once or at a very early period, descends into one of the bronchial tubes, from which, however, during a violent expiratory effort, it may again be impelled upwards, not only into the trachea, but even into the larynx. A needle, pin, bit of bone, or, in short, any sharp and slender body, might be permanently retained in the trachea, in consequence of its extremities becoming implanted in its walls ; so also might a cockle-bur, a piece of meat, a lump of cheese, or a piece of sponge. A solid or a heavy body, as a bullet, pebble, shot, or grain of corn, will, on the contrary, be almost certain to pass at once into the bronchial tubes, in obedience simply to the laws of gravity. A case in which seven arti- ficial teeth, set in hard rubber, were arrested at the junction of the larynx and trachea, has been recorded by Mr. Henry G. Croly, of Dublin. When a foreign body passes into the bronchial tubes, its tendency is to lodge in the right; a circumstance which has long been known, and variously explained. Thus, it has been supposed to be owing to the difference in the capacity of the two tubes, the right being considerably larger than the left. The real cause, however, would seem to be the ridge, or spur, in the lower part of the trachea, the position of which, towards the left of the mesial plane, has the effect of throwing the foreign body, as it descends, over towards the right side, an effect still further favored by the greater diameter of the passage. Sometimes, each bronchial tube contains a foreign body ; and occasionally, again, the substance is forced beyond the primitive division into a secondary one. Artificial Teeth. Puff-dart. 320 DISEASES AND INJURIES OF A I R - P A SS X G E S . CHAP. VIII. The glottis, although by far the most common, is not the only avenue by which foreign bodies may reach the windpipe; occasionally they enter the tube from without, either by penetrating the skin and muscles of the neck, as in the remarkable instance observed by De La Marti nifcre, in which a little boy, in cracking a whip, forced a brass pin into the windpipe ; or they may be pushed into the passage from the oesophagus, in tlie attempts made to extract them from this canal, as in a case which occurred to Dr. Paul F. Eve. Again, foreign bodies may enter the lungs through the walls of the chest, instead of passing into them by the more natural and common route of the glottis. Finally, a case has been recorded by Mr. Edwards, of England, in which a bronchial lymphatic gland, an inch in length, passed through an vdcer in one of the bronchial tubes, and suffocated the patient, a boy eight years of age, by becoming impacted in the rima of the glottis. Expansion—When the foreign body is of a vegetable or an animal nature, it is liable to imbibe more or less of the moisture of the surface with which it lies in contact, and thus increase in volume. The heat of the part, no doubt, also contributes to this result. The degree of expansion produced under the joint influence of these causes varies too much to admit of precise statement. Beans, peas, and grains of corn, seem to be particularly prone to increase in bulk ; sometimes a great deal even in a very short time. Occasionally the substance exhibits signs of germination. On the other hand, there are certain bodies which are incapable of thus expanding, as melon, orange, pear, and similar seeds, and bits of beef, cartilage, tendon, apple, cabbage, turnip, and other vegetable matter. It is probable that the particular situation of the foreign body may exert some influence upon the change of bulk and consistence wrought upon it during its sojourn in the wind- pipe. A substance impacted in one of the bronchial tubes will be likely to undergo more rapid softening and expansion than one lodged in the trachea or larynx. The extent of contact should also be taken into account, as well as, indeed, the character and quantity of the secretion excited by the presence of the extraneous body. A case has been related by Professor Alonzo Buck, in which a dime, lodged for four years in the right bronchial tube, had been converted into sulphuret of silver, and was coughed up in three seperate pieces as black as charcoal. When a foreign body is long retained, especially in one of the bronchial tubes, it not unfrequently becomes incrusted with various kinds of matter, as inspissated mucus, mucus and lymph, lymph alone, or carbonate and phosphate of lime. Pathological Effects The foreign substance may produce various changes in the structures with which it lies in contact, as well as in those in its neighborhood. Occasionally, although rarely, remote parts, as the lungs, trachea, and larynx, become affected, either primarily or secondarily, in consequence of the irritation thus induced. Inflammation of the mucous membrane, generally, however, of limited extent, is a very common occurrence. When the foreign body is bulky, and creates great inconvenience, or is retained for a long time, the morbid action is diffused, often spreading a considerable distance beyond the part originally affected, and leading to deposits of lymph, if not also to softening. In chronic cases, the mucous membrane is liable to become thickened, indurated, deeply congested, or even ulcerated. Sometimes the foreign body is partially imbedded in lymph, which thus serves to lix it in its situation. When the extraneous substance is retained in the bronchial tubes, serious disease is liable to occur in the lungs, especially inflammation, which sometimes involves an entire lobe, if not the whole of the corresponding organ ; now and then, indeed, the mischief extends even to the other lung, or both viscera may suffer simultaneously. Occasionally abscesses form, and continue to discharge for an indefinite period; they generally occur at the seat of the obstruction, or in its immediate vicinity, but sometimes at remote points. Their contents are of an unhealthy character, being more or less fetid, tinged with blood, and intermixed with mucus. The pulmonary tissues around them are usually densely hepatized and deeply discolored. A remarkable instance in which a foreign body—the hull of a bean—excited gangrene of the lung, fell under my observation in 1844, in a lad eleven years of age, a patient of Dr. Bryan and Dr. Rodman. The disease came on about two months and a half after the accident, and was followed by the discharge of a large quantity of thick, blackish pus, of the most fetid character. Hectic fever, with rigors and night sweats, was present, and the body was reduced to a mere skeleton. After progressing in this manner for a number of weeks, the substance was finally ejected in a violent paroxysm of coughing, ultimately succeeded by complete recovery. Fetid matter continued to be CHAP. VJIT. FOREIGN BODIES. expectorated for a long time after, and the chest, over the left lung, became permanently contracted. Sometimes, again, the foreign substance, especially if retained for any length of time, induces a deposit of tubercle in the tissues immediately adjoining it, as in the case of a patient of mine, nine years of age. Pulmonary emphysema is another effect, but also a very rare one ; and the same remark is true of oedema of the larynx. The bronchial lymphatic glands are liable to suffer, the most common alterations being enlargement, preternatural vascularity, and softening of their substance. Suppuration is infrequent. The morbid action sometimes extends to the pleura, leading to effusion of serum and lymph, extensive adhesions, and, also, occasionally, to the formation of pus. It is a singular fact that all of these pathological changes may occur, to a greater or less extent, in cases where the obstruction is exclusively seated in the larynx, or in the upper portion of the trachea. In a few instances, the heart and pericardium have been found inflamed, but whether from an extension of the morbid action from the respi- ratory organs, or from embarrassment in the pulmonary and cardiac circulation, has not been determined. When abscesses form, after this accident, whether as a consequence of simple pneu- monia or of the softening of tubercular deposits, the matter generally passes into the bronchial tubes, whence it is afterwards discharged by coughing or expectoration. Occa- sionally it points externally at one of the intercostal spaces, where it sometimes forms an opening through which the foreign body ultimately escapes. Dr. John L. Atlee has communicated to me the particulars of a case in which he ruptured a large abscess in the lung in an attempt at extracting the foreign body. When the substance is long retained, it may excite ulceration of the bronchial tube, and finally drop in the pleural cavity, causing destructive inflammation. A case has been recorded by Mr. J. F. West, of Bir- mingham, in which a needle upwards of two inches and a half in length, lodged in the right bronchial tube, causing death by piercing the right ventricle of the heart. Finally, a foreign body may provoke fatal hemorrhage, as in a case related by Roki- tansky, in which a small dart had been sucked into the trachea, and was forced into the innominate artery during a paroxysm of coughing. Dr. A. R. Terry, of Detroit, has communicated to me an instance in which frequent attacks of copious hemorrhage were excited by a gun-cap, which was spontaneously expelled at the end of three years. Symptoms The symptoms following and accompanying this accident may be divided into primary and secondary, or into those which take place at the moment of the introduc- tion of the foreign body, and those which arise as a consequence of its sojourn in the air passages. The moment a foreign substance, however small, touches the windpipe, it excites severe distress and coughing, by the spasm which it induces in the muscles of the larynx. A familiar illustration of this occurrence is afforded in the suffering which takes place when a drop of water, a crumb of bread, or a particle of salt accidentally slips into the glottis. Instantly the most violent distress is excited, which generally continues until the intruder is dislodged. These symptoms, however, are commonly slight and transient compared with those that attend the intromission of a foreign body, properly so called. In the latter case, the patient is usually in imminent danger of suffocation, and, consequently, very fortunate if he escapes with his life. In the great majority of instances, he is seized with a feeling of annihilation ; he gasps for breath, looks wildly around, coughs violently, and, perhaps, loses his consciousness. Ilis countenance is livid, the eyes protrude from their sockets, the heart beats tumultuously, the body is contorted in every possible manner, and froth, or froth and blood, issue from the mouth and nose. Now and then he grasps his throat, utters the most distressing cries, or falls down in a state of insensibility. Some- times he vomits, especially if the accident occurs after a full meal; and the relief occa- sionally experienced from this source is veiy great. In some instances, again, there is an involuntary discharge of feces, and even of urine. A considerable quantity of pure blood is now and then thrown up during the violent coughing, immediately consequent upon the accident. The duration of the first paroxysm varies from a few seconds to several minutes, or in severe cases, as when the foreign body is arrested in the larynx, even several hours. With the restoration of the respiration, the features resume their natural appearance, and the patient recovers his consciousness and power of speech. The voice, however, fre- quently remains somewhat altered, the breathing is more or less embarrassed, and there are frequent fits of coughing, often attended with a recurrence of all, or nearly all, the 322 DISEASES AND INJURIES OF AIR-P A SS A G ES . CHAP. VIII. original symptoms. Thus the case may progress for an indefinite period, until the foreign body is expelled, or until it produces death by disease of the air-passages. If the obstruction continue, even if oidy for a few days, the patient will be in two- fold danger; for he will not only be liable to be suffocated at any moment by the foreign body passing up into the larynx, during a paroxysm of coughing, but the probability is that the lungs, resenting its presence, will take on inflammation, which no skill, however well directed, can always effectually arrest. Occasionally there is almost an entire absence of symptoms, the foreign body causing little or no inconvenience. Thus, in a case reported by Louis, the patient, after the first few minutes, experienced no bad symptoms for an entire year. At the end of that time, he coughed up a cherry-stone, followed by such copious expectoration as to destroy him in three days. The cough is usually spasmodic, sudden, short, and uncontrollable, lasting from a few seconds to half an hour or more. During its continuance, the patient frequently expe- riences a sense of tickling in the throat, with soreness and pain in the respiratory tubes and at the top of the sternum ; the countenance is suffused, and even livid ; the brain is oppressed by sanguineous determination ; and, when the paroxysms are violent and pro- tracted, there is occasionally a discharge of blood from the nose and mouth. Sometimes the cough is of a croupy character. Posture often exercises a marked influence over it. Thus, the patient may be perfectly free while sitting up, or lying down, but the moment he rises, or moves his body, he may be seized with a severe fit. The voice is variously affected. Generally it is natural, or so nearly natural as to render it dilficult, if not impossible, to detect the change. Occasionally, however, it is remarkably altered, both in quality and strength. Thus, it may be croupy, hoarse and low, sharp and sibilant, or, as if cracked, reduced to a mere whisper, or entirely extinct. These alterations may occur immediately after the accident, or not until the foreign body has set up irritation in the vocal cords. Sometimes the power of speech is temporarily lost, and then returns, either suddenly or gradually, without any assignable cause. The expectoration is ordinarily small, and of a thin, sero-mucous character. In pro- tracted cases, however, and especially when there is a good deal of bronchial irritation, it may be very copious, thick, and ropy, more or less opaque, of a dirty, rust-colored aspect, or tinged with blood. When cavities form around the foreign body, whether from gan- grene, or from the softening of tubercle, the expectoration is generally almost insupport- ably offensive. Sometimes the patient throws up blood, either pure or mixed with frothy matter. The quantity is usually very small, not exceeding a few drachms. The accident may occur immediately after the introduction of the foreign substance, or not until serious structural changes have taken place in the lungs. The pain which follows this accident is generally very slight, except when the resulting inflammation has produced serious structural lesion. In its character, it may be sharp and pricking, or dull, heavy, and aching ; it may be limited to the seat of the foreign body, or it may pervade the trachea, larynx, bronchial tubes, and lungs, if not also the throat, oesophagus, and muscles of the chest. It is commonly accompanied by a sense of constriction, tightness, or suffocation, and is liable to be aggravated by coughing and the slightest change in the situation of the foreign body. It is occasionally fixed for a long time at one spot, and then suddenly shifts to another. Sometimes, again, it remains at its original site for a considerable period after the extrusion of the foreign substance. Instead of pain, there may merely be a feeling of soreness. This may occur at various points of the respiratory apparatus, and is, perhaps, more frequently present than is com- monly imagined, owing to the want of a thorough examination, or the fact that the patient is not always able to indicate the nature of his sufferings. No substance can remain for any length of time in the air-passages without causing more or less serious disturbance in the respiratory functions. The patient has hardly escaped from the immediate effects of the accident before his life is endangered by inflam- mation, which, if not promptly relieved, may speedily prove fatal. This effect, which is always to be dreaded in every case of the kind, devolves upon the attendant the absolute necessity of frequent examinations of the chest, both by auscultation and percussion. One of the most remarkable circumstances after this accident is that, while the patient can freely inspire, he often finds it almost impossible to expire. This is particularly the case when the foreign body lies in one of the bronchial tubes, which may thus be almost completely closed, neither allowing the air to enter nor to pass out. Nevertheless, as the other canal remains free, inspiration may be carried on with considerable vigor, whereas CHAP. VIII . FOREIGN BODIES. 323 every attempt to expel the air from the obstructed lung will be attended with great suffering and a feeling of exhaustion. If, under such circumstances, the ear be applied to the chest, the respiratory murmur on the affected side will be found to be greatly diminished, if not entirely inaudible, while the sound on percussion will be perfectly clear, or perhaps even increased in intensity, provided, of course, that the pulmonary tissues are not hepatized or excessively engorged from the effects produced by the irritation of the foreign body. The respiration in the opposite lung will either be perfectly natural, more or less peurile, or characterized by various rales. Occasionally, the air, as it rushes by the foreign body, gives rise to sounds so peculiar that they may be regarded as pathognomonic of the nature of the affection. Thus, in a case observed by Mr. McNamara, of Dublin, the noise resem- bled that produced by blowing through a whistle, the foreign substance, a plum-stone, having been perforated at the middle. Occasionally, the substance, as it plays up and down the windpipe, produces a peculiar flapping sound. Finally, the symptoms may be of an asthmatic character. The posture of the patient varies. Generally he finds it most agreeable to sit up; for as soon as he attempts to lie down he is seized with increased embarrassment of breath- ing, with a disposition to cough and a feeling of suffocation : during sleep he is, conse- quently, obliged to be propped up in bed, or to rest in a chair. Sometimes, however, he lies best on his back, or on one side. The general health is variously affected ; sometimes slightly, sometimes severely, some- times, again, not at all. In most cases, however, eve?i when the foreign substance is not retained beyond a few days, the system is feverish, the appetite and sleep are interrupted, and there is an anxious expression of the features. If the irritation continues, inflamma- tion of the lungs and air-tubes soon takes place, with an aggravation of the cough, ema- ciation, and loss of strength. Diagnosis.—As these accidents occur most frequently in infants and children, who can but ill express their feelings, one of the first duties of the practitioner is to inquire, most carefully and circumstantially, into the history of the case. Very frequently some time elapses before he can reach the patient, or it may be that, although the interval between the occurrence and his visit may be very short, the first symptoms may have entirely dis- appeared, and the patient act and feel as if nothing had taken place. Now, it is just in such cases as these that errors are most liable to happen, for the reason that the profes- sional attendant, seeing that there is apparently nothing the matter, allows his mind to be lulled into a state of security, frequently not less injurious to himself than destructive to his patient. It is different with adults, who are usually conscious of the time and man- ner of such accidents, and who, therefore, rarely fail to give a correct account of them. If the patient, supposing him to be a child, has been playing with a grain of corn, bean, pebble, or any similar body, and has been suddenly seized with symptoms of suffocation, violent spasmodic cough, lividity of the face, pain in the upper part of the windpipe, and partial insensibility, there will be a strong presumption that the substance, whatever it may have been, has slipped into the air-passages, and is the immediate and only cause of the suffering. The presumption will be converted almost into positive certainty if the child was just previously in the enjoyment of good health ; if he was romping, jumping, or laughing at the moment of the accident, with the substance, perhaps, in his mouth, or while attempting to throw it into that cavity ; and especially, if the symptoms, alter having been interrupted fora few minutes, continue to recur, with their former, or even with increased, intensity, at longer or shorter intervals. The symptoms here enumerated, how- ever, are sometimes most painfully simulated by the cough and embarrassment of breath- ing occasioned by cold and other affections. The difficulty in arriving at a correct diag- nosis is still further augmented, in some of these cases, by the coincidence of the respiratory trouble and the fact of the child, at the moment of the seizure, having been engaged in playing with a substance such as that above mentioned. Laryngoscopic inspection, if available, will often determine the presence of a foreign body in the larynx, or even of a body impacted in the upper portion of the trachea. Important information may frequently be obtained by auscultation and percussion, par- ticularly when the foreign body is situated in the lower extremity of the trachea, or in one of the bronchial tubes, where, especially if bulky, or firmly impacted, it must neces- sarily affect, more or less seriously, the respiratory functions, and thus manifest itself by the alterations which it induces in the sounds of the lungs and chest. These alterations are always less distinct, and they may even be entirely absent, when the extraneous sub- stance occupies the larynx, or the upper portion of the trachea. A stethoscopie examination, however, although generally useful, does not always afford DISEASES AND INJURIES OF A IR - P A SS A G E S. CHAP. VIII. satisfactory evidence of the nature of the affection, as I know from the observation of sev- eral instances, in none of which, notwithstanding the most careful and repeated explora- tion, could the situation of the intruder be determined. Two circumstances may be men- tioned as likely to occasion such a result. In the first place, the auscultatory signs may be masked by previous disease, or by disease awakened by the accident, as inflammation of the windpipe, lungs, or pleura; and, in the second, the patient, especially if a child, may offer such resistance, either by his cries or struggles, as to render it utterly impossi- ble to make a thorough investigation. In the latter case, the obstacle may, fortunately, always be promptly and effectually surmounted by the use of an anaesthetic. Some inference, too, of.a diagnostic character, is generally deducible from the nature of the foreign substance itself. Ponderous bodies, such as bullets, shot, metallic buttons, peb- bles, arid pieces of coin, generally at once descend into the bronchial tubes, from which they are afterwards unable to rise in the act of coughing, sneezing, or other violent expi- ratory efforts, as bodies are liable to do when they are of an opposite description. If the foreign body is large, and at the same time very rough, angular, or spiculated, it will probably be arrested in the larynx or trachea. A similar occurrence may be expected if it be long and narrow, as in the case of a needle, pin, nail, or fish-bone, unless it enter the glottis vertically, when it may at once fall into one of the bronchial tubes. In some instances, as stated elsewhere, the foreign substance is capable of producing a peculiar noise, occasionally detectable even at a distance from the patient’s body. No definite information can be derived from the state of the voice when the foreign body lies in the trachea or in one of the bronchial tubes. Under such circumstances, it may be more or less changed, or, in rare instances, perhaps be even entirely absent; but as the alterations are not peculiar, but altogether similar to those produced in ordinary affections of the air-passages, it is evident that they are of no diagnostic value. The reverse, how- ever, is the case when the foreign substance is retained within the larynx ; for then the changes in the vocal functions, if not actually characteristic, may, in conjunction with other symptoms, afford most important, if not conclusive, information. The pain accompanying this accident cannot be regarded as diagnostic, inasmuch as it may be produced by other causes, as inflammation, neuralgia, or spasm of the air-passages. The symptoms of extraneous bodies in the respiratory organs may be imitated by dif- ferent diseases, either directly affecting these organs or acting upon them sympathetically. Of these diseases the most important are croup, hooping cough, ulceration of the larynx and trachea, aneurism of the aorta, and worms in the intestines. It is generally easy to distinguish between the symptoms of a foreign body and those of spasmodic croup, by observing that, in the latter affection, the chief difficulty of breath- ing exists during inspiration, while in the former it exists during expiration. Important information may also be derived from the state of the voice, which is usually characteristic in croup, and from the state of the pulse and skin, which are rarely excited until after the extraneous substance has had time to cause inflammation and sympathetic irritation, whereas they are usually more or less seriously disturbed at an early stage in laryngeal disease. Besides, in the latter affection, the symptoms are continued, whereas in the case of a foreign body in the air-passages, there are frequent intermissions, followed by sudden aggravations of suffering. The late Professor J. B. S. Jackson communicated to me the particulars of two cases, in which the symptoms produced by foreign bodies in the air-pas- sages were mistaken for those of membranous croup. Alarming symptoms, simulating those of a foreign body in the air-passages, may arise during an attack of hooping cough. Here mistake may be prevented, first, by a careful consideration of the history of the case; secondly, by the existence of the peculiar hoop, which is always wanting in the former affection ; and, lastly, by the fact that the embar- rassment of breathing occurs in this disease, as in croup, not during expiration, but inspi- ration. Spasm of the glottis, by producing suffocation, may give rise to symptoms simulating those of a foreign body in the windpipe. A common cause of this is ulceration of the larynx. If such an occurrence should take place while the patient is eating, it would be very natural to ascribe it to the presence of a foreign body in the air-passages, although they might be entirely free from mechanical obstruction. The diagnosis, in such an event, would, of course, be extremely difficult, if not impossible. The history of the case might furnish some clue, but hardly any of a satisfactory character. Upon whatever cause the symptoms depend, tracheotomy alone, performed without delay, would be likely to save the patient. Similar embarrassment may arise from an aneurism of the thoracic aorta. The press- FOREIGN BODIES. 325 CHAP. V 1 I I . ure of such a tumor may produce great narrowing both of the trachea and of the bronchial tubes, particularly the latter, thereby seriously impeding the passage of the air to the lungs. The diagnostic signs, in cases of doubt, are the gradual approach and persistent character of the symptoms in aneurism, and their sudden, violent, and intermittent char- acter when occasioned by the presence of an extraneous substance. Moreover, it is worthy of note that such accidents are most frequent in children, while aneurism of the thoracic aorta is almost exclusively confined to elderly subjects. The sympathetic irritation induced by worms in the alimentary canal may closely simu- late the phenomena produced by the presence of a foreign substance in the windpipe. The most certain diagnostics, in circumstances of doubt, are the history of the case, and the prompt relief which usually follows the exhibition of anthelmintic remedies, when the atfection is of a verminous character; and the failure of these means, when the symptoms depend upon the presence of a foreign body. Symptoms, closely resembling those produced by foreign bodies in the air-tubes, may be caused by the lodgment and impaction of extraneous substances in the pharynx and oesophagus, often exciting violent, it' not fatal, spasm of the glottis. Finally, it is well known that, if a foreign body, such, for instance, as a piece of meat, or cartilage, is retained even for a short time in the (esophagus or fauces, the irritation occasioned by its presence will often remain for hours, if not days, after its removal. Such is the distress sometimes, under these circumstances, that it is very difficult to per- suade the patient that the substance is not still in its original situation ; and hence, as the same thing may occur when the foreign body is in the windpipe, the surgeon, unless fully on his guard, may be led into most serious error. It is not always easy to determine, from a consideration of the history and symptoms of the accident, whether the offending substance is in the larynx, or in some other por- tion of the windpipe. From an analysis of sixteen cases, I am led to conclude that, as a general rule, whenever there is aphonia, whether partial or complete, the substance is situ- ated in the larynx; at all events, there is a strong probability of this, a probability con- verted into certainty, if, conjoined with this symptom, there is pain, soreness, or uneasiness in the region of the larynx, along with dyspncea, a whistling sound in respiration, absence of serious disease in the bronchial tubes and lungs, and inability to perceive the offending body moving up and down the trachea. It is important, however, to bear in mind that the voice may be seriously affected, and yet the foreign body not be lodged in the larynx, but in the trachea, or in one of the bronchial tubes. When doubt exists the difficulty may sometimes be readily solved by the use of the laryngoscope, as in the cases reported by Czermak, Gibb, Tiirck, Beigel, and others. When a foreign body descends into one of the bronchial tubes, the respiratory murmur in the'corresponding lung is generally more or less affected. The wall of the chest, how- ever, is not always, perhaps not even generally, dull or fiat, as in pneumonia and phthisis, in which the parenchymatous substance of the organ is condensed by abnormal deposits ; on the contrary, the sound is frequently unnaturally clear and resonant, very much, indeed, as in pulmonary emphysema. This peculiarity may involve the entire lung, or it may be limited to particular portions, as one-half, a third, or one-fourth, according to the size and situation of the foreign body. When the extraneous substance is so large as to obstruct the bronchial tube completely, there must necessarily be marked dulness on per- cussion, and great diminution, if not entire absence, of motion in the ribs. The respiratory murmur, under the same circumstances, maybe very much diminished, or wholly absent, according to the amount of the pulmonary obstruction. In most in- stances it is lessened only somewhat in intensity, because a certain quantity of air still enters the lung by the side of the foreign body. It is only when the extraneous substance is very bulky, or when the tube is completely closed by it, or partly by it, and partly by abnormal deposits, as mucus* pus, or lymph, that the respiratory murmur can be no longer recognized, or only in the most imperfect manner. The extraneous substance may, as already stated, change its place in consequence of the impulse which it receives during coughing, during violent expulsive efforts of the lungs, or even during the various movements of the body. Thus, in one of my cases, the foreign body, a grain of corn, was impacted for upwards of a week in the right bronchial tube, when suddenly, in a severe paroxysm of coughing, it passed over into the left, where it was discovered on the dissection. Its former presence on the right side was denoted not only by the alterations in the respiratory murmur and by the extraordinary resonance on percussion, but by the peculiar pathological appearance of the mucous membrane in the corresponding bronchial tube. It should also be recollected that the changes in the res- 326 DISEASES AND INJURIES OF A1 R-P ASS AG ES . CHAP. VIII. piration may be materially influenced, if not entirely masked, by the deposits produced by the irritation of the foreign substance, thus frequently divesting them of tbeir diag- nostic value. The foreign body occasionally plays up and down the trachea, either in consonance with the respiratory movements, or in consequence of severe fits of coughing. During these changes, it is very liable to cause severe spasm and irritation by impinging against the mucous membrane of the larynx, sufficient, in some instances, to induce suffocation. The patient, in many of these cases, is rendered conscious of this occurrence, not only by the pain and spasmodic cough, but by the peculiar sensation which the substance produces as it passes up and down the windpipe. Sometimes, again, the extraneous body may be dis- tinctly felt and even heard during these movements, as in an interesting case communi- cated to me by Professor J. F. May. The patient was a child five years old, and the substance, a grain of corn, was perceptible at every expiration as it struck the upper part of the trachea. Occasionally, the noise produced by the foreign body, or, more properly speaking, by the air, as it rushes past it, is so peculiar that it may be regarded as pathognomonic of the nature of the accident. The sound may be of a whistling nature, a cooing rhonehus, or a peculiar flapping. The preceding facts will commonly serve to show whether the foreign substance is firmly impacted in one of the bronchial tubes, or whether it is capable of moving up and down the trachea during coughing and respiration. As a general rule, the substance, whatever it may be, remains loose. This is often true in cases even of long standing, but it is particularly so of recent ones, before the occurrence of much secretion, tending to attach the foreign body or to impair its mobility, and before the development of serious structural lesion, as for example, the formation of an abscess, in which the body may become permanently imprisoned. When, to the above facts, we add the absence of all laryngeal disease, and the unaffected state of the voice, the conclusion will be inevitable that the intruder is lodged in one of the bronchial tubes, or alternately in one of these tubes and in the trachea. 1 do not think it is possible to determine, from anything we know, whether a foreign body is permanently arrested in the trachea. The number of sucb accidents is exceed- ingly limited, and the phenomena attending them have not been studied with sufficient attention to justify the deduction of any special conclusions. Spontaneous Expulsion Almost every possible variety of substance, capable of enter- ing the windpipe, may be spontaneously expelled. In my Treatise on Foreign Bodies in the Air-Passages, are detailed the particulars of numerous cases illustrative of the subject. Among the more ordinary substances may be mentioned cherry-stones, nuts, and fragments of their shells, watermelon seeds, beans, grains of corn and of coffee, bits of bone, nails, and tacks ; among the more uncommon, teeth, pieces of coin, bullets, cockleburs, and ears of grass and grain. Professor F. F. Hamilton has communicated to me the particu- lars of an instance in which a tin whistle was spontaneously ejected. Nunn, Colles, and Heustis have, respectively, reported cases in which riddance was thus effected of a pop- dart, a pop-gun, and a piece of feather nearly two inches in length. The expulsion usually occurs in a paroxysm of coughing, and the effort is, no doubt, greatly facilitated by dependency of the head, as when it is hanging over the edge of the bed. Jn forty-nine cases, tabulated in the work above referred to, riddance was effected, in this manner, in thirty-seven; in one, in sneezing; in one, in dreaming; and in one, in spontaneous vomiting; the mode of expulsion in the remainder not being mentioned. Two cases have been communicated to me of the spontaneous expulsion of bullets in the act of coughing; and several examples in which shot were similarly disposed of are upon record. In all these instances, the patient's head was at the moment in a dependent state. The time at which the expulsion occurs varies from a few hours to many years. In a case reported to me by Professor Flint, nearly three years elapsed ; and in another, for which I am indebted to Dr. Wulkupf, the interval was upwards of eleven years. Although the patient generally recovers after riddance has been effected, he now and then perishes from the injury sustained by the sojourn of the foreign substance, as inflammation of the lung, or of the lung and pleura. In a case mentioned by Lescure, in which the foreign body, a piece of bone, was expelled at the end of seventeen years, death occurred in eighteen months, from pulmonary disease. On the other hand, the lung may be greatly disorganized by the foreign substance, and yet complete recovery ensue, as in the case previously alluded to, of a boy, eleven years of age, whom 1 saw with Dr. Ilodman and Dr. Bryan. FOREIGN BODIES. 327 CHAP. VIII. The expulsion usually takes place by the glottis; but now and then through the walls of the chest. In the former case, the substance generally escapes with a good deal of force, in a violent expiratory effort or in a paroxysm of coughing. In children, the sub- stance is occasionally swallowed, thus creating a painful state of uncertainty in regard to its disposition, perhaps only relieved by finding it in the alvine evacuations. Treatment—The treatment of foreign bodies in the air-passages is medical and surgi- cal ; the former being intended to protect the patient from suffocation and disease of the respiratory organs, the latter to effect riddance of the intruder. An individual with a foreign body in his windpipe should be regarded as an invalid, unfit to leave his room, or to attend to business. The treatment, in the early stage of the complaint, should be limited to a general supervision of the patient’s health ; that is, his diet should be carefully regulated, the bowels gently moved from time to time, and the temperature of the apartment uniformly maintained at about 75° Fahr. The chest should be thoroughly examined at least once a day by auscultation and percussion, to ascertain the condition of the lungs and bronchial tubes. Cough should be subdued with mild expectorants, containing, if there be frequent spasms, a suitable quantity of morphia. Symptoms of pneumonia, bronchitis, or pleuro-pneumonia must be promptly met by the ordinary remedies, particularly the lancet, active purgatives, and tartar emetic, in conjunction, if necessary, with leeches and blisters. By watching the patient in this way, the respiratory organs may be protected from mischief, and the extraneous substance be expelled spontaneously; or, if an operation become necessary, he will be in a much better condition to undergo it with impunity. The expulsion of the foreign body does not always secure immunity from danger. The air-passages, irritated by its presence, may have taken on inflammation before its extru- sion, or this action may be set up soon after, and in either case the danger to life may be very great. As it respects the use of emetics, experience has shown that they are not only useless, but often dangerous, by impelling the foreign body into the larynx, and thus causing vio- lent spasm of the glottis. Besides, their employment may occasion loss of valuable time. In forty-six cases, analyzed by me, in which various articles of this kind were exhibited, there was not one in which they were of any material service, while in a con- siderable number they were positively injurious. Sternutatories of every description, mild and harsh, vegetable and mineral, have been employed, with a view of aiding the expulsion of the intruder, but, with the exception of the case related by Boyer, in which the nose was tickled with snuff, while the patient was partially asleep, no relief followed their use. It is possible that this class of reme- dies might occasionally be beneficially conjoined with the use of chloroform. The proper plan would be to make the patient inhale the fluid until he is nearly insensible, and to irritate the Schneiderian membrane with snuff, or some other substance, the moment he begins to regain his consciousness. Should sneezing ensue while he is this condition, with the air-tubes in a state of perfect relaxation, it is easy to conceive that the foreign body might be ejected. Nature would be taken, as it were, by surprise, as she has some- times been by a dream, as in the remarkable ca.se of Mr. Cook. A very interesting case, in which a piece of fish-bone was expelled from the windpipe under the influence of the inhalation of iodine, occurred in 1832, in the practice of Mr. Day. Inversion of the Body This operation, as the name implies, consists in suspending the patient by the heels, or in securing his body, with the head inclined downwards, to a chair, narrow table, or other suitable object. While in this position, the chest and back are repeatedly and smartly struck with the hands, to aid, first, in dislodging the offending substance, and, next, in propelling it through the glottis, or, in case of bronchotomy, through the artificial opening in the neck. With the same view, the thorax is some- times suddenly and forcibly compressed, the patient having previously taken a full in- spiration. The object of this manoeuvre is to empty the lungs as rapidly and completely as possible, in order that the air, as it rushes through the windpipe, may carry the in- truder before it. The compression is usually effected with the hands, applied at opposite points of the trunk ; but. perhaps, a better method is to make it with a broad bandage, arranged so as to encircle the chest, and slit at the ends, after the fashion of the bandage used in tapping the abdomen. The patient having taken a full inspiration, the extremi- ties of the bandage are suddenly drawn in opposite directions, thereby compressing the thoracic walls equably and forcibly at every point. The great objection to this operation is the risk the patient incurs from suffocation, oc- 328 DISEASES AND INJURIES OF A 1 R-P A S S A G E S . chap, vm. casioned by spasm of the glottis, from the contact of the extraneous body in its attempt to pass through the larynx. The only way of preventing this is either to administer chloroform, or, what is preferable, to open the windpipe as a preliminary measure. By this procedure, all danger of producing spasm of the glottis will he avoided, and the for- eign body will have a chance of escaping either through the larynx, or at the wound in the neck. Without this precaution, inversion of the body, unless practised with the greatest possible care, may be attended with very serious, if not fatal, consequences. In the interesting case of Mr. Brunei, recorded by Sir B. C. Brodie, inversion invaria- bly produced the most distressing cough, with symptoms of impending suffocation, com- pelling the experimenter at once to desist. The object was, by permitting the patient’s head and shoulders to hang over a chair while the body was in the prone position, to af- ford the extraneous substance, a half-sovereign, an opportunity of slipping through the rima of the glottis into the mouth. During every effort of this kind, there was a distinct perception of a loose substance passing forward along the trachea, and striking against the larynx. Tracheotomy was afterwards performed, and an attempt made, but in vain, to extract the coin with the forceps. Finally, at the expiration of the sixteenth day alter the operation, the patient’s body and shoulders were secured to a peculiar contri- vance, a sort of platform, made movable on a hinge in the centre, and so arranged as to permit the head to be brought to an angle of about 80° with the horizon. The back being now struck with the hand, severe coughing ensued, followed almost immediately by the ejection of the intruder. Extraction by the Mouth Since the laryngoscope 1ms been applied to the investiga- tion of affections of the upper part of the windpipe, several cases have occurred in which foreign bodies were promptly and successfully extracted with the aid of this instrument through the mouth. Thus, in the instance of a man, thirty-six years old, treated by Dr. Beigel, a bean, lodged at the anterior angle of the vocal cords, was readily seized and re- moved with the forceps, after its previous detection with the laryngoscope. Dr. Min- shull, in a similar manner, in 1870, extracted a penny that had been impacted for six years in the larynx of a lad, sixteen years old. More I’ecently a number of other success- ful examples have been reported. It may well be supposed that the extraction of a for- eign body through the mouth, with the aid of the laryngoscope, must require an immense amount of skill on the part of the surgeon, and the most perfect cooperation on the part of the patient. The procedure is, of course, only applicable to cases in which the sub- stance is lodged within the larynx, more particularly its superior portion. Operative Interference It is very important, before operative interference is employed, to explore the throat, as the foreign body may lie at the very entrance of the larynx, and admit of ready removal with the linger. The case of Gilbert, so graphically described by Rieherand, painfully illustrates the sad effects of such an omission. This unfortunate young man, in a fit of insanity, locked up his manuscripts in a press, to prevent them from falling into the hands of his enemies, and then swallowed the key. It lodged in the mouth of the windpipe, prevented the entrance of air, and suffocated him after three days of the most cruel suffering. Pieces of meat, bone, bread, potato, and other substances are often arrested here, and, if not speedily removed, are almost sure to cause asphyxia, either by direct occlusion, or by the induction of spasm in the muscles of the larynx. Having satisfied himself that the foreign body is in the air-passages, the sooner the surgeon opens the windpipe the better. For the want of this precaution 1 have known a number of children to be lost, in the vain hope that extrusion might occur spontaneously. A violent cough coming on, the patient may drop down in a tit of unconsciousness, from spasm of the glottis, and be instantly choked to death. Now, although the operation may not be immediately followed by the escape of the foreign body, it will at least effec- tually prevent spasm of the glottis, and thus afford the extraneous substance an oppor- tunity of being extruded either by the natural or artificial route. The patient has thus two chances of coughing it up, whereas, before, he had hardly one, the contraction of the muscles of the larynx constantly acting as a barrier to its escape. Even when the wound finally closes, wjthout the foreign body being expelled, the operation may have been of the greatest possible benefit in preventing suffocation. The operation usually selected is tracheotomy, as it affords much easier access to the foreign body than laryngotomy, as well as a much better chance for its spontaneous ex- pulsion. The latter operation, however, should always be selected when it is certain that the substance is impacted in one of the ventricles of Morgagni, unless the patient is a child, with a very short, thick neck, rendering it difficult to obtain a sufficiency of room for the easy introduction of instruments. The incision in the trachea may occasionally CHAP. VIII. FOREIGN BODIES. 329 be advantageously prolonged into the larynx, and conversely. In laryngotomy it is some- times extended upwards through the greater portion of the thyroid cartilage. The man- ner of executing these operations, for this and other purposes, will be described under a distinct head. When they are performed for the removal of foreign bodies, the patient should always take chloroform or ether, and the whole procedure should be conducted in the most careful and deliberate manner. The moment the operation is completed, the patient is turned upon his abdomen, with the face towards the floor. The object of this procedure is to relax the edges of the wound, so as to afford a freer passage for the escape of the foreign body, and of any blood that may have accidentally entered the windpipe. If the patient is partially asphyxiated, the wound should be kept open with a pair of polyp-forceps. In a case of this kind lately under my charge, the foreign body, a large pebble, was projected into the blades of the instrument, while in this position, and at once extracted. Its size was such as almost to close the trachea, and the child, who was only three years of age, evidently had not the power to expel it. If the substance be not speedily ejected, the best plan is to invert the patient’s body, and to strike the chest with the hand, or with a pillow, especially if the intruder be a ball, coin, shot, pebble, pea, bean, watermelon seed, plum-stone, cherry-stone, button-mould, or similar article. Inversion of the body, with previous opening of the tube, is a com- paratively safe operation. Succussion and percussion are important auxiliaries in such an event. If these measures fail, search should be made for the substance with the finger, forceps, or hook ; but all such attempts must be conducted in the most gentle manner, nor should they be prolonged beyond a few seconds at a time, inasmuch as they almost invariably excite violent cough and suffocative feelings. The employment of chloroform and the bending of the head will greatly facilitate this step of the procedure. The finger can only be advantageously used, as a means of exploration, when the foreign body lies in the larynx or high up in the trachea, in connection with a large wound. An operator sometimes makes a fortunate hit with the forceps, as in a remarkable case treated by Dr. J. I). Lyman, in which, in an attempt to remove a bullet which had cut its way through the right side of the larynx, and lodged in the neck, the missile accident- ally slipped out of the grasp of the instrument into the trachea, causing most violent suffocative symptoms. The opening was at once enlarged, and the bullet seized at the bifurcation of the windpipe. When the foreign body is hollow', as, for example, when it consists of a portion of trachea tube, extraction may occasionally be readily effected with forceps, provided with long blades, passed down into the tube, and kept gently expanded during the withdrawal of the instrument. An attempt to seize the extraneous substance wrould be likely to prove abortive. The foreign body, both in laryngotomy and tracheotomy, may escape either at the arti- ficial opening or by the glottis, and, in either case, it may be thrown to a considerable distance, perhaps the very moment the tube is pierced ; or it may be intercepted by the edges of the wound; or it may, if it take the natural route, lodge in the mouth, or pass into the stomach. Great care is taken not to permit any blood to enter at the artificial opening, as the smallest quantity may not only induce violent cough and spasm, but instant suffocation. If the accident be unavoidable, the patient must immediately be turned upon his abdo- men, and the blood, if necessary, sucked out of the tube with the mouth. It is worthy of remark that the thyroid veins, which are generally so much distended in consequence of the difficulty of breathing and the struggles of the patient, often cease to bleed the moment the windpipe is opened and the air is freely admitted into the lungs. When the patient is asphyxiated, whether by spasm of the glottis or by the presence of blood in the windpipe, the only resource is artificial respiration, steadily and diligently maintained until there is reason to believe that life is completely extinct. In a remarka- ble case observed by Dr. J. F. May, the artificial respiration was kept up for half an hour before the child, a boy nearly three years old, evinced signs of returning life. The air may be introduced by the application of the operator’s mouth, or, what is far better, by means of a gum-elastic tube, inserted through the wound into the trachea. When the extraneous body refuses to escape, or resists the efforts at removal, the edges of the wound in the trachea should be kept apart with blunt hooks, in order to favor ex- trusion. No canula should be inserted, as it wrould effectually prevent the expulsion of the 330 DISEASES AND INJURIES OF AI R-P A S S A G E S . cit a r. VIII. extraneous substance. To guard against the ingress of flies and dirt the outer wound should he covered with a piece of gauze, arranged in the form of a hag. Riddance having been effected, the wound is closed with adhesive strips, aided, if necessary, by a few interrupted sutures, care being taken not to carry them through the substance of the trachea. Simple water-dressing is the best application, but even this may, in general, be omitted. The after-treatment must be strictly antiphlogistic; the respiratory organs must be diligently watched ; and the air of the patient’s apartment must be both moist and warm, the temperature being steadily maintained at 80° to 85° Fahr. If difficulty of deglutition supervene, as often happens from the third to the fifth day, it will be proper to avoid the use of fluids, on account of their tendency to enter the windpipe in conse- quence of the impaired condition of the epiglottis. No patient is safe, or out of danger, after this accident, so long as there is inflammation of the respiratory passages, whether the intruder has been expelled or not. Bronchotomy does not always insure the speedy expulsion of the offending body ; on the contrary, cases not unfrequently arise where the only apparent good from it is the relief which it affords from spasm of the glottis, the extraneous substance being, perhaps, either permanently retained, or, at any rate, not ejected until some time afterwards, occa- sionally, indeed, not until the wound is entirely cicatrized, as happened in one of my own patients. On this account it might become necessary to perform the operation a second and even a third time. Instruments—Various instruments have been contrived for effecting the dislodgment and removal of foreign bodies. Of these, a few of the most eligible and important require particular notice. 1. Fig. 251 represents a pair of forceps, constructed for me by Mr. Kolbe, after a model of my own. They are composed of German silver, and are a little upwards of eight Fig. 251. Trachea Forceps. inches in length. The handle is considerably curved on the flat, and has two large rings for the thumb and finger. The blades, which are rounded and very slender, are five inches long, and terminate each in a fenestrated extremity, nine lines in length by three lines in width, the outer surface being smooth and convex, the inner flat and slightly ser- rated. The great advantages of this instrument are, first, that it may be used with equal facility as a probe or an extractor; secondly, that it maybe bent at any point and in any direction, according to the pleasure of the operator; and, thirdly, that it cannot possi- bly seriously impede the passage of the air, during the attempts which are necessary to explore the windpipe for ascertaining the precise situation of the foreign substance. 2. The forceps, delineated in fig. 252, are intended for holding apart the edges of the wound in the trachea, while the surgeon attempts to extract the foreign substance with other and more suitable instruments, introduced between their expanded blades. I have repeatedly found them very serviceable. 3. Fig. 253 represents a long, slender hook, composed of silver, and well adapted for extracting foreign bodies, as beans, grains of corn, coins, prune-stones, pebbles, and bits of bone, situated in the inferior portion of the trachea, or in one of the bronchial tubes. The curved part of the instrument is very short and blunt at the extremity. 4. For exploring the air-passages, or dislodging foreign bodies from the larynx, espe- cially the ventricles of Morgagni, hardly anything better could be imagined than the probe sketched in fig. 254. It is about nine inches in length, bulbous at the extremity, and, as it is composed of silver, any curve may be imparted to it that may be desirable. 5. The instrument delineated in fig. 255 is merely a whalebone probang, bent at an angle of about 45°, and surmounted at its extremity by a small piece of very soft sponge. It is admirably adapted for removing extraneous matter from the larynx, and should find a place in every surgeon’s drawer. CHAP. VIII. FOREIGN BODIES. 6. Another instrument wdiich the operator should have at hand, especially when the extraneous body is impacted in one of the ventricles of the larynx, is a flexible, grooved director, such as is usually found in the common pocket case. The scoop-shaped ex- tremity may be used with great advantage under such circumstances, particularly if it is slightly bent. Fig. 252. Fig. 253. Fig. 254. Fig. 255. Trousseau’s Forceps. Blunt Hook. Probe. Sponge Mop. 7. In a case under the care of Dr. John L. Atlee, the foreign body, consisting of a piece of clay pipe-stem, an inch and a half long, was readily seized and extracted with a pair of Toynbee’s ear forceps, one of the blades of which happily slipped into the interior of the tube, and thus enabled the operator to take a firm hold of it. The patient, a child four years of age, recovered without any untoward symptoms. Difficulties The difficulties experienced in these operations, especially in tracheotomy, arise chiefly from the imperfect manner in which the patient’s head is held, extraordinary shortness and thickness of the neck, uncommon turgescence of the cervical vessels, or irregularity in their distribution, ossification of the rings of the trachea, enlargement of the thyroid gland, and, finally, the occurrence of hemorrhage. These difficulties may usually be easily obviated by proper care. The rule is never to cut anything that can be avoided, but to hold it out of the way ; and any vessels that may be accidentally opened must im- mediately be ligated. 332 DISEASES AND INJURIES OF AI R-P A SS A G E S. chap, v i n . In laryngotomy, the crico-thyroid artery, a small branch of the superior thyroid, about the size of a crow-quill, is necessarily divided as it crosses the crico-thyroid membrane. The proper plan is not to open the tube until the vessel has been tied. I am cognizant of several cases in which, from the want of this precaution, the patient died of hemorrhage. In tracheotomy, the bleeding may proceed from the tracheal plexus of veins, or from the middle thyroid artery, given off either by the innominate or the common carotid ; in some instances it is double, one offset being derived from the former, and the other from the latter, vessel. In a preparation in the possession of Dr. S. W. Gross, the middle thyroid arises from the left subclavian, about three-quarters of an inch in front of the thyroid axis. Although the hemorrhage in tracheotomy is usually insignificant, it may occasionally be very profuse, if not fatal ; only so, however, in the hands of an ignorant, timid, or inex- perienced operator. I have heard of at least half a dozen cases of death from this cause. Sometimes a very considerable flow of blood follows upon the division of the mucous membrane, especially when it is highly congested or inflamed, as it is very liable to be when the foreign body has been retained for any length of time. The hemorrhage will then, of course, be internal, and may proceed to such an extent as to induce the most serious impediment in the respiratory functions. When such an occurrence is threatened, the patient should instantly be placed upon his face, in order that the fluid may escape at the artificial opening as fast as it is effused. Penally, in opening the trachea, it should be borne in mind that the innominate artery and vein may ascend unusually high up in the neck, or that they may cross this tube in such a manner as to incur the risk of being injured by the incautious use of the knife, as in the celebrated case recorded by Desault, in which death was produced from a wound in- flicted upon the former of these vessels. In a case reported by Guersant, the carotid artery was accidentally pierced, and Sedillot refers to one in which the oesophagus was opened. Contraindications Under no circumstances should bronchotomy be performed with- out a thorough exploration of the chest and oesophagus. It should be remembered, as already stated, that mere spasm of the glottis, caused by the lodgment of a foreign body in the fauces or gullet, or by derangement of the digestive, respiratory, and nervous sys- tems, may induce a train of phenomena closely resembling those occasioned by the presence of a foreign body in the air-tubes. An important question here presents itself: At what period after the occurrence of an accident of this kind should an operation be considered as improper? Or, more properly speaking, what are the circumstances which contraindicate a resort to the knife? It must be obvious that the mere lapse of time should not be taken into the account in the deci- sion of such a question ; for it is well known that one individual may experience as much damage from the presence of a foreign body in a week as another in a month or a year. Thus, to particularize, the lungs may become seriously diseased, if not partially disorganized, in a few days, in one case, while in another they may suffer little, if, indeed, at all, during any stage of the accident. Hence, in every instance of the kind, a careful and thorough examination of the chest should be instituted as a preliminary step, with a view of ascertaining the precise condition of the respiratory apparatus. If this be found to be healthy, or even comparatively healthy, an operation, all other things being equal, would not only be justifiable, but highly proper, whatever length of time might have elapsed since the inhalation of the extraneous substance; if, on the other hand, it be seriously diseased, the knife should be studiously withheld, certainly temporarily, if not altogether, on the ground that the artificial opening would be very likely to complicate the morbid action, and thereby greatly enhance the patient’s danger. Mortality from Foreign Bodies In the work already several times alluded to are recorded the particulars of 159 cases, in which spontaneous ejection took place in 57, 8 terminating fatally. Inversion of the body alone was successful in 5 cases, and unsucces- ful in G. Of G8 cases of tracheotomy, 8 died, and 60 recovered. 01 17 persons upon whom laryngotomy was performed, 13 lived, and 4 died. Laryngotracheotomy was practised in 13 cases; in 10 (lie operation was followed by recovery, and in 3 by death. Thus, of the 98 cases in which the windpipe was opened for the removal ot foreign bodies, 83 were successful and t15 fatal, or in the ratio of about to 1. From an analysis of 554 cases of foreign bodies in the air-passages by Mr. A. E. Dur- ham, of London, it would appear that of 271 not subjected to surgical interference 115, or 42.5 per cent., died. Spontaneous extrusion took place in 164, ot which 15 were fatal; 95 perished without ejection; 2 out of 7 recovered after the discharge ot the foreign sub- CHAP. VIII. FOREIGN BODIES. 333 stance at a late period through a thoracic abscess; and of 5 expulsions after emetics all recovered. In 283 cases operative measures were adopted, with a mortality of 70, or 24.8 per cent. Of 231 cases of tracheotomy, 170 recovered and 61 died; laryngotracheotomy in 20 cases resulted in 5 deaths; laryngotomy, followed by extrusion, was successful in 13 out of 14 cases, while of 3 cases of laryngotomy, without expulsion, all perished ; inversion and succussion of the body were successful in the 12 instances in which they were resorted to, as was also direct extraction in 3 cases. From the above summary it would appear that the best results followed surgical inter- ference, the mortality after operation, in almost an equal number of cases, having been less by 17 per cent, than that where surgical measures, were withheld. In the three operations performed in the above cases, the results were nearly equally favorable, the recoveries after tracheotomy having been 73 per cent., after laryngotomy 76 per cent., and after laryngo-tracheotomy 75 per cent. All these operations are, other things being equal, more successful the earlier they are performed, as there is then less disturbance of the re- spiratory organs. In an elaborate and exhaustive paper on foreign bodies in the air-passages read before the American Surgical Association, at its session, at Philadelphia, May, 1882, Dr. J. R. Weist, of Indiana, presented in tabular form the chief facts in relation to 1000 cases col- lected by him from original sources, 897 never having previously been reported. Of these cases no operation was performed in 599, with 460, or 76.79 per cent, recoveries, and 139 deaths, or a mortality of 23.20 per cent. In 63 cases the foreign body was re- moved with the forceps through the mouth, with the aid of the laryngoscope. Of 338 cases in which bronchotomy was performed, 245, or 72.48 per cent, recovered, and 93, or 27.42 per cent., perished. In 276 of these cases tracheotomy was performed, with 196 recoveries, and 80 deaths; laryngotomy 36 times with 30 recoveries and 6 deaths; and laryngotracheomy in 26 cases, with 19 recoveries, and 7 deaths. Among the substances spontaneously expelled were 92 cases of grains of corn, with 66 recoveries and 26 deaths; 75 cases of watermelon seeds, of which 70 were saved ; 51 cases of beans with 30 recov- eries ; and 34 cases of coffee grains, of which 29 got well. Of 26 cases of cocklebur, a very rough body, spontaneous expulsion occurred in 19, all followed by recovery. Of the 338 cases subjected to bronchotomy there were 85 cases of grains of corn with 66 recoveries and 19 deaths; 34 cases of watermelon seeds with 26 successes; 39 cases of beans with 24 recoveries; 25 cases of coffee grains, of which 14 were saved ; and 11 cases of cocklebur, of which every one got well. From a study of his tables, Dr.Weist concludes that the mere presence of a foreign body in the windpipe, unaccompanied by symptoms, especially symptoms of a threatening, or dangerous nature, does not warrant the use of the knife. On the other hand, bronchotomy is indicated when symptoms of suffocation are present, or occur at frequent intervals; when the substance, whatever it may be, moving to and fro in the trachea, excites fre- quent paroxysms of strangulation; and, lastly, when the foreign body is lodged in the larynx, and causes increasing dyspnoea from oedema or inflammation, although there may be no symptoms or strangulation. Dr. Weist finds that emetics, errhines, and similar means, are not only useless but are likely to decrease the chances of recovery; and, secondly, that inversion of the body and succussion are dangerous, and should not be prac- tised unless the windpipe has been previously opened. These conclusions, with the ex- ception of the first, are fully in accord with the results of my own researches as given in my treatise on the subject in 1854. I certainly cannot, as stated sometimes, agree with Dr. Weist that a foreign body in the air-passages is a harmless tenant, even when it does not provoke any dyspnoea or special symptoms. Such a body may, it is true, be spon- taneously ejected, but the annals of surgery abundantly show that its presence not unfre- quently occasions instantaneous suffocation, or, if it be retained even for a short time, severe, if not fatal, pneumonia. The causes of death after bronchotomy are various. The most common, undoubtedly, is inflammation of the lungs, which, as already stated, is liable to arise at various periods after the accident, and which often makes great, if not destructive, progress before the operation is performed. When death results from this disease, it may occur soon after the windpipe is opened ; or, as is, perhaps, more generally the case, it may be postponed lor a considerable time; until, in fact, the wound is completely cicatrized. Death is sometimes occasioned by an inordinate deposit of mucus at the former site of the foreign body, or in its immediate vicinity; it may also be produced by apoplexy of the brain, and by hemorrhage into the air passages. The adjoining sketch, fig. 256, for which I am indebted to Professor J. H. Brinton, illus- trates a very singular case of foreign body in the larynx, which I saw with him in October, 334 DISEASES AND INJURIES OF AIR-PASSAGES. CHAP. VIII. loob, in a boy nine years old, who, on the 24th of September, had inhaled the shell of a chinkapin. The symptoms being urgent, tracheotomy was performed the next day, but no extraneous substance could be detected, anywhere with the probe. Nearly three weeks after the accident, Dr. Brin ton, satis- fied that he had discovered the situation of the shell, enlarged the wound, which had been all along kept open with hooks, by dividing the cricoid cartilage and the crico-thyroid membrane. Again, however, nothing of a reliable nature was found, not- withstanding a large probe was repeatedly pushed up into the fauces. The boy experienced some benefit from the operation, and was for awhile even under the impression that he had swal- lowed the intruder. He progressed favorably enough until the 5th of November, except that he had occasionally a spasmodic attack, which he was in the habit of relieving by holding the edges of the wound temporarily apart with a pair of curved for- ceps. At the time here alluded to, having a more violent par- oxysm of dyspnoea than usual, he thrust the instrument forcibly through the posterior and lateral wall of the trachea, and thus ruptured a small artery, the blood of which, descending into the trachea, caused instantaneous suffocation. The shell, on dissection, was found to be firmly imbedded in the right ventricle of the larynx, a portion being hooked around the inferior vocal cord; it was three-quarters of an inch in length by four lines in width, was covered with bands of lymph, and could not be detected by the probe carried upwards through the wound in the neck. An opening, the result, doubt- less, of ulceration, existed in the posterior and lateral wall of the larynx, through which the boy had pushed the forceps so as to cause the fatal hemorrhage. The trachea was completely filled with blood. XVIII ASPHYXIA. The aid of the surgeon is occasionally required in cases of asphyxia, apnoea, suffocation, or suspended animation. This condition of the system maybe induced, first, by mechani- cal obstruction to the entrance of air into the lungs, as in submersion and strangulation; secondly, by the inhalation of certain gases, causing spasmodic contraction of the glottis; thirdly, by the want of a due supply of oxygen; and, lastly, by the introduction of gases, which, while they replace the air in the lungs,at the same time exert a powerfully poison- ous influence upon the blood and nervous system. The period at which death occurs from these several causes varies with many circum- stances and can hardly be defined even in a general manner. In the case of some of the gases, the extinction of life is almost instantaneous, whether it be occasioned simply by closure of the glottis, or by the direct poisonous action of these vapors upon the system. In hanging, garroting, manual strangulation, and submersion, the average period of death, when no complications exist, as injury of the spinal cord, brain, larynx, or other important organs, ranges from one and a half to two minutes. Exceptional examples both of recovery and of death, of a very remarkable character, occur in all forms of apnoea. The immediate cause of death in drowning and in mechanical obstruction to breathing generally, is apnoea, suffocation, or insufficiency of air. Respiration being thus arrested, the blood is unaerated and, consequently, unfitted to support life, although the circulation may go on for a short time after breathing has completely ceased. Dr. Lefevre, of Roche- fort, found that, among the Navarino sponge-divers, there was not one, accustomed as they were to their occupation, who could sustain submersion, on an average, longer than seventy-six seconds, while the pearl-divers of Ceylon, according to Mr. Marshall, can seldom remain under water with impunity more than about two-thirds of that time. From these facts, as well as from experiments performed upon dogs, it may be concluded that asphyxia is induced under water in a very few seconds. Complete death, however, does not occur at once. Unless the person is overcome by fright, shock, apoplexy, concussion of the brain, or intoxication, he invariably makes an effort to save himself. In his strug- gles he rises to the surface, and draws in more or less air. If he is a good swimmer, and retains his presence of mind, a considerable length of time may elapse before he is fatally exhausted. As unconsciousness approaches, more or less water enters the lungs, as well Fig. 256. Perforation of the Larynx 335 CHAP. VIII. ASPHYXIA . as the stomach, thus greatly increasing the danger of suffocation. Syncope under immer- sion is favorable to recovery, as is shown in the case narrated by Dr. Wooley, of a girl who, while in this condition, fell into the water but recovered after having been submerged exactly six minutes. The presence, on the contrary, of foreign matter in the air-pas- sages, as weed, sand, water, or even a large quantity of frothy mucus, necessarily accele- rates death, as the lungs can neither receive nor expel air by respiration. When at the moment of the submersion, the windpipe is completely plugged, the process may be con- tinued longer without fatal results than when the occlusion is partial. Thus, if two dogs of the same size and strength, be submerged, the one with the trachea completely closed, and the other with the tube open, the former will be much more likely to live when re- moved from the water than the latter, seemingly, because no water in this condition enters the lungs nor are the air tubes obstructed with frothy mucus. The period at which a person after submersion may be resuscitated varies very much in different cases and under different circumstances. In some cases, for reasons not always explicable, recovery is found to be impracticable at the end of one minute. The chances are never good after submersion of twice this length of time, especially when the water and the air are both uncommonly cold. Occasionally, however, restoration is possi- ble after a much longer period, as for example, in the instance of Dr. Wooley, already referred to, and in another related by Mr. Jennings, where the patient was saved after having been under the water for twenty minutes. Dogs submerged for four minutes are effectually killed, although the heart may continue to beat for several minutes after they are taken out of the water. When reanimation after a very brief submersion is imprac- ticable, it may generally be assumed that death is due to concussion of the brain, shock, apoplexy, congestion of the lungs, or spasmodic closure of the glottis. The treatment of apncea from drowning must be prompt and decided. Every moment of time is most precious. The body, being removed from the water to a dry place, is im- mediately stripped, wiped, and covered with a blanket, especially in cold weather. The mouth, nostrils, and throat are cleared of mucus, froth, and any other substances likely to intefere with the admission of air to the lungs; the tongue is pulled out at the corner of the mouth, and prevented from falling back upon the glottis; ammonia is rapidly passed to and fro under the nose ; and the body is stretched out at full length with the face down- wards, the forehead resting upon one arm, for the purpose of allowing any water that may be in the stomach and air-passages to escape by the mouth and nose. If these means do not speedily revive the patient, artificial respiration is instituted, the plan usually adopted, since the abandonment of that of Marshall Hall, being the one devised by Dr. Silvester, of London. For this purpose, the body being placed upon its back, with the head slightly elevated, the arms, grasped just above the elbows, are carried outwards and upwards from the chest almost perpendicularly, and retained in this position for about two seconds, the object of the procedure being designed to promote the introduction of air into the lungs as in natural breathing. They are then lowered and brought closely to the sides of the chest, where they are held for about the same length of time, in order to expel the air as during the act of expiration, the effort being aided by pressure applied to the inferior and lateral portions of the chest. These alternate movements of elevation and depression are repeated from twelve to fourteen times a minute, and are performed with all possible gentleness. As soon as signs of animation are observed, dryr warmth should be applied to the extremities, the region of the heart, loins, and abdomen, a little brandy and water, or a few drops of aromatic spirit of hartshorn, being administered, or, if deglutition be impracticable, thrown into the rectum. A warm bath at a temperature of 98° Falir. may be used, provided it can be done without worrying the patient. As soon as breathing is established, the body should be placed in bed, and carefully watched, a little warm broth, wine whey, or milk punch being given from time to time, as may be deemed necessary. Dr. Benjamin Howard, of New York, who has devoted much attention to the subject of death by drowning, and to whom was awarded the prize for his essay on the “ Treat- ment of Persons Apparently Found Dead from Suffocation,” by the American Medical Association, in 1871, has modified the method of Dr. Silvester, in several important par- ticulars, uniting drainage with direct manual compression of the chest. After having cleared away all mechanical obstruction, the patient is placed with his face downwards, with a large roll of clothing under his stomach to promote the evacuation of the contents of this organ by the mouth and nostrils. As soon as this has been effected, the patient is turned on his back, and the roll of clothing is put underneath, opposite the lower ex- tremity of the sternuip, so as to render this the most prominent point. Artificial respira- tion is then instituted, an assistant pulling out the tongue and managing the arms very 336 DISEASES AND INJURIES OF AI R-P A SS A G E S . much as in the method of Silvester, while the surgeon, kneeling beside, or astride, the pa- tient’s hips, applies the balls of his thumbs on each side of the pit of the stomach, the fingers lying in the lower intercostal spaces. Using his knees as pivots, he throws all his weight forwards upon his hands, which, with a grasping effort made at the same time, effectually compresses the most yielding and elastic portions of the chest between the hands and the opposing roll of clothing. Gradually increasing the pressure for about two seconds, he suddenly relinquishes his hold with a kind of push, which restores him to the kneeling posture, in which he rests for a similar space, when he proceeds as before, re- peating the alternate movements about fifteen times a minute. A very efficient contrivance for producing alternate contraction and dilatation of the chest, used by the Humane Society of London, is represented in the annexed sketch, fig. 257, and is known as Leroy’s compressor. It is formed by tearing a piece of strong CHAP. VIII. Fig. 257. Leroy’s Compressor. flannel or muslin, six feet in length by eighteen inches in width, into strips, each two feet and a half long and two inches broad, the central portion being placed under the back, while the extremities, crossed in front and tied in a knot, are drawn by two assistants in opposite directions, thus imitating the natural movement of the thorax in respiration. If, under any of the above procedures, signs of resuscitation do not speedily ensue, in- sufflation must, without delay, be employed, either by the mouth to mouth process, or by means of Leroy’s apparatus. The former method is the more ready of the two, but it possesses the disadvantage of filling the lungs with respired air, or air partially deprived of oxygen. The apparatus of the French surgeon consists of a tube, a pair of bellows, and a copper vessel for heating the air prior to its introduction. The tube, fig. 258, is com- posed of three pieces, the two outer of which are connected together near the centre by a hinge, and are so arranged as to depress the tongue and elevate the epiglottis. The bel- lows, represented at fig. 259, is double valved, and provided with a stop-cock at one end, and at the other with a graduated arc, indicating the quantity of air proper to be intro- duced at different ages. A moderate quantity of air having been thrown into the lungs, the chest and abdomen are compressed to expel it, and these two alternate processes are then continued as long as may be deemed necessary. In the mouth to mouth insufflation, the nostrils must be closed with the fingers, and the larynx well pressed back against the oesophagus, lest the air, passing into the stomach, should so distend that organ as to in- terfere seriously with the play of the diaphragm. Laryngotomy should only be performed in desperate cases of apnoea, in which ordinary insufflation is found to be impracticable or unavailing. How long these efforts should be continued must depend upon circumstances. Unless the body, when taken out of the water, is perfectly cold and rigid, showing that life is irretrievably extinct, they should be steadily maintained for at least from three to four hours. A remarkable instance has been related by Mr. Douglas, in which no evidence of 337 CHAP. VIII. ASPHYXIA. respiration was perceived until after the manipulations had been uninterruptedly continued for eight hours and a half. The signs of returning animation are flushing of the countenance, warmth of the sur- face, slight convulsive tremors, especially of the muscles of the face, sensibility to light and noise, and gasping, sobbing, or sighing respiration. When the case is unpromising, the body remains cold, pale, or livid, there is an absence of muscular contraction, and special sensation is annihilated. Fig. 258. Fig. 259. Leroy’s Tube for Inflating the Lungs. Leroy’s Bellows for Inflating the Lungs In the treatment of suspended animation from hanging, garroting, or manual strangula- tion, the principal means of resuscitation are exposure of the body to currents of cold air, affusion of cold water, flagellation, artificial respiration, insufflation of the lungs, the ap- plication of sinapisms to the extremities, spine, and precordial region, and the abstraction of blood from the arm or jugular vein, especially when there is unusual lividity of the countenance, indicative of cerebral and pulmonary congestion. Galvanization along the course of the spine and over the heart has occasionally been found serviceable. These efforts, as in suspended animation from drowning, should be continued for several hours, except in cases attended with dislocation or fracture of the neck, severe lesion of the larynx, or great delay in the employment of appropriate measures. In asphyxia caused by the inhalation of noxious gases, as carbonic acid and sulphur- etted hydrogen, the treatment is conducted upon the same general principles as in appa- rent death from drowning and strangulation by hanging. The moderate abstraction of blood will usually be called for in cases of this kind. When there is reason to believe that the cause of the apnoea is spasm of the glottis, not a moment should be lost in opening the trachea. A curious form of asphyxia occasionally occurs in infants, while asleep, not from being overlain, as is usually supposed, by the mother or nurse, but from being smothered by the manner in which the head is buried under the bedclothes. Similar accidents are liable to take place, in cold weather, in railway and other journeys. Death, under such circum- stances, is evidently due to the small quantity of air which surrounds the victim’s face, and which soon becomes unfit for respiration by the abstraction of its oxygen and the substitution of carbonic acid gas. Resuscitation should be attempted in the usual manner. No writer, so far as my information extends, has made any mention, in connection with the resuscitation of asphyxiated persons, of what I conceive to be, next to artificial respiration, the most valuable element in the treatment of this class of affections. I allude to flagellation, or slapping of the surface, either with the bare hands, a bundle of thin switches, a lash made of thin pieces of cord, or the fringed end of a towel, used either dry, or wet with cold water, the latter mode being particularly serviceable in warm weather. I know of nothing that is so powerful an excitant of the vaso-rnotor system of nerves, and of the cerebro-spinal axis, as this. Persons, after having partially recovered from asphyxia, sometimes perish from the 338 DISEASES AND INJURIES OF AIR-PASSAGES. CHAP. VIII. secondary effects, as congestion of the brain and lungs, spasm of the glottis, sheer exhaus- tion, or, as in drowning, from the presence of water in the air-passages. The only way to avoid such untoward occurrences is to confine the patient to his bed, to supply him with proper nourishment and stimulants, and to keep steady guard over him, in order that, if any unfavorable symptoms arise, they may be promptly met by suitable measures. XIX BRONCHOTOMY. Under this denomination are included the four operations known, respectively, as laryngotomy, tracheotomy, laryngotracheotomy, and subhyoidean laryngotomy. These operations may be rendered necessary by the following circumstances: 1. The presence of foreign bodies in the air-passages. 2. Spasm of the glottis, and oedema of the larynx. 3. Ulceration, scalds, fracture, and contusions of the larynx. 4. Morbid growths. 5. Laceration of the windpipe. 6. Tonsillitis and retropharyngeal abscess. Pharyngeal tumors. 7. Impacted matter in the oesophagus. 8. Suspended animation. 9. Carotid aneurism. 10. Acute laryngitis, membranous croup, diphtheria, erysipelas of the fauces, and smallpox of the larynx. 11. Stenosis or stricture of the larynx. 12. Paralysis of the posterior crico-arytenoid muscles. Laryngotomy Laryngotomy is a very simple and easy operation, the only structures that are divided being the skin, the cervical fascia, and the crieo-thyroid membrane. The patient is placed upon a narrow table, the head and shoulders being properly elevated and horizontalized by pillows. The head thrown backwards, is held by an assistant, in such a manner as to render the parts as prominent as possible, the chin looking directly forwards. The operation will be greatly facilitated by the use of an anaesthetic. An incision, embracing the skin and cervical fascia, is made along the centre of the larynx, from the top of the thyroid cartilage to the base of the cricoid, its length, in the adult, being fully one inch and a half, and hardly any less in a short, thick-necked child. The crieo-thy- roid artery is at once ligated, or forcibly twisted, lest the blood finding its way into the windpipe should occasion severe cough, if not suffocation. The crico-thyroid membrane is divided, in its entire extent, in the direction of the cutaneous wound. If the opening thus made is not sufficiently large, the incision may be prolonged into the contiguous car- tilages, or a piece of the membrane may be cut away on each side of the wound. Some surgeons prefer a crucial incision, and such a proceeding is quite proper when it is desira- ble to afford free play to the instruments without interfering with the thyroid and cricoid cartilages. Tracheotomy.—If laryngotomy is simple and easy, it is far different with tracheotomy. This is particularly true of tracheotomy in children with a short, thick neck, to say nothing of the cries and struggles which they are sure to make if they are not fully anaesthetized, or nearly choked to death. The use of an anaesthetic greatly facilitates the operation, and divests it of much of the dread always so justly entertained respecting it. In tracheotomy, fig. 260, the same general rules are to be observed as in laryngotomy. The patient being recumbent, with the neck well elevated and extended, an incision is made through the common integument, directly along the middle line, extending from the base of the cricoid cartilage to within a quarter of an inch of the top of the sternum. The sterno-hyoid and sterno-thyroid muscles are next separated from each other at their raphe, by a cautious use of the handle of the knife, aided, if necessary, by the point of the instrument, when the cervical fascia and the thyroid plexus of veins will be fully brought into view. The former is divided in the same careful manner, while the latter is pushed aside, and protected by a blunt hook. If the middle thyroid artery is cut, which, how- ever, is a rare contingency, it must instantly be secured. The isthmus of the thyroid gland, even when it descends unusually low, seldom occasions any serious embarrassment; when it does, it must be held out of the way, or be included in two ligatures, and divided at the middle, otherwise copious hemorrhage may ensue. Although ligation of this por- tion of the thyroid gland may occasionally be dispensed with ; and, although, perhaps, more stress has been laid upon this precaution than it really merits, I would strongly recommend its observance in all cases as a matter of safety. Satisfied that there is no blood at the bottom of the wound, the surgeon steadies the trachea with the left index finger, or, what is better, with a tenaculum, and divides at least three of its rings. In executing this step of the operation, the knife, entered at a right angle to the surface of the tube, with its back towards the sternum, is carried from below upwards, lest injury be inflicted upon the great vessels at the root of the neck. The incision in the trachea must strictly correspond with the centre of the external CHAP. VIII. BRONCHOTOMY. 339 wound, and should be at least an inch in length. If shorter than this, it will scarcely suf- fice for the spontaneous ejection of the foreign body, or the proper play of the forceps. Tracheotomy by a single incision, as practised by some French surgeons, is a hazard- ous procedure ; and tracheotomes fashioned like trocars and canulas, are liable to inflict great, if not irreparable, injury. I am not an advocate of tracheotomy as performed with the hot iron, whether in the form of the galvano-cautery, or the thermo-cau- Fig. 260. Operation of Tracheotomy. tery. The operation, originally suggested, if not actually practised, by Yon Bruns, of Tubingen, has received the sanction of numerous practitioners, especially in France and Germany, on account of the alleged facility of its execution and freedom from hemor- rhage. Opposed to these advantages, if such they really be, may be mentioned the fact that the operation always leaves a disfiguring scar, and that, so far from being easy, it is often tedious and more bloody than when done with the knife. Boeekel, in 1881, reported forty-one cases of tracheotomy performed with the thermo-cautery, showing the practica- bility of the operation, and its comparative immunity from hemorrhage. The instrument, heated to a dull-red heat, is carried down along the middle line of the neck as far as the trachea, which is then opened in the usual manner with the knife, any bleeding vessels being, of course, previously secured with the ligature. So far as I am aware, this opera- tion was first performed in this country, in 1881, by Professor Hunter McGuire, of Richmond. Laryngotracheotomy—In performing laryngotomy, it not unfrequently happens that the opening afforded by the division of the crico-thyroid membrane is inadequate for the pur- pose for which it was made. In this event, it may very readily be enlarged to the requisite extent, by dividing the cricoid cartilage and one or two of the upper rings of the trachea. The operation, thus performed, is denominated laryngotracheotomy, as denotive of the parts concerned in it. The chief objection to it is the danger of wounding the isthmus of the thyroid gland, and the branch of the superior thyroid artery which so frequently courses along its upper border. When the foreign body is so firmly impacted in the larynx as to render it impossible to remove it by the ordinary operation, the thyroid cartilage may be divided in its whole length along the middle line. Suhhyoidean Laryngotomy—This operation, in reality a pharyngotomy, originally sug- gested by Malgaigne, may occasionally be advantageously employed when the larynx is obstructed by a foreign body, or by a morbid growth, situated high up in the passage, or projecting into the fauces. It might also be proper in impending asphyxia caused by the presence of an abscess' in the spongy structure at the base of the epiglottis. The parts involved in the procedure are, the common integument, superficial fascia, platysma-myoid 340 muscle, and thyro-hyoid membrane, bounded on each .side by the omo-hyoid, sterno-hyoid, and thyro-hyoid muscles. A synovial burse, of variable size, exists at the middle line, beneath the fascia. The superior laryngeal artery and vein, the only vessels of any importance in this region, course along the upper border of the thyroid cartilage, and ate, therefore, in no danger of being wounded. The laryngeal nerve pursues a similar direction. The operation consists in carrying the knife horizontally along the inferior border of the hyoid bone for a distance of about one inch and three-quarters, dividing, first, the skin, fascia, and platysma-myoid muscle, then the inner half of each sterno-hyoid muscle, and, lastly, the thyro-hyoid membrane, along with its mucous lining. As soon as the incisions are completed, the epiglottis, forced into the wound by the expiratory efforts of the patient, is seized with the tenaculum, and firmly held until the larynx, now fully exposed to view, has been thoroughly explored, and the object of the operation accom- plished. XX INTRODUCTION' OF TUBES. The introduction of tubes into the windpipe is rendered necessary whenever that canal is opened to favor the ingress of air, in cases of mechanical obstruction. The only excep- tion to this rule is, or should be, when the dyspnoea is occasioned by a foreign body, the expulsion of which might be prevented by such instruments. These tubes, which are generally made of silver, should possess the qualities of light- ness and of accurate adaptation to the parts which they are destined to serve. Their length varies from an inch and a half to two inches and a quarter, according to the stature of the patient, and their diameter should be such as to admit of easy introduction, without at all encroaching upon the surface of the windpipe. Their shape is cylindrical, with a slight antero-posterior curvature, the concavity of which is directed forwards. The supe- rior extremity of the instrument is provided with two rings, for the passage of tapes, which, tied at the back of the neck, secure it firmly in its place. The blacking of a metallic tube, too, affords an early indication of local gangrene of the tract, which is not furnished by a hard-rubber tube. A great variety of tubes, as to form and size, is before the profession. Among the more recent and valuable of these is the one devised by Mr. Durham, which is so shaped as to pass straight back into the trachea, and then turn in such a man- ner as to lie in the middle of the canal, without exerting any pressure upon its walls. The distal portion of the inner canula is articulated or joined together in the lobster-tail fashion. This arrangement necessitates frequent supervision to remove the de- siccated mucus which adheres to the edges and irregularities of the joints, in the earlier days after the operation. Most instruments of this kind are made double, as seen in fig. 261, the inner one, which is nearly a fourth of an inch longer than the outer, being so constructed as to admit of easy removal for the purposes of cleanliness; a matter of the greatest importance, as the tube soon becomes clogged with thick, tough, adherent mu- cus, thus rendering frequent withdrawal absolutely indispensable. Meanwhile, the outer instrument, or sheath, being retained, the introduction of the inner is thereby much facilitated; so that, in fact, the operation may readily be intrusted to any intelligent nurse, or even, in some cases, to the patient himself. The two tubes are fastened together by a button. The breathing orifice should always be care- fully covered with a piece of gauze, to prevent the ingress of flies and other extraneous substances. The first introduction of a tube being liable to present difficulties, it is well to insert a properly adjusted flexible catheter within the outer tube or sheath, so that its projecting extremity shall serve to guide the canula safely between the edges of the ineision, which is to be kept patent by the finger-nail of the disengaged hand. A metallic guide on this prin- ciple, with an external projection turned downward, such as is used by Dr. Cohen, fig. 262, presents the double advantage of not intercepting respiration during adjustment, and of directing the expelled mucus and blood downwards, away from the face of the opera- tor. The hollow conductor is much safer than the solid pilot of Durham and others, and much more easily manipulated than the bivalve and trivalve dilators, often recommended for separating the edges of the incision during the introduction of the tube. DISEASES AND INJURIES OF AIR-PASSAGES. CHAP. VIII. Fig. 261. Trachea Tube. CHAP. VIII. INTRODUCTION OF TUBES. 341 When a tube is intended to be worn in the larynx, the re- moval of an elliptical section of the crico-thyroid membrane will generally be necessary, in order to afford sufficient room for its accommodation. Occasionally, the object may be attained by a large crucial incision. The period during which such an instrument should be worn must, of course, depend upon circumstances, or, more properly speaking, upon the necessity which led to its introduction, and the complications which may ensue subsequently. In some in- stances it may be dispensed with in a very short time, while in others it may require to be retained for years, if not during the remainder of life. In acute disease, the tube should not be re- moved until all danger of suffocation is passed, as the wound, in general, rapidly contracts, and might thus lead to a return of dyspnoea. Whenever the patient wishes to speak, he must place his finger upon the orifice of the instrument. The diameter of the tube must vary according to the size of the trachea. In the adult, there is usually no difficulty in this respect. In children it is different. Dr. Morax, who has carefully measured the trachea in children between the ages of two and fifteen years, finds that the diameter ranges from three lines to half an inch, as the minimum and maximum, at these different periods of life. Hence, a tube for a child under four years of age should be about a quarter of an inch in diameter; one-third of an inch, for a child from four to eight years ; two-fifths of an inch, for one from eight to twelve ; and half an inch, for one from twelve to fifteen. About three-fifths of an inch is the proper size for an adult, in whom the diameter of the trachea varies from five-eighths to two-thirds of an inch. When a tube of this kind is worn for a long time, it is liable to become corroded, and, breaking, a portion may fall into the widpipe, causing suffocation, as in the cases narrated by Ghelius, Spence, and others. For this reason hard rubber tubes should never be em- ployed. The first introduction of these tubes is generally attended with more or less spasmodic cough, or even a momentary apncea; but this soon subsides, and in a short time the parts cease to resent the intrusion. In croup and diphtheria, death has occasionally occurred from a portion of false membrane becoming entangled in the canula, as in an instance mentioned to me by Dr. Thomas Buckler, of Baltimore. Ulceration in the edges of the wound, and of the windpipe around the instrument, is not uncommon, and may be pro- ductive of serious consequences. Several cases have been reported in which the innomi- nate artery was laid open in this way; and others in which fatal hemorrhage arose from perforation of some of the smaller cervical vessels in the immediate vicinity of the trachea. In addition to the danger encountered from these sources, the irritation exerted by the pressure of the instrument may give rise to violent inflammation and abscess of the neck, bronchitis, pneumonia, erysipelas, and even pyemia. When bronchotomy is performed for the relief of croup, diphtheria, and other acute af- fections of the air passages, the best plan is to dispense with the use of tubes, inasmuch as they must always be a source of irritation and interfere more or less with the discharge of blood, mucus, or other matter, to say nothing of the difficulty of removing and rein- serting them in order to keep them clean and pervious. The wound, if sufficiently spa- cious in the first instance, can always be kept sufficiently open for the object for which it is made by means of two strong silk ligatures passed through its edges and secured over a compress on the back of the neck. Dr. Henry A. Martin, of Boston, has warmly advo- cated this mode of treatment, which has always guided me in my own operations performed for the expulsion of foreign bodies in the air-passages. When unusual difficulty is expe- rienced in keeping the wound properly open, a safe and certain remedy will be found in the removal of an elliptical portion of the trachea, care being taken, of course, that the piece is not so large as to lead to undue contraction of the tube during the healing of the wound. The most careful watching is essential when a tube is not used, in order to maintain the patency of the opening, as an unfortunate movement of the child may close the orifice and reproduce the asphyxia, even though the disease and the wound are both doing well. The opening left by a section of the trachea, being closed over by the integument only, will always remain a weak spot, and liable to give rise to considerable dyspnoea under conditions impeding respiration, from the atmospheric pressure exerted upon the flexible obturator during movements of difficult or forced inspiration. Fig. 262. Cohen’s Tube with hollow Guide. 342 DISEASES AND INJURIES OF AIR-PASSAGES. CHAP. VIII. Serious injury is not unfrequently sustained by the trachea from the pressure of the canula, even when the tube is retained only for a short time, especially when it is unduly large, too movable, or too angular, the effects usually manifesting themselves in hypere- mia, diphtheritic deposits, erosion, and, occasionally, even in perforation. Of 30 cases, re- ported by Dr. Bloch, of Copenhagen, 1G, or 53.3 per cent., had experienced lesions from this source. Nine cases are recorded in which the canula caused death by hemorrhage, chiefly from pressure on the innominate artery, and in 8 other cases this artery was sepa- rated from the canula only by a thin, fibrous membrane, which, if the patient had sur- vived, would soon have given way. When broncliotomy is performed for the relief of croup, diphtheria, and similar affec- tions, the wound in the windpipe should not be sucked, with a view of promoting respira- tion, without the precaution of washing out the mouth and throat well immediately after, with a strong solution of chlorinated sodium, or some other disinfecting fluid, for the pur- pose of promptly neutralizing the poison contained in the secretions of the parts. From a want of this precaution, a number of valuable practitioners, as Weber, Regnault, Biset, Hunt, Sanford, and Foulis, have lost their lives, while not a few others have severely suffered without fatal consequences. XXI LARYNGECTOMY. The entire larynx, along with one ring of the trachea, was first extirpated, on account of syphilitic disease, in 18G6, by Patrick Heron Watson, of Edinburgh ; but the astound- ing feat of removing that organ for epithelioma, and supplying its place with an artificial larynx, was performed by Billroth, in 1873. The patient, it would seem, breathed with comparative ease for some time after the operation, but perished at the expiration of seven months from the effects of a return of the disease. Of 37 complete excisions, collated by Dr. S. W. Gross, 19 recovered and 18 died, at periods varying from ten to sixteen days, the cause of death in 12 having been pneumonia. Of the entire number 30 were for carcinoma, of which 16 perished from the effects of the operation ; 7 died of recurrence of the disease in from four to nine months; 1 died from the passage of a bougie into the mediastinum six weeks after the operation ; and 6 were still living, respectively, at the end of twenty-four, seven, five, four, and three months, free from disease, the precise date in one being uncertain. Of the 5 extirpations for sarcoma, the case of Bottini was perfectly well at the end of thirty-nine months; that of Caselli, in which the pharynx, base of the tongue, soft palate, and tonsil were also removed with the galvanic cautery, was well at the expiration of twenty months; that of Foulis died of phthisis fifteen months after the operation ; and 2 perished, respectively, at the expiration of seven and fifteen months from recurrence. In the remaining 2 cases, in which the operation was done for syphilis and necrosis of the cartilages, the result was fatal. The operators were Watson, Billroth, and Czerny, each in three cases; Maas, Bottini, Foulis, and Carl Reyher, each in two examples, and Heine, Schmidt, Schcinborn, Yon Langenbeck, Gerdis, Reyher, Kosinski, Wegner, Yon Bruns, Rubio, Macewen, Caselli, Lange, Bircher, Pick, Del Toro, Carreros-Arago, Gussenbauer, Thiersch, and Albert, respectively, in one case. The affected organ may be reached by a vertical incision extending from the hyoid bone to the second ring of the trachea. The larynx having been divested of its cover- ings, the trachea, pi’eviously drawn forward with a tenaculum, is cut across, and tam- poned with a Trendelenburg canula, after which the posterior and upper attachments of the larynx are divided, the scissors being used in this stage of the operation. When the operation is limited to the larynx the procedure is sufficiently simple, and is not at- tended with serious bleeding. When, however, the pharynx, oesophagus, base of the tongue, soft palate, and tonsils are involved in the disease, the operation is a formidable one, demanding a second incision carried from the border of one sterno-nuistoid muscle to that of the other, immediately above the hyoid bone. In a case of this description Yon Langenbeck tied forty arteries, notwithstanding which the patient, a man of fifty-seven years of age, made a good recovery. From a careful study of the cases of complete laryngectomy for carcinoma, I find that the operation has not been conducive to pi'olongation of life. Hence, if it be justifiable at all, it should only be practised when the disease is limited to the larynx of comparatively young persons. In sarcoma, on the other hand, the procedure is worthy of more extended trial. The prognosis of partial excisions is not so good as that of complete operations. Thus, CHAP. IX. WOUNDS. 343 of 7 cases in the hands of Foulis, Caselli, Billroth, Gerster, and Carl Reyher, in 4 of which one-half of the thyroid cartilage was removed, 2 died from the effects of the opera- tion, 3 perished in from two to six months, 1 died without recurrence of pleurisy in one year, and 1 was living, free from recurrence, at the end of fourteen months, the case being one of carcinoma, for which the left half of the larynx was excised. The loss of the larynx by extirpation is supplied, when practicable, by an artificial ap- pliance representing a tracheotomy tube, with an extension into the pharynx, the latter being provided, in some instances, with a supplementary epiglottis. These tubes are fur- nished with a removable, vibrating reed, which yields a monotonous, metallic tone, and serves as a substitute for the vocal cords. This idea, which is due to the ingenuity of Gussenbauer, has been variously modified. The artificial larynx of Foulis is, on the whole, the best contrivance of the kind that has as yet been devised. CHAPTER IX. INJURIES AND DISEASES OF THE NECK. SECT. I WOUNDS. Although wounds of the neck are treated upon the same general principles as wounds in other parts of the body, yet they possess certain peculiarities which render it neces- sary to notice them separately. Of these peculiarities, the most important are hemor- rhage, inflammation of the air-passages, emphysema, inanition, and the occurrence of fistule. Wounds of the larnyx and trachea are discussed in the preceding chapter. In regard to their character, wounds of the neck may be incised, contused, lacerated, punctured, or gunshot, precisely as in other regions of the body. In their extent, they vary from the merest scratch to almost complete severance of the neck, involving, of course, in the latter case, muscles, fasciae, nerves, and vessels, along with the windpipe and oesophagus. The most frightful injuries of this description are generally inflicted in attempts at suicide, and yet, strange to say, these attempts are often entirely abortive, depending upon the fact that most persons, intent upon self-destruction, select the upper part of the neck, in the belief that suffocation will speedily ensue simply by opening the larynx. The consequence is that, although the gash may be most horrible, yet, the large vessels and nerves escaping, the patient not unfrequently makes a good recovery. The sources of hemorrhage in wounds of the neck vary according to the situation of the injury. When the knife is drawn deeply across the lower cervical region, the bleeding usually proceeds from the carotid artery and jugular vein ; when the larynx is involved, the thyroid vessels generally furnish the blood, while high up, as when the lesion occu- pies the interval between the hyoid bone and the chin, the hemorrhage is derived from the lingual artery. It has been doubted whether the windpipe and oesophagus could be completely severed without injury of the carotid artery and jugular vein ; but the possi- bility of the occurrence has been attested by a number of well-authenticated cases. The cervical portion of the internal carotid is sometimes laid open, and the hemorrhage thus occasioned may be so excessive as to prove fatal in a few seconds. The most com- mon cause of the injury is a stab, puncture, or gunshot wound in the neck directed ob- liquely upwards and inwards towards the throat; or the lesion may be inflicted in the opposite direction, as when a person is shot through the face, or when he falls down with a knife, piece of wood, or tobacco-pipe in his mouth. The hemorrhage attending wounds of the neck may be almost instantaneously fatal, especially when it proceeds from the large vessels; or, the patient fainting, a temporary stop may be put to it until the surgeon has time to apply a ligature. Not unfrequently death is occasioned by the blood flowing into the air-passages, and so causing suffocation, even, perhaps, when no important artery has been laid open, or, if laid open, before it has been tied. In wounds of the cervical veins, the patient sometimes perishes suddenly from the admission of air. A remarkable case has been related by Mr. Samuel Cooper, of a soldier who was almost instantly suffocated by the pressure of a large quantity of blood that had been effused between the integument and the trachea. The hemorrhage, caused by a gunshot wound of the internal jugular vein, was entirely subcutaneous. The ball 344 INJURIES AND DISEASES OF THE NECK. CHAP. IX. had entered behind the mastoid process, and passed obliquely downwards and forwards towards the sternum. Sometimes, again, the event is brought about by secondary hem- orrhage, at the distance of several days or even several weeks from the receipt of the injury. A rare case of wound of the neck followed by secondary hemorrhage has been recorded by Hennen. A soldier at the battle of Waterloo was struck on the tip of the nose by a ball, which split upon the bony edge of the organ at its junction with the cartilage. A piece of the ball was extracted on the spot. The cure went on without accident until the tenth day, when suddenly violent hemorrhage appeared in the nose and mouth, causing death in a few hours. The dissection showed that a very small fragment of the missile had lodged in the sinus of the internal jugular vein, which had ulcerated and burst. A case in which a missile may occasionally pass deeply among the structures of the neck without doing any serious mischief has been kindly communicated to me by Dr. John II. Packard, as having occurred at the Satterlee Hospital during our late war. A soldier, while lying on the ground with his head turned towards the right, was struck at the angle of the jaw, on the left side, by a Minie ball, which, after having fractured the bone, passed down aci'oss the neck, breaking the right clavicle, and finally lodged beneath the lower border of the great pectoral muscle, whence it was extracted a few days after- wards. Some difficulty was experienced for a few days in breathing and swallowing, rendering it pretty certain that the bullet had forced its way between the trachea and oesophagus. Evidently no large vessel or nerve had been injured. Recovery took place without a bad symptom. In 91 cases of wounds of the neck, involving the internal jugular vein, and made, for the most part, in the removal of morbid growths, analyzed by Dr. S. W. Gross, the ves- sel was tied in 43, of which only 4 terminated fatally, the cause of death in all having been secondary hemorrhage coming on about the period of the separation of the ligature. In only one of the cases was there any evidence of pyemia; in none of diffusive phlebitis. Of 23 cases, of which the treatment is not designated, all were fatal; 4 from the entrance of air, 6 from primary hemorrhage, 6 from secondary hemorrhage, o from pyemia, 1 from epilepsy, and 1 from softening of the brain. Of 16 cases in which compression was em- ployed, 2 died, 1 from apoplexy, and 1 from secondary hemorrhage. In 9 cases the caro- tid artery—generally the common trunk—was wounded at the same time, with the result of an aneurismal varix, usually productive of little inconvenience. The average period of the separation of the ligature was 14 days, the minimum 4, and the maximum 23. Gunshot wounds of the internal jugular vein, in all the cases tabulated by Dr. Gross, were fatal, either from primary hemorrhage, secondary hemorrhage, or pyemia. A curious case of gunshot wound of the neck is mentioned by Velpeau, in which a com- munication existed between the carotid artery and internal jugular vein, in the latter of which the ball was found, on dissection, fifteen days after the accident. The treatment of hemorrhage of the neck consists in ligating the affected vessels, O o o 7 whether arterial or venous. As a general rule, two ligatures should be applied ; on the carotid, to prevent reflux bleeding from the distal side of the wound, and on the internal jugular vein from the cardiac side. This procedure I was compelled to adopt in 1866, in the case of a man, forty-eight years of age, in which I accidentally divided this vessel in removing a deep-seated cystic tumor of the neck. With the exception of a slight attack of erysipelas, he recovered without an untoward symptom. When the jugular vein is merely nicked, the safest plan, if the bleeding cannot be staunched in any other way, is to surround the vessel with a ligature, instead of encir- cling the edges of the wound, as hitherto so generally recommended. Such a procedure is always liable to be followed, on the detachment of the ligature, by hemorrhage, from the insufficiency of the adhesions of the sides of the vessel. Besides, there is much greater risk of pyemia and diffuse phlebitis. When the internal jugular vein is inaccessible to the ligature, the wound should be plugged with pieces of sponge or patent lint, supported by adhesive strips and a roller, the head being maintained in an easy, elevated position. In punctured wounds of the neck involving the carotid artery, the quantity of blood effused in the connective tissue is sometimes so great as to render it difficult to find the orifice of the bleeding vessel. In such an event, the only way to effect the object is to enlarge the opening freely upon the grooved director, to turn out the clots, and then to apply the ligature in the usual manner. Hemorrhage of the cervical portion of the inter- nal carotid requires ligation of the primitive carotid, as the injured vessel itself seldom admits of direct interference. In secondary hemorrhage of the carotid, caused by slough- CHAP. IX. ing or extensive suppuration, direct compression, by means of a sponge wet with a strong solution of subsulphate of iron, is sometimes the only available method of arrest- ing the flow of blood, and saving the patient’s life. The wounded artery, inflamed and disintegrated, is unable to support the ligature until an efficient clot is formed. Wounds of the oesophagus and fauces should be treated upon the same general princi- ples as wounds of the intestines ; that is, by sutures, placed from two to three lines apart, the needle being carried close down to the mucous membrane, and the ends of the liga- ture, drawn very tightly, cut off very near to the knot, in order that the thread may eventually find its way into the interior of the tube. The patient is supported by the stomach tube, introduced several times a day, and also, if necessary, by nutritive enemata. Wounds of the cervical nerves are always objects of deep interest. Division of the phrenic nerves is necessarily instantaneously mortal, and the same is true of division of the pneumogastric nerves, although this has occasionally been denied. If only one of the pneumogastric nerves be severed, the patient may survive, as in the cases of Labat, J. II. B. McClellan, Liicke, and Billroth, or he may finally perish from the effects of congestion and inflammation of the lungs. Wounds of the neck are sometimes followed by paralysis of the superior extremity, from violence inflicted upon the axillary plexus of nerves. In 1858, a young man, a pa- tient at my Clinic at the Jefferson College, was struck in the neck with a long, narrow knife, the blade entering a little to the left of the median line, and passing behind the trachea and oesophagus, both of which, as well as the large cervical vessels, escaped injury. Paralysis of the right superior extremity immediately ensued, succeeded by a sense of numbness in the thumb and first two fingers, rendering it thus probable that the weapon had wounded the median nerve, either close to its origin, or at the axillary plexus. The muscles soon began to waste, and when I saw the case, about six weeks after the accident, the whole limb was excessively atrophied, icy cold, and of a purple color. The deltoid was very tender on pressure, and severe pain extended along the arm as far as the ends of the fingers, which hardly admitted of the slightest motion. The general health had suf- fered a great deal, the countenance was very pallid, and there was great disorder of the digestive organs, with loss of sleep. Such lesions, unfortunately, are usually hopelessly irremediable. In the case here described, I was induced, as the man was poor, and en- dured great pain, to advise amputation at the shoulder-joint, if, in the course of a few months, there should not be marked amelioration. SECT. II WRYNECK OR TORTICOLLIS. Wryneck, the torticollis of the older surgeons, consists in a permanent structural short- ening of some of the cervical muscles, especially the sterno-cleido-mastoid and splenius, twisting the head over to the corresponding side, while the chin projects proportionately in the op- posite direction, as seen in fig. 263, from one of my clinical cases. The distortion thus produced is characteristic, causing a disagreeable, sinister, and constrained appearance, which nothing else can imitate. When existing in a high degree, the ear is approximated to the upper extremity of the sternum, the clavicle is elevated and deformed in consequence of the excessive tension of the sterno- cleido-mastoid muscle, and the chin is thrown far beyond the middle line, almost into a horizontal position, by the inordinate contraction of the splenius and trapezius muscles. The expression of the features is remarkably altered ; the face on the affected side has a withered, atrophied appear- ance, the corner of the mouth is depressed, and the eye is much lower than the opposite one. The head is nearly immovably fixed, so that, if the patient wishes to look at any object, he is obliged, unless it is directly in front of him, to turn his whole body; and there is generally, in the more aggravated cases, a peculiar lateral curvature of the neck, the concavity of which presents towards the contracted side, due to the shortening of the scalene muscles. WRYNECK OR TORTICOLLIS. 345 Fig. 263. Wryneck. 346 INJURIES AND DISEASES OF THE NECK. CHAP. IX. Wryneck occurs in both sexes, but my experience has afforded a larger number of cases in females than in males, and there is no doubt that the affection is generally considera- bly more frequent in the former than in the latter. The lesion, which is most common in children from three to ten years of age, sometimes begins soon after birth. It has been said to be occasionally congenital, and cases of this description are no doubt now and then met with, but they must be extremely rare, none having ever fallen under my observation. The affection recognizes several distinct causes, of which the principal are inflammation, disease of the cervical vertebrae, and paralysis of the muscles. It may also be induced simply by a vicious position of the head, in consequence of the existence of an enlarged and painful condition of the lymphatic glands of the neck, compelling the patient to keep the cervical muscles in a constrained and rigid state. Any circumstance, in fact, that has a tendency to destroy the equilibrium of these muscles, and to place them in an antagonistic condition towards each other, may produce the distortion at any period of life, particularly in children during the rapid development of the body. However induced, the affected muscles soon become permanently contracted and greatly indurated, as is rendered evident both to the touch and the knife. They feel like dense, rigid cords, which hold the head firmly in its unnatural position, and of which the outline is easily traced along the neck. They are diminished not only in length, but also in breadth and thickness; their fibres, in cases of long standing, are converted into pale, fibrous filaments, united by unyielding connective tissue, and hence, when an attempt is made to divide them, they offer an extraordinary degree of resistance, almost creaking under the knife. These circumstances, taken in connection, afford indisputable evidence that, whatever the exciting cause of wryneck may be, the muscles concerned in its pro- duction become the seat of inflammation and plastic effusion, probably at an early period after they have lost their equilibrium, unfitting them for the resumption of their functions without the division of their fibres. In addition to these changes in the muscles, the integument, fasciae, and ligaments are permanently shortened, and the articular surfaces of the vertebrae are often rotated upon their axes, as in lateral curvature of the spine. The number of muscles affected in wryneck varies in different cases. Although the sterno-cleido-mastoid always suffers more than any other, yet it is by no means the only one which is concerned in producing and maintaining the distortion. The platysma, trapezius, scalene, splenius, and even the elevator of the scapula, not unfrequently parti- cipate in the disorder. It has been found that the sternal portion of the mastoid always suffers first, but I have never seen a case of confirmed wryneck where the clavicular divi- sion was not also implicated, generally in a very marked degree. The prognosis of wryneck depends upon circumstances. In the more simple forms of the affection, caused solely by muscular contraction, a cure may generally be certainly calculated upon, especially when the case is comparatively recent. If, on the other hand, the deformity is of a complicated character, as when it is associated with organic disease of the spine, serious lesion of the nervous system, or a crippled state of a large number of muscles, the patient may consider himself fortunate if he obtains any relief at all. In the treatment of this affection, the first indication is to ascertain, if possible, the nature of the exciting cause. If it depends upon rheumatism, the diagnosis may usually be easily determined by observing that this disease exists at the same time in other parts of the body, and that the muscles of the neck are extremely painful and intolerant of motion and manipulation ; more or less fever will probably be present, and the features will exhibit a wan and contracted appearance, expressive of the local and constitutional distress. If the case is seen early in the attack, bleeding by leeches will prove beneficial; the bowels should be well moved ; and the system should be promptly brought under the influence of calomel and opium, followed by colchicum. Anodyne embrocations, and the application of steam, directed to the part by means of a tube, will be the most suitable local remedies. The subcutaneous injection of a minute quantity of sulphate of atropia has been attended with happy results in the hands of Professor Da Costa, and faradization holds out excellent prospects for relief. A careful examination will generally be sufficient to detect the presence of organic dis- ease of the cervical vertebrae. The most important signs are, the existence of the strumous diathesis, unnatural projection of the spine, and the impossibility experienced by the patient in performing the most simple movements of the neck. The proper treatment will be the prone position, maintained for months together, and a course of alterants and tonics, with a caustic issue at the seat of the disease. Paralysis of the sterno-cleido-mastoid muscle lias been more frequently accused as a source of wryneck than it probably deserves. Very few of the cases that have fallen CHAP. IX. WRYNECK OR TORTICOLLIS. 347 under my observation could be traced to such an origin. The affection usually begins insidiously, and may depend upon various causes, especially disorder of the digestive organs and of the cerebro-spinal axis. It may affect both muscles, but, in general, it is limited to one, and then the other, continuing the exercise of its functions, contracts upon itself, and is eventually converted into a dense, rigid cord, in obedience to a law that a muscle, deprived of antagonism, is gradually reduced to a kind of fibrous mass, much below the volume of the original. The diagnosis is easily established by a careful exam- ination, which will disclose the great difference in the state of the two muscles, the excessive distortion of the features, and the atrophied condition of the face on the side correspond- ing with the contraction. The treatment must be directed to the removal of the exciting cause ; when this cannot be detected, the case must be managed upon general principles. Gentle purgation, a judicious regulation of the diet, and strict attention to the secretions, will always be bene- ficial, and must, therefore, not be neglected. Chalybeate tonics, the cold shower-bath, followed by dry friction with the flesh-brush, and exercise in the open air, will be required for the weak and anemic. Shampooing and electricity have been highly lauded in this form of wryneck, but their value has been greatly overrated. When the affection has reached its confirmed stage, the only remedy is the division of the contracted muscle, and it is well to know that nothing is to be gained in such a case by delay or by a resort to extending apparatus, however ingeniously constructed, or diligently and perseveringly applied. Such a hope is perfectly futile. The subcutaneous operation possesses great advantages over the direct section practised in former times, which always exposed the patient to severe suffering and to protracted suppuration, be- sides generally eventuating in an imperfect cure. The modern procedure is entirely free from all such contingencies. The only objection that can be at all alleged against it is the difficulty of its execution, but this, I am satisfied, has been greatly exaggerated, for there is no educated surgeon who need be afraid of undertaking it, provided he recalls to mind, at the time, his knowledge of the anatomy of the parts. None but the merest bungler could possibly injure the carotid artery or the internal jugular vein ; and as to the Fig. 264. Fig. 265. Tenotome. external jugular, which lies immediately behind the sterno- cleido-mastoid muscle, no serious harm could result from its subcutaneous division, as the bleeding could easily be con- trolled by pressure. In performing the operation, which should be done while the patient is under the effects of anaesthesia, the head, in- clined slightly forwards, should be held as firmly as possible by an assistant, while another has charge of the extremities. The left finger is then insinuated behind the sternal portion of the muscle, immediately above its origin, when a delicate tenotome, fig. 264, such as that used in the operation for clubfoot, is inserted flatwise behind the muscle at its outer edge, and thence carried on in close contact with its poste- rior surface, until its point meets the finger on the opposite side. The cutting edge being now turned forwards, the muscle is carefully divided from behind forwards by a kind of sawing motion, from nine to twelve lines above the ster- num. The sudden retraction of the belly of the muscle, sometimes with a distinct noise, will denote the completion of the operation. If the clavicular portion be now found to be tense and resisting, the knife should next be passed be- neath it, and its division effected in the same cautious man- ner. Bands of the cervical aponeuroses occasionally project, and may be severed with a narrow, blunt-pointed bistoury, having only about a line of cutting edge near its extremity. If the border of the trapezius is at fault, it may now be divided, and so also any other muscle, provided its proximity to the great cervical vessels and nerves do not absolutely forbid interference. Kolb6’s Apparatus for Torticollis. INJURIES AND DISEASES OF THE NECK. CHAP. IX. The above procedure is one which I have always adopted, and in no instance has it been attended by any casualty. The fact is, it is a very simple operation, and one entirely free from danger. The puncture made with the tenotome is closed with a bit of adhesive plaster, and the patient is placed in bed with his head in a relaxed and easy position. Light diet is en- joined, and a mild purgative may be given the morning after the operation. As soon as he is able to get up, which will usually be in four or five days, the head should be sup- ported with a suitable apparatus, so constructed as to produce gradual extension of the affected side or the neck. Various contrivances of this kind may be obtained of any of the more respectable cutlers, all of them possessing more or less merit, and well calculated, if judiciously applied, to effect a cure, although not without protracted perseverance. The annexed drawing, fig. 205, exhibits the apparatus of Mr. Kolbe, one of the best of the kind yet devised. It consists of a leather corset for the pelvis, and a lever for the head, with a strap to support the chin, connected by a steel rod, which is moved by a ratchet-wheel, turned by a key, the whole arrangement being such as to permit the head to be inclined to one side or the other at pleasure. The cure is promoted by daily frictions with stimulating liniments. Sometimes I dispense with the use of apparatus altogether. SECT. Ill CLONIC SPASM OF THE CERVICAL MUSCLES. Under this denomination may be described a very singular and distressing affection of the muscles of the neck, consisting in a spasmodic contraction of their fibres, attended with great irregularity of action, and a helpless condition of the head, the movements of which the patient is utterly unable to control. The muscles which are the most liable to suffer in this manner are the trapezius and the sterno-cleido-mastoid; but in the more severe and protracted forms of the complaint, all the cervical muscles, large and small, are apparently implicated, although not so far, as we are able to judge, in an equal degree. The true pathology of the lesion is not understood, but the probability is that it resides in sclerosis of the upper portion of the spinal cord, causing irritation of the cervical nerves, especially of the spinal accessory, which are so largely distributed through the trapezius and sterno-cleido-mastoid muscles, and so intimately connected with filaments derived from the pneumogastric. The complaint is similar to what is called scrivener’s spasm, while in some of its features it closely resembles chorea, but differs from it in being of more limited extent, and unaccompanied by any disorder of the mental faculties. In cases of long standing the affected muscles undergo a species of atrophy, similar to what occurs in wasting palsy. All the cases—probably about a dozen—that have come under my obser- vation, occurred in persons after the age of thirty, and of these the majority were females of a nervous, hysterical temperament. It occasionally begins at a comparatively early period of life. The affection generally commences without any assignable cause, and gradually pro- gresses, from bad to worse, until at length the patient is often unable to support his head, or to exercise any control whatever over its movements. In nearly all the cases under my observation, it was subject to temporary aggravation, apparently consequent upon dis- order of the digestive apparatus, irregularity of the menses, or derangement of the ner- vous system, especially the presence of spinal irritation. Mental anxiety, fatigue, over- work, disordered secretions, and the rheumatic diathesis act as predisposing causes. In one of my cases the affection, after an absence of several years, recurred in an aggravated form in consequence of a severe blow on the head. Hereditary influence is occasionally concerned in its production. I have never seen an instance which could be traced to a syphilitic taint of the system, and yet the possibility, of such an occurrence cannot be denied. Sometimes the muscles are quiescent for days together, when, perhaps, all of a sudden, they begin to twitch and jerk, until the patient is nearly exhausted with fatigue. The contractions are often so rapid as to render it difficult to count them. Most com- monly the head is drawn to one side, evidently by the inordinate, action of the sterno- cleido-mastoid, which is thrown into a tense cord that no force can relax. At other times it is thrust powerfully backwards, the neck forming an arched appearance, very much as in opisthotonos. When the affection is fully established, the patient is obliged to support his head almost incessantly with his hand. One of my patients is in the habit of con- trolling the spasm with the index finger gently pressed against the chin or side of the jaw. It is seldom that the head is inclined directly forwards against the sternum. Great pain is sometimes experienced; and in a case mentioned to me by Dr. S. Weir Mitchell, the spasm was so severe as to crush in some of the teeth. CHAP. IX. CLONIC SPASM OF THE CERVICAL MUSCLES. 349 The general health is usually materially impaired ; the digestive powers are weakened, the bowels are constipated, and the patient is easily fatigued on taking exercise. The extremities are nearly always cold. Great difficulty is sometimes experienced in mas- tication and deglutition. The mind preserves its natural vigor. Disorder of’ the menstrual function is often present. Occasionally the affection coexists with similar suffering in other parts of the body. The diagnosis is readily determined by the history of the case, by the peculiar charac- ter of the spasm, and by the fact that muscles are generally perfectly quiescent during sleep. In most of the cases that I have seen, the muscles of the neck, both superficial and deep, seemed to be involved nearly in an equal degree. The prognosis is unfavorable. Temporary relief may generally be afforded, but a per- manent cure is very uncommon ; and, on the other hand, I have never witnessed a case that proved fatal from this cause alone. Epilepsy occasionally supervenes during the progress of the complaint. The treatment must be mainly by tonics, alterants, and purgatives. The secretions must be well looked after. In the female, benefit may be expected from the use of em- menagogues, valerian, assafcetida, and iron with bark. Electricity, medicated frictions, the cold shower-bath, hypodermic injections of morphia, or of morphia and atropia, and ex- ercise in the open air, often afford temporary relief. Full doses of the bromides, and of chloral are also generally beneficial. The bromide of zinc, in gradually increasing doses, has occasionally been useful. Bartholow speaks favorably of the strong galvanic current, interrupted every half minute ; and Poore has reported an instance in which galvanism effected a cure. Subcutaneous division of the contracted muscles is sometimes advanta- geous, but seldom to the extent that might be anticipated by one who has no experience in the treatment of this disease. I have performed tenotomy most extensively in some of these cases, with no ulterior advantage in any, except one, and in that the relief was per- fect and permanent. Dieffenbach signally failed with this operation. Guerin has practised it with varying, but in no instance with complete, relief. Nerve stretching has been em- ployed in a number of cases. Hansen has reported two successful cases, and Mosetig and several other surgeons have been equally fortunate. In general, however, the operation is either a complete failure, or is only temporary benefit. Simple division of the spinal accessory nerve has had several successes, but more disappointments. Mr. Bennett and Professor Annandale each cured his patient after failure with stretching. Mr. Campbell de Morgan, in 1866, reported an instance of a very inveterate form of this complaint, in which he effected a cure by the excision of a portion of the spinal accessory nerve, one fourth of an inch in length. Mr. Walter Rivington and Professor Annandale have each recorded a successful case of excision ; and to these may be added another of partial re- lief, reported in 1882, by Tillaux, of Paris. In this instance one inch of the nerve was cut away, followed by marked control over the spasm. Other examples of all these oper- ations are, doubtless, scattered through our surgical literature, and should be worked up into a monograph for ready reference. An issue established in the back of the neck with the hot iron has afforded good results in several cases in my hands; chiefly, however, as a temporary expedient. To be pro- ductive of benefit, the sore should be large, and a free discharge maintained for six to eight weeks. When the affection is irremediable, the sufferer will be benefited by artificial sup- port, such as may readily be supplied by any ingenious cutler. In an instance recently under my observation, the good effect of this treatment was most marked. An excellent contrivance of this kind, the invention of Dr. E. C. Webster, is described and delineated in the Boston Medical and Sugical Journal for May, 1882. The best way of exposing the spinal accessory nerve is to make an incision, either straight or slightly curvilinear, along the posterior border of the sterno-cleido-mastoid muscle, com- mencing immediately below the tip of the mastoid process of the temporal bone, and extending downwards a distance of three to three and a half inches. The sheath of the muscle is then carefully opened, and the nerve traced along the under surface of the muscle, the body of which it pierces about two inches above the level of the thyroid cartilage. At least one inch of the nerve should be excised, and we shall the more fully discharge our duty if, at the same time, we remove sections of all the cervical nerves within reach. In making his dis- section the operator must not lose sight of the close proximity of the large vessels of the neck. In operating upon the spinal accessory nerve, it must be borne in mind that it is the larger portion, usually described as the external, that animates the sterno-cleido-mas- toid and trapezius muscles, and that this branch, after having perforated the former of these muscles, separates into two branches, one of which supplies it with filaments, while the 350 INJURIES AND DISEASES OF THE NECK. CHAP. IX. other, passing beneath the trapezius, is lost in its substance. The internal, or smaller portion, the true accessory nerve, anastomoses with the pneumogastric nerve, both before and after it leaves the cranium. The division of the sterno-cleido-mastoid muscle may be effected, subcutaneously, in any portion of its extent, the safest point being about an inch and a half above the clavicle. Unless the muscle is very rigid, the operation will prove difficult, and not free from danger. In such an event, I should cut down upon it, and divide its sheath and libres upon the grooved director. In a case of this distressing disease in a stout and otherwise healthy man, fifty-six years of age, under the joint charge of Dr. S. Weir Mitchell and myself, after the failure of every other remedy hitherto employed in this direful complaint, including stretching of the spinal accessory nerve by Mosetig, Dr. S. W. Gross, at our request, removed a por- tion, one inch and a half in length, of the external branch of the spinal accessory nerve, and divided the sterno-cleido-mastoid muscle completely across, about two inches below the mastoid process of the temporal bone. The effects were immediate and striking ; but the morning after the operation the patient was found to be very hoarse, to complain of great pain in deglutition, and to be somewhat delirious. The wound gradually assumed an unhealthy appearance, an issue which had been established three weeks before became diphtheritic, and the back of the neck showed marked evience of erysipelas. There was at no time much febrile excitement, but the restlessness was excessive, and the delirium never entirely ceased, although it was at no time even considerable. The temperature never rose above 102° Fahr. Death occurred at the end of three days from suffocation, consequent upon what all had every reason to believe was an attack of diphtheria, a disease then rather prevalent in the city. It is proper to add that hardly any blood was lost in the operation, and that the incision made to expose the nerve was carried closely along the posterior border of the sterno-cleido-mastoid muscle a distance of about three inches. Had the man survived there is every reason to believe that he would have been entirely relieved of the spasmodic trouble from which he had suffered so atrociously for the last three years of his life. So far as I know, this double operation is the first of the kind ever performed for such an object. Massage and various lotions, issues made on the back of the neck with the hot iron, stretching of the spinal accessory nerve, and the sub- cutaneous division of the sterno-cleido-mastoid muscle a short distance above its lower attachment, had all been tried, with the effect rather of aggravating the spasm than of relieving it. Large doses of chloral and bromide of potassium, and the liberal use of morphia hypodermically administered, always afforded temporary mitigation from suffering. SECT. IV DISEASES OF THE THYROID GLAND. The thyroid gland is subject to various diseases, of which abscess, cysts, and hypertro- phy are the most frequent and important. The malignant formations rarely affect this organ. 1. Abscess.—Abscess of the thyroid gland is very uncommon; it is attended by the usual symptoms, and may, when neglected, acquire a large bulk, hanging down the neck like a big pouch. In its earlier stages, it is not always easy, or even possible, to form a correct idea of the nature of the disease ; but when the quantity of matter is considerable its presence will be indicated by a sense of fluctuation, by pain and difficulty of breathing, and by a swollen, discolored, and oedematous state of the integument. These symptoms, conjoined with the history of the case, and the concomitant febrile excitement, are quite sufficient, in every instance, to establish the diagnosis. The matter, bound down by the cervical fasciae and muscles, is often long in reaching the surface, to say nothing of its tendency to extend down the neck, and its escape should, therefore, always be encouraged by an early incision in the lower part of the swelling. Such an abscess is sometimes of a latent character, as in a case which I attended, along with Dr. Charles Woodward, in a man, forty-four years of age, who died of pneu- monia, after an illness of three weeks. On inspection, we found the whole of the thyroid gland, with the exception of a small portion of its inferior extremity, converted into a thin, delicate sac, containing nearly ten ounces of thick, yellowish pus, free from odor. The thyroid cartilage was completely denuded, and the matter had burrowed upwards, underneath the hyoid bone on the left, side, as far as the root of the tongue. No symp- toms whatever, indicative of disease of the thyroid gland, had existed during life. The abscess was evidently of a strumous character. 2. Goitre or Bronchocele Goitre, technically termed bronchocele, is an enlargement CHAP. IX, DISEASES OF THE THYROID GLAND. 351 of the thyroid gland. The affection, which is much more common in women than in men, and in children than in adults, notunfrequently exists as an endemic, especially in the valleys of the Alps, Apennines, and Pyrenees. In riding from Interlachen on a Sunday to Luzerne, one is struck with the immense number of goitrous girls and women he meets with. The disease, however, is not peculiar to the female sex. Many boys and men are similarly affected. In this country goitre is often observed in the mountanous regions of Vermont, New Hampshire, Connecticut, New York, Virginia, and Pennsylvania. In our South- ern States it is uncommon. It has occasionally been noticed among our aborigines, but not to any extent. I have never seen an instance of it in the negro ; but Dr. James E. Peeves, of Wheeling, informs me that he has met with it repeatedly among colored peo- ple, especially the mulatto, in West Virginia. In England, it is most common in Derby- shii'e, Norfolk, and Surrey. The disease is very prevalent in India, so much so that in certain districts one person out of every ten is affected with it. In the valleys and gorges of the Alps, it is frequently associated with cretinism. The afflicted being has a short, stunted body, shrivelled limbs, a large, unseemly head, a vacant countenance, and a depraved intellect. In many cases, in fact, he is idiotic. The cause of bronchocele is evidently closely connected with the locality in which the disease occurs. Low and moist situations are most obnoxious to it, while high and airy regions are comparatively exempt. Confined, ill-ventilated localities, affected with fre- quent inundations, are remarkably favorable to its production. The recent observations of Professor Lebour render it exceedingly probable that the habitual use of water, strongly impregnated with calcareous and metalliferous material, acts as as a powerful predispos- ing cause. He has ascertained that the greatest number of cases both in England and France, occur in localities abounding in this association. In regions in which calcareous matter alone prevails, the disease is much less frequent. Goitre seldom makes its appear- ance, even in countries where it is indigenous, before the tenth or twelfth year. Occa- sionally it is hereditary, and it not unfrequently occurs in several members of the same family. It has been observed in the horse, cow, sheep, dog, and other inferior animals. Goitre presents itself under four distinct varieties of form, the hypertrophic, cystic, acute, and exophthalmic. Every enlargement of this kind in its early stage, before it has undergone the various tranformations to which it is liable, is found to be of the nature of adenoma or cystic adenoma, due to hyperplasia of the epithelial elements of the normal gland vesicles, the majority of which contain, in addition to the follicular cells, a clear albumi- nous fluid. The connective tissue is only slightly involved in the enlargement, but, in what is known as fibrous goitre, ordinarily mistaken for scirrhus, it is greatly increased in quantity and indurated. o. Hypertrophic Goitre—The tumor in this variety ranges in size, from the slightest increase of the natural volume of the gland, to that of a fist, a cocoa-nut, or an adult head. When of the latter dimensions, it may reach as high up as the ears, backwards as far as the trapezius muscles, and downwards over the sternum, forming a most disgusting and shock- ing mass. Both lobes are usually affected, although seldom in an equal degree. Sometimes the dis- ease is confined exclusively to the isthmus, or to this part and to one of the lateral lobes, and cases occur in which it is of a conical form, with a small, narrow pedicle. The swelling increases very slowly, and often remains stationary for years to- gether. Its surface maybe smooth and uniform, or rough and lobulated. A very common accom- paniment is an enlargement of the subcutaneous veins. No pain attends goitre, except what re- sults from its pressure on the neighboring struc- tures : the skin is free from discoloration, and the general health is unimpaired. When the tu- mor is of unusual bulk, there may be difficulty of breathing, headache, vertigo, noises in the ears, and an altered state of the voice, which often be- comes hoarse and croaking. In such cases the trachea is more or less flattened, elliptical, or even triangular, from the pressure of the superincumbent mass. The external characters of this variety of goitre are well exhibited in fig. 266, from a preparation in the Mutter collection. Fig. 266. Hypertrophic Goitre. 352 INJURIES AND DISEASES OF THE NECK. CHAP. IX. The internal structure of the tumor is liable to considerable variety, depending upon its age and progress. When of moderate standing, it is generally of a soft, gelatinous consistence, emitting on pressure a ropy, glutinous fluid. In more ancient cases it is of a pale cinnamon tint, hard to the feel, and interspersed with numerous cysts, due to mucoid softening of the parenchyma of the gland, generally not larger than a pea, con- taining a serous, glairy, or melicerous substance, and occasionally pus, fibrin, or even pure blood. Fig. 267, taken from one of my specimens, exhibits this form of degeneration, the alveoli being occupied by a white, semiconcrete, waxy, amyloid substance. Calcareous concretions are sometimes found, either alone or in union with cartilaginous and osseous productions. In a small goitrous tumor in my private collection, obtained from a man fifty years of age, there are several small, steatomatous masses, with a circular nodule of bone, about six lines in diameter. It is of a yellowish color, very compact in texture, and surrounded by a thin, imperfect capsule. Occasionally the whole organ is trans- formed into an osseous cyst, filled with various kinds of matter, especially the jelly-like, Fig. 267. Fig. 268. Cystic Degeneration of the Thyroid Gland Ossified Thyroid Gland. amyloid, and meliceric. In a specimen of this kind in my cabinet, one of the lobes has almost entirely disappeared, while the other, Fig. 2G8, which does not exceed the volume of a hen’s egg, is converted into a thick, firm, solid capsule, as hard as bone, and occupied by a white, curdy, friable substance, not unlike semi-concrete cheese. The diagnosis of hypertrophic goitre is sufficiently easy. Its early appearance, its tardy progress, its situation in front of the neck, its indolent character, and its ascent with the larynx and trachea in deglutition, leave little room for doubt in any case. The dis- eases with which it may be confounded are aneurism of the carotid artery, varix of the in- ternal jugular vein, cystic tumors, and swelling of the lymphatic glands. When goitre is excessive, and occupies the side of the neck, a part of it will necessarily project over the carotid artery, and thus receive its pulsation. In this manner the dis- ease might easily enough be mistaken for aneurism. The signs of distinction are, the slow and indolent nature of the swelling, the absence of bellows-sound, and the facility with which the morbid mass may, in most instances, be pressed away from the cervical vessels, when the head is bent forwards so as to relax the muscles of the neck. An instance now and then occurs in which the whole tumor is the seat of a violent pul- sation imparted to it by the action of the carotid and enlarged thyroid arteries, in conse- quence of an anemic state of the system. The nature of the lesion is readily detected by the appearance of the patient and by the history of the case. Varix of the internal jugular vein is uncommon. The enlargement is seated low down in the neck, immediately above the sternum, and forms a tumor of an oblong shape, about the size of an egg, soft, elastic, and compressible. It is of a bluish color, has a tremu- lous, pulsatory motion, and is diminished, or temporarily effaced, by pressure upon the distal portion of the vessel. A cystic tumor, situated directly over the thyroid gland, may simulate goitre. Seldom exceeding the volume of a walnut, it is free from pain, partially translucent, soft, elastic, and obedient to the motions of the windpipe. AVhen the diagnosis is at all equivocal, recourse is had to the exploring needle. A scrofulous lymphatic gland, occupying the site of the thyroid body, may prove to be a source of error. The history, however, of its origin and progess, the hardness of the swelling and its tendency to suppurate, the presence of the strumous diathesis, and the CHAP. IX. DISEASES OF THE THYROID GLAND. 353 existence of similar enlargements in the neighboring parts, will always be sufficient to enable the surgeon to distinguish between the two affections. Treatment—The treatment of goitre is generally conducted too much upon empirical principles. Hence, failure is too commonly the rule ; success the exception. At the pre- sent day, reliance is mainly placed upon iodine and its various combinations in conjunc- tion with the use of leeches, blisters, and purgatives. It must be obvious that no reme- dies, however valuable in themselves, or however judiciously and faithfully employed, can avail in every instance. When the tumor is of long standing, when it has attained a large bulk, and, above all, when it has undergone some organic transformation, no mode of treat- ment whatever will be likely to make the slightest impression upon it. Such cases are lite- rally hopeless. It is only in the milder forms of the disease, and in its earlier stages, that any decided benefit is to be looked for. Of the spontaneous disappearance of goitre, spoken of by some authors, I have never witnessed any examples. My plan in this disease, for many years, has been to subject the patient to a kind of preliminary treatment, consisting of light diet, and gentle, but steady, purgation. When plethora is present, a full bleeding may advantageously be premised. After the lapse of ten or twelve days, the use of iodine may be commenced, either in substance, or in the form of Lugol’s solution. The tincture I rarely employ, as it is apt to prove irritating. In whatever form iodine be administered it is best always to combine with it a small quantity of opium or hyoscyamus ; the dose should be graduated according to the age and suscepti- bility of the patient, and the effects of the remedy should be carefully watched. After it has been taken for a fortnight or three weeks, its use should be suspended for several days, when it may be resumed and continued as before. In some instances, the protiodide of mercury exercises a very beneficial influence, especially if carried to the extent of slight ptyalism. This article is particularly serviceable in recent cases, before degenerative changes have occurred. Chloride of ammonium is also a valuable remedy, in doses of ten to fifteen grains, thrice daily. Dr. Edward Woakes recently reported twenty cases of goitre, of which seventeen were cured by the use of half drachm doses of fluoric acid administered three times in twenty-four hours. The treatment was aided by the occasional injection of iodine into the substance of the tumor. The bowels are not to be neglected. Much purging, however, is neither necessary nor proper. The diet should be farinaceous. Change of residence is frequently indispensable, especially when the individual lives in a country in which the disease is endemic. The topical treatment consists of the inunction of iodine, leeching, and blistering. The detraction of blood from the affected part is almost always beneficial, from its tendency ’to unload the capillary vessels, and to rouse the action of the absorbents. From ten to a dozen leeches may be applied every six to eight days, directly over the swelling, and the bleeding encouraged by fomentations. In some instances, a rapid reduction of the tumor is effected under the use of blisters, repeated once a week. But I have found no local remedies so efficacious as a combination of equal parts of the iodine and camphorated mercurial ointments, rubbed thoroughly upon the tumor twice a day. A piece of oiled silk is worn next the skin, and over this, in cold weather, a piece of flannel, for the double purpose of preventing the unguent from soiling the dress, and keeping the neck sufficiently warm. In India, where goitre is extremely common, the ointment of biniodide of mercury has been found the most reliable remedy ; and I can bear ample testimony to its efficacy from personal observation. In whatever form iodine is applied, it should not be so strong as to fret and irritate the skin, otherwise inflammation, and not absorption, will be the result. The hypodermic injection of tincture of iodine, diluted with six, eight, or ten parts of alcohol, has occasionally been found serviceable in the milder forms of goitre. The quan- tity of fluid thrown in at one time should, at first, not exceed five drops, from which it may be gradually increased to ten, fifteen, or even twenty, according to the tolerance of the affected structui’es, a new site being selected at each operation, repeated every third fourth, or fifth day, the effects being carefully watched. Starvation of the tumor, by tying the thyroid arteries, has been practised, but without any encouraging results. The operation was first executed by Mr. Blizzard, of London, and since then it has been done by Walther, of Germany, Dr. Jameson, of Baltimore, and other surgeons. In some of these cases no inconvenience ensued, and the bronchocele, in a short time, became considerably reduced in size ; in others, no visible effect of any kind was produced ; while in a third class the patient either died of hemorrhage or of inflammation. Whether the diminution of volume was permanent, in any instance, remains undetermined. • The probability, However, is that it was not; for such is the 354 INJURIES AND DISEASES OF THE NECK. CHAP. IX. amount of blood which the tumor receives, and so great the number of anastomosing ves- sels, that its proper circulation would, no doubt, be speedily reestablished. When the tumor resists our curative efforts, and endangers suffocation, it has been pro- posed to afford relief by extirpation. The great obstacle to the employment of the knife in goitre has been the fear of hemor- rhage and shock, in the first instance, and afterwards, if the patient survive the immediate effects of the operation, the danger of inflammation of the air-passages from the exposure of the larynx and trachea by so large a wound of the neck. Most of the cases of excision that occurred in the hands of the older surgeons perished from the first of these causes, either before the completion of the dissection, or shortly after from exhaustion. To this category belong the examples referred to in the writings of Bonetus, Severinus, Pal fin, Gooch, Bell, and Desault. Dupuytren appears to have been the first to perform an ope- ration of this kind upon strictly scientific principles, the plan which he pursued consist- ing in the ligation of the thyroid arteries prior to their division, as a means of preventing hemorrhage ; but, although he removed a very large tumor in this way with the loss of only a few ounces of blood, the woman never recovered from the shock of the operation, and expired within thirty-five hours after, Roux lost a case under similar circumstances. Occasionally an operation of this kind was successful. Thus, as related by Fodere, Gi- raudi, an adventurous surgeon of Marseilles, saved two patients by it. Desault dissected out the right portion of an enlarged thyroid gland from a woman, who recovered without any bad symptoms. In 1807, Dr. Charles Harris, of New York, successfully extirpated from a lady a large goitre, of twenty-two years’ growth, extending from the chin, which it buoyed up, to one inch below the top of the sternum, and far outwards, on each side of the neck, beyond the ears. The mass, being exposed by a long incision along the middle line, was gradually enucleated with the knife and fingers, and then separated from its deep muscular attachments, as well as from the trachea and hyoid bone, a stout ligature having previously been thrown firmly around the ligamentous bands which connected it to the latter, lest it might contain important vessels which, if divided, would occasion serious hemorrhage. Only two small arteries were tied. The wound was closed with five inter- rupted sutures, and in three weeks the patient was well. Valentine Mott, early in his professional life, extirpated, unsuccessfully, a thyroid gland, weighing three pounds. Modern experience shows that, under improved methods of operating, the mortality is far from being excessive. In 1871, the late William Warren Greene, of Portland, reported three successful extirpations of goitrous tumors. In 1873, Patrick Heron Watson recorded four recoveries; and Billroth, during the past five years, lost only 4 out of 48 cases. In 2 the tumor was enucleated from its capsule, with 1 death ; in 24 one-half of the diseased gland was extirpated, with 1 death ; while, of 22 complete extirpations, only 2 proved fatal. Of 46 operations, in the majority of which the entire gland was removed, reported in 1880 and 1881, by Dumreicher, Albert, Courvoisier, Brochin, Bottini, the Reverdins, Baumgartner, Mosetig-Moorhof, Wyeth, Richelot, Monod, Whitehead, Perier, Kohler, and Cheever, only 7 died, so that the mortality of these 101 operations was only 6.93 per cent. In removing a goitre comparatively little difficulty will be experienced if the precau- tions of Watson be observed. These consist, first, in making a free incision from the larynx to the notch of the sternum, and in dividing the fascia between the sterno-hyoid and sterno-thyroid muscles to the same extent, any vessels being secured as fast as they are divided to prevent obscuration of the succeeding steps of the operation ; secondly, in pass- ing the fingers between the cervical fascia and the capsule of the tumor, with the view of recognizing and successively ligating the thyroid arteries; and, thirdly, in opening the capsule, and carefully severing its attachments to the growth with the scissors. The second is the important step in the operation, since, if the capsule be divided before the vessels are tied, the latter will be found to be so fragile as to be easily torn during the manipulations, in which event their ligation will be very embarrassing. As a further precaution against hemorrhage, all fibrous bands passing from the capsule to the tumor should be ligated before they are severed. Although experience demonstrates that even large tumors may be removed with com- parative safety, 1 am clearly of the opinion that no operation should be attempted, except where the patient is in imminent danger of suffocation, or where life is imperiled by pro- fuse and fetid suppuration, as in the case recorded by Holmes, when the growth has a very broad base with deep and extensive attachments, and is pervaded by large arterial and ven- ous trunks. The risk, on the contrary, will be much less, as occasionally happens, when the tumor is pendulous and pedunculated, as in an instance under the care of the late Professor CHAP. IX. DISEASES OF THE THYROID GLAND. 355 Blackman, in which a growth of this kind, after division of the integument, was com- pletely isolated with the fingers and handle of the scalpel, with but trifling hemorrhage, until its base was reached, when the whole mass was suddenly wrenched from its connec- tions. The excessive bleeding which followed this step of the operation was speedily arrested by means of two sponges, placed upon each other in the deep wound beneath the flaps of skin, which were fastened over them with twisted sutures. One of the sponges was removed at the end of the sixth, and the other on the eleventh day, the fetid odor having in the mean time been corrected with carbolic acid. The parts healed with but little suppuration, and the woman left the hospital in less than a month after the operation. Although in this case the bleeding consequent upon the forcible evulsion of the tumor was easily staunched, it would be much safer, as a general principle, to remove the pedi- cle with the ecraseur; or, if such an instrument is not at hand, to throw a stout ligature around the footstalk prior to its separation, as either procedure would thus effectually pre- vent hemorrhage. Finally, when the case is utterly hopeless, and life is threatened by suffocation, tempo- rary relief may occasionally be afforded by the subcutaneous division of the cervical apon- euroses and muscles, at the seat of the greatest constriction, thereby removing tension and pressure from the respiratory passages. f3. Cystic Goitre In what is known as cystic goitre the organ is the seat of one or more cysts, due to enlargement of the normal gland vesicles, and similar to those of the liver, ovaries, and other structures. Varying in number, in different cases, from one to several dozens, they are situated either directly in front of the neck, or at one side of the middle line, and are found of all sizes, from that of a cherry-stone to that of an egg. They are composed of thin, elastic coats, and are occupied by a watery, yellowish, or oily- looking fluid, coagulable by heat, alcohol, and acids, thus showing its albuminous consti- tution. The development of these tumors is, in general, very tardy; they are free from pain and discoloration of the integument, and they communicate to the finger a soft, elas- tic sensation, which readily distinguishes them from solid tumors in the same situation. The disease is rarely met with under the age of twenty-five or thirty. In cystic disease of the thyroid gland the quantity of fluid may reach as high as fifteen, twenty, or even thirty ounces, as in the case of a young woman at the College Hospital, represented in Fig. 269. Generally of a serous, but occasionally of a turbid, dirty, or Fig. 269. Cystic Goitre. sero-sanguinolent character, it is usually contained in a single cyst, although sometimes the cyst is multiple, compound, or proliferous. The enlargement is commonly slow and 356 INJURIES AND DISEASES OF THE NEOK. CHAP. IX. painless; but as it increases it compresses the windpipe and oesophagus, and may thus give rise to more or less embarrassment in respiration and deglutition, both tubes being occasionally considerably flattened and contracted by the steady and persistent pressure of the swelling, as in some remarkable cases recorded by Gooch and other writers. The diagnosis is easily established by the history of the case, by the presence of fluctuation, and by the fact that the tumor ascends with the larynx when the patient swallows. If any doubt exists, it will readily be dispelled by the insertion of an exploring needle. For the cure of cystic goitre six methods of treatment are at the command of the sur- geon, the seton, puncture, injections of iodine, incision, excision, and electrolysis; all more or less serviceable, but not one entirely free from danger. The seton, originally recommended by Celsus, and reintroduced into practice, in 1824, by Dr. Quadri, of Naples, acts upon the same principle as in the treatment of hydrocele of the vaginal tunic of the testicle. It should be inserted with great care, and the result- ing inflammation should be sedulously watched, lest overaction arise, imperilling life, removal being effected the moment the parts become tender and painful. The danger will be greatly lessened if, when the swelling is of great size, the fluid be withdrawn eight or ten days prior to the introduction of the seton, so as to diminish materially the area of the secreting surface. The operation has occasionally been followed by fatal hemorrhage, and a number of patients have perished from the violence of the local inflammation, from pyemia, or from a low form of fever. In at least one case death was caused by the punc- ture of a vein at the root of the neck, admitting air. Mere tapping of a cystic goitre is not always free from danger. Curling mentions a case in which a large tumor of this kind rapidly increased in size after the operation, and caused death suddenly from rupture of the cyst and the discharge of its contents into the pharynx and larynx. A similar accident occurred in a case recorded by Gooch. Injections of iodine occasionally succeed ; but the operation is liable to be followed by severe inflammation, eventuating in rapid reaccumulation, and is, in the main, less cer- tain than the use of the seton. When the cyst is very large, previous tapping will be advantageous. From one to two drachms of equal parts of iodine and alcohol will be a suitable quantity of fluid. If the water reaccumulates, it must be let out by an early and free incision, and no effort must be spared to keep the inflammation within proper limits. Billroth, in 1877, reported thirty-five cases of cystic goitre, in twenty-nine of which he effected a cure with the injection, in each, of half an ounce of pure tincture of iodine. The operation was always followed by severe inflammation, and one case was fatal. Incision of the morbid mass is occasionally practised, and cases have been reported in which the operation was followed by marked diminution. The procedure is mainly adapted to tumors composed of large cysts, and the chances of success will be much increased if it be combined with the mopping of the affected cavities with iodine and the use of a tent to provoke suppuration and granulation. Great care must be exercised, otherwise the free use of the knife will be attended with copious hemorrhage. Incision combined with packing the sac with lint appears to be a favorite practice with the surgeons of Freiburg. Of 100 cases treated in this way, recorded by Dr. Schinzinger, of that city, in 1879, including fifteen of his own, only 3 died. Incision of the sac and uniting its walls with those of the skin, an operation which I believe originated with Yon Bruns, has been performed 11 times by Billroth, with 3 deaths. Dr. Beck, of Freiburg, in 1836, reported three cases of excision of cystic goitre, of which two, after great suffering, recovered, while the other perished from pyemia. The late Di\ F. F. Maury removed the thyroid gland on two occasions for cystic enlarge- ment. One of his patients made a rapid recovery, while the second was seized with pneumonia, from which she died on the sixteenth day. In both instances the loss of blood was insignificant, each thyroid artery being ligated near the tumor as it was ex- posed. In his first case the enlarged gland was peeled away from the windpipe to the extent of three inches and a half, with extensive exposure of the sheath of the carotids. Electrolysis has been successfully employed in some cases of this affection ; but the treatment is tedious and painful, and, withal, so uncertain that few practitioners will be likely to give it a fair trial. A Daniell’s battery may be used, as directed in the section on Minor Surgery; or a needle connected with the negative pole of an Althaus perma- nent battery may be inserted into the tumor, the circuit being closed by placing a moist- ened sponge, connected with the positive pole, upon the neck. The current may be maintained, at first, for a few minutes, and afterwards for a longer time, the application being repeated, on an average, once a week. A good deal of swelling generally succeeds, but when this subsides the gland is found to be smaller than it was before. The patient will commonly require an anaesthetic during the operation. CHAP. IX. DISEASES OF THE THYROID GLAND. 357 y. Acute Goitre.—Acute goitre is so called because it often acquires a very large bulk in a very short time, as in the course of a few weeks ; it occurs both sporadically and endemically, and is generally attended with great embarrassment of respiration from the pressure made upon the tumor by the cervical aponeurosis, which from its dense and resisting texture, is unable to expand proportionately before the growing mass beneath and around it. The consequence is that the larynx, trachea, (esophagus, and cervical vessels and nerves are so violently compressed as to cause not only severe pain but exces- sive dyspnoea, leading finally, if prompt relief be not afforded, to fatal asphyxia. In this form of goitre, fortunately a very rare one, our main reliance must be upon gene- ral and local depletion, followed by early and thorough vesication of the tumor, and, in urgent cases threatening asphyxia, upon the free division of the fascia of the neck. Tra- cheotomy is of course impracticable. 5. Exophthalmic Goitre.—There is a form of this affection, generally known as exoph- thalmic goitre, pulsating goitre, or Graves’s disease, from the fact that it was first accu- rately described by Dr. Graves, of Dublin, the chief peculiarities of which are, enlarge- ment of the thyroid body, prominence of the eyeballs, and functional disturbance of the heart, as manifested by various kinds of murmurs, and the increased force and frequency of its pulsations. It is usually associated with anemia and chlorosis, and is most com- mon in young women of a nervous, irritable temperament. Of fifty cases analyzed by Witherisen, only eight occurred in males. The most remarkable feature of the complaint is the protrusion of the eyeballs, which is sometimes so great as to interfere materially with the closure of the lids, although it is not productive of pain, impairment of vision, or disorder of the globes. The enlargement of the thyroid body is generally most conspicuous on the right side, and rarely attains any great bulk, so often witnessed in common goitre. The malady, the pathology of which is still undetermined, is essentially chronic. The heart is seldom organically affected. The thyroid and carotid arteries beat with extra- ordinary vigor ; and various murmurs, arterial and venous, loud, and often musical, are discernible upon applying the ear to the enlarged gland. The most appropriate remedies are tonics, as iron and quinine, a generous diet, rest of mind and body, change of air and scene, and, in short, whatever has a tendency to invig- orate the system. Hygienic measures are generally of the greatest importance. Little, if any, benefit is to be expected from local treatment. Small doses, as two drops of the tincture of the root of aconite, twice daily, are generally of signal benefit, by controlling the heart’s action. 3. Malignant Disease The primary malignant affections of the thyroid gland are carcinoma and sarcoma, especially the encephaloid varieties. Carcinoma, which is most common after the age of forty-five, may usually be suspected when the gland, in advanced life, is the seat of sharp, lancinating pains, when the affected part steadily augments in size, when the skin becomes adherent and involved, and when there is progressive emacia- tion, with hectic irritation, a sallow, sickly expression of the countenance, and the exist- ence of secondary growths in other organs. Encephaloid, or round-celled, sarcoma here, as elsewhere, always proceeds with great rapidity ; the tumor soon acquires a large bulk ; there is commonly considerable enlargement of the subcutaneous veins, and the general health is early and severely affected. The clinical features of encephaloid sarcoma are well illustrated in the case of a young man, twenty years of age, who was admitted into the Jefferson Medical College Hospital in October, 1878. The growth, which was first noticed three years previously, exhibited a well-marked lobulated appearance, and ex- tended on the-left from the sternal end of the clavicle to the mastoid process of the tem- poral bone above, across the front of the neck to the left side, pushing the thyroid carti- lage nearly two inches in this direction, and the left carotid artery along the posterior border of the tumor. The mass was of enormous size, its longitudinal diameter being eleven inches, and the transverse ten. Within the last few months, it had caused great change in the quality of the voice, which has become feeble and husky, and considerable difficulty in swallowing, particularly solid food. One of the most singular features of this tumor was the remarkable sense of fluctuation imparted to the finger. Upon punc- turing it, however, at different points, nothing but a little blood escaped. The subcu- taneous veins were not materially enlarged. The patient was much emaciated. The firmer variety of the affection proceeds with frightful rapidity, as in a case which I re- cently saw with Dr. Schureman, in which death occurred in less than four months from the first appearance of the disease. The tumor involved both lobes, was of a very firm consistence, and occupied the entire front and lateral portions of the neck. The patient was a man thirty-nine years of age, apparently in robust health at the outbreak of the 358 INJURIES AND DISEASES OF THE NECK. CHAP. IX . disease, for the origin of which no cause could be assigned. Nothing is to be expected from medicinal means in these affections ; and as to extirpation, I know of no circum- stances that would render it advisable. SECT, y TUMORS OF THE NECK. Various tumors, mostly of an innocent character, are liable to form in front and at the side of the neck, and are often very embarrassing in their diagnosis and treatment. Among the more common of these growths are the lymphatic and the cystic, the latter of which are not unfrequently congenital. 1. Cutaneous Tumors Hypertrophy of the skin of the neck, constituting what may be called a pachydermatous growth, is sometimes met with, and is of surgical importance chiefly on account of the deformity occasioned by it. The affection in the five or six cases of it that have fallen under my observation was always congenital. In one of the cases the development was of gigantic proportions, involving not merely one side of the neck, but also the corresponding side of the head, face, and chest, forming a large pendu- lous and a sadly disfiguring mass. Portions of such tumors are often of a brown or dark- ish color, thickly covered with hair; and there is generally considerable enlargement of the subcutaneous veins. Indeed, the whole structure is usually excessively vascular, owing to the fact that it partakes more or less of a nevoid character. The only remedy for such a growth is removal with the knife, the ligature, or the ecraseur. Excision must not be attempted, if the tumor is very large, without due preparation for the emergency, on account of the copious hemorrhage which is sure to attend it. 2. Lymphatic Tumors—The most common tumors of the neck are the lymphoid, or lymphatic glandular, caused by hypertrophy of the absorbent glands so abundantly found in this region. They consist essentially of hyperplasia of the cells of the lymph follicles, which, consequently, become much enlarged while the corpuscles of the support- ing connective tissue proliferate and assume the features of lymph cells. In lympho- sarcoma, on the other hand, with which these tumors, particularly the medullary forms, are often confounded, the cells of the interstitial connective tissue are converted into spindle or small, round cells with large nuclei, which by their progressive multiplication cause atrophy of the lymph follicles. The enlargement dependent upon the strumous diathesis, derangement of the general health, exposure to cold, or disease of the gums, teeth, jaws, throat, or windpipe, may be limited to a single gland, but this is uncommon ; in general, it affects a considerable number of these bodies, and cases are met with in which it involves the entire chain stretched along the edges and posterior surface of the sterno-cleido-mastoid muscle. When the enlargement is very great, and implicates both sides of the neck, it occasions the most hideous deformity, giving rise to that peculiar appearance of the neck to which, from its resemblance to the neck of the swine, the term scrofulous is usually applied. Persons affected with this complaint often labor under leucocythemia, or a remarkable increase of the white corpuscles of the blood; the countenance has a pasty, pale, anemic appearance; the digestive organs are out of order, the extremities are habitually cold, and the vital powers are at a low ebb. Chronic enlargement of the spleen is a frequent, but not an invariable, concomitant. Whether leucocythemia is the cause of the disease, or simply one of its effects, is still a mooted question. The glandular tumor of the neck is generally tardy in its progress, and, in great mea- sure, if not wholly, free from pain. It is of a firm, dense consistence, with a slight degree of elasticity, and is usually remarkable for its irregular, lobulated surface, the in- dividual glands of which it is composed being either closely grouped together, or sepa- rated by distinct intervals. When the disease upon which the hypertrophy depends is extensive, it commonly involves most of the deep as wrell as the superficial glands, extend- ing, perhaps, on the one hand, from the parotid gland down to the collar bone, or even beneath it, and, on the other, from the margin of the trapezius muscle behind to the larynx and trachea in front. In this way the tumor may include in its substance not only most of the muscles of the neck, but also the great vessels and nerves, in one con- fused and inextricable mass. When the tumor is of long standing the component glands are generally completely altered in their structure, being of a dense, firm consistence, and of a whitish, drab, or pale straw color ; their capsules are thickened and indurated, and the interstitial connec- tive tissue is either of a fibroid character, constituting the so-called fibrous tumor, or thoroughly infiltrated with cellular elements. CHAP. IX. TUMORS OF THE NECK. 359 The diagnosis of this disease is deduced, first, from the history of the case, especially the nature of the exciting cause and the existence of the strumous diathesis; secondly, the tardy progress of the enlargement; and, thirdly, the nodulated character of the morbid growth, the mass feeling as if it were composed of numerous bodies, more or less closely adherent to each other. The only malady with which it is liable to be confounded is sarcoma, but from this it may generally be readily distinguished by the facts just men- tioned, by the presence of the scrofulous dyscrasia, and by the slower march of the enlargement. Moreover, in sarcoma the tumor is usually more circumscribed than in ordinary glandular hypertrophy. Another valuable diagnostic is that, in the latter affec- tion, some of the lymphatic glands not unfrequently take on suppurative action, which is not the case in sarcoma. The treatment of lymphoma is governed by the nature of the exciting cause, the con- dition of the system, and the progress of the disease. The milder cases often promptly yield to the influence of antiphlogistics and sorbefacients, aided, when there is evidence of the tubercular dyscrasia, by the different preparations of iodine, barium, mercury, and cod-liver oil. If leucocythemia exist, great benefit may be expected from the use of quinine and iron, especially the tincture of the chloride, milk punch, and change of air. When the disease is very obstinate or intractable, the knife may be necessary, but it is well to know that the operation may not only be extremely difficult, tedious, and bloody, but that it is generally fraught with danger, and that loss of life will almost be inevitable when the tumor involves the deep-seated structures of the neck, the most frequent sources of death being shock, hemorrhage, erysipelas, and pyemia. 3. Bursal Tumors A cystic tumor sometimes forms in the upper and forepart of the neck, taking its rise in the synovial sac, situated between the hyoid bone and the notch of the thyroid cartilage. This sac, which, in its natural state, is hardly a few lines in diameter, may, in consequence of inflammation, acquire the volume of an egg, if not of a small orange. It is of an oblong shape, elastic, slightly translucent, and tilled with a thin, serous, oily, or viscid fluid. The superincumbent skin is healthy, and the swell- ing is entirely free from pain. A tumor of a similar nature may form in connection with the burse which occasionally exists between the integument and the thyroid cartilage. The diagnosis is determined, if need be, by the exploring needle. The treatment is by seton, injection, or incision, as in cystic tumors in other parts of the body. 4. Sebaceous Tumors Occasionally a sebaceous tumor forms in the thyro-hyoid region, where it may be productive of serious deformity and other annoyance. The most re- markable example of the kind I have ever seen came under my observation in 1841, in a lady twenty-eight years old. The tumor had made its appearance at an early age, and had attained the size of a large orange, without causing any pain or discoloration of the skin. Slightly movable from side to side, it extended upwards nearly as far as the chin, while below it overlapped the thyroid and cricoid cartilages. The operation was not difficult, and the patient made a rapid recovery. No vessels required to be tied. The tumor was occupied by a tough, putty-like substance, and had evidently originated in a sebaceous follicle. An instance of a similar kind, successfully treated by operation, came under my obser- vation at the College Clinic, in 1871, in a young woman, twenty-four years old. The tumor, the size of a common orange, had commenced at the age of twelve, and occupied the thyro-hyoid region, to the membrane of which it had contracted very firm adhesions. Deep epidermic cysts, or pearly tumors, probably originating in the chain of lymphatic glands along the sheath of the carotid vessels, with which they are intimately connected, have been observed by Adelmann, Thiele, Yon Langenbeck, and other surgeons. The best description of these growths, and of the operations required for their removal, with which I am acquainted, has been furnished by Von Langenbeck, in a valuable article, entitled “ Beit rage zur Chirurgischen Pathologie der Venen” in the first volume of his Archiv. Invariably situated in the carotid triangle above the omo-hyoid muscle, usually on the left side, they give rise to smooth, elastic tumors, of a rounded, ovoidal, or fusiform out- line, corresponding to the direction of the great vessels, from which they receive distinct pulsation. Pulpy fluctuation may be detected by palpation with one finger in the pharynx and another on the surface; while the imparted pulsation ceases by drawing the head downwards and to the corresponding side. The only efficient remedy is extirpation by a careful dissection, lest the carotid vessels be wounded. In one of his cases Yon Langenbeck excised a small portion of the internal jugular vein, the walls of which were closely attached to, if not actually incorporated with, the posterior surface of the cyst. 360 INJURIES AND DISEASES OF THE NECK CHAP. IX. 5. Fibrous Tumors.—A fibrous tumor now and then forms in front and at the side of the neck, and may, in time, acquire an enormous bulk, seriously interfering with the patient’s looks and comfort. The annexed drawing, fig. 270, exhibits a growth of this description, removed by me from a youth of seventeen. It had been in progress for several years, and, although free from pain, was productive of great inconvenience. After removal, it was found to weigh upwards of five pounds, and to present a beautiful specimen of the fibrous structure. The tumor was situated superfi- cially, but much care was, nevertheless, re- quired in its excision on account of the great enlargement of the subcutaneous and other veins. No untoward symptoms followed the operation. 6. Fatty Tumors Fatty tumors of the neck are very uncommon. They are distin- guished by their tardy growth, their mobility, their doughy, inelastic consistence, and their freedom from pain, joined to the integrity of the general health, and the absence of discoloration of the skin. Adults and elderly subjects are most liable to them. They seldom attain much bulk. Care should be taken not to confound them with chronic abscesses. When the diagnosis is doubtful, the exploring needle must be employed. The proper course is extirpation, and this may generally be effected by enucleation. 7. Serous and Bloody Tumors.—A cystic tumor, occupied by serum, blood, or sanguino- lent matter, occasionally forms in front of the neck, between the sternum and the thyroid gland, taking its rise apparently in the connective tissue between the sterno-hyoid and sterno-thyroid muscles. Its progress is chronic, and it seldom acquires a volume larger than that of a small orange, which it also generally resembles in shape. It fluctuates dis- tinctly under pressure, is free from pain, and readily obeys the movements of the larynx during efforts at deglutition, rising as the tube ascends, and falling as it descends ; circum- stances which, together with its tardy development, the absence of enlargement of the subcutaneous veins, and the unimpaired condition of the general health, are always diag- nostic of the nature of the affection. From chronic abscess of the neck it is readily dis- tinguished by the presence of cholesterine, as evinced on puncturing the cyst. The cystic tumor, according to my observation, is almost exclusively met with in young and middle- aged females. Cases occur in which it is congenital. The proper remedy for this morbid growth is excision, which, with ordinary care, may always be performed with perfect safety. The knife should be used in such a manner as not to penetrate the cyst, otherwise the operation will be one of great difficulty, whereas, under opposite circumstances, removal may generally be effected by enucleation. Very little hemorrhage attends the procedure, and the recovery is usually rapid. I have seen a number of cases where this tumor was greatly diminished by the long-continued appli- cation of iodine, but I have never known the treatment to be followed by a permanent cure. Mr. Stanley has recorded the particulars of a cystic tumor at the side of the neck, in a lad sixteen years of age, which, on being punctured, gave vent to a pint of fluid blood, and never refilled, this simple treatment sufficing to effect obliteration of its cavity. A very extraordinary case of cystic tumor of the neck and chest, of enormous size, was published in the North American Medico-Chirurgical Review, for March, 1860, by Dr. O. B. lvnode, of Missouri. Occupying the anterior cervical region, it extended out- wards on each side nearly to the shoulder, and down some distance below the ensiform cartilage, being eighteen inches in length, and more than two feet in circumference. It fluctuated distinctly on pressui’e, and contained a gallon and three pints of inodorous and insipid fluid, of the color and consistence of weak coffee. When the fluid had been with- drawn, a hard, nodulated mass, as large as a double fist, was found with strong attach- ments to the hyoid bone, thyroid cartilage, and sterno-cleido-mastoid muscle. Immediately after the operation, the parts were firmly strapped with adhesive plaster, and the patient put under the use of iodide of potassium, in doses of five grains thrice a day. At the Fig. 270. Fibrous Tumor of the Neck. C [HP, IX. TUMORS OF THE NECK. 361 end of a fortnight, the fluid had reaccumulated to the extent of two quarts. It was again evacuated and the part strapped as before. In less than a week, all discharge had ceased, the solid mass gradually diminished in size, and the man eventually completely recovered. 8. Congenital Cystic Tumor Under this denomination may be described a form of tumor which, commencing as an intrauterine affection, not unfrequently extends far into adult life, often acquiring an enormous bulk, and giving rise to great deformity. In a case recently under my observation, the tumor, situated on the left side of the neck, was, at birth, of the volume nearly of a double fist. Dr. Adolph Wernher has described the disease very accurately under the name of cystic hygroma, while others have character- ized it as hydrocele of the neck. 'fhe growth occurs in two varieties of form, the unilocular and the multilocular, of which the latter is by far the more common. The cyst is composed of fibrous tissue, of a pale, whitish appearance, and of a tough consistence. The cavities, in the multilocular tumor, range in size from a pea up to that of an orange ; their form is generally irregu- larly rounded, and their walls are, for the most part, very thin in early life, but often very thick, dense, and firm, in cases of long standing. The outer surface of the cyst is more or less rough ; the inner, smooth and glistening. In very young infants, the cyst, when completely uncovered, or divested of extraneous matter, is frequently as thin and trans- parent as a child’s bladder. The origin of compound congenital cysts of the neck is supposed, by some, to be inti- mately connected with the intercarotid ganglion, first described by Luschka, and repre- sented by him as consisting of a follicular structure, similar to that of the coccygeal gland. Doubt, however, has been thrown upon this conclusion by the researches of Julius Arnold, who inclines to the opinion that the intercarotid ganglion is essentially a plexus of nerves enveloped in soft matter, divisible into small, separate masses. The contents of the tumor are either clear and limpid, or of a pale brownish or reddish hue, from being stained with blood, saline in taste, and coagulable by heat, alcohol, and acids. Sometimes they are of a grayish color, and of the consistence of gruel. Choles- terine is nearly always present, generally in considerable quantity. In rare cases, there is an admixture of fluid and solid matter, in varying proportions. Otto has reported an instance in which firm, fleshy masses were found within the growth, and I have met with a similar occurrence. The most common situation of the congenital cystic tumor is the side of the neck, but it may occur in any portion of the cervical region, in front, laterally, or posteriorly, lying underneath the deep fascia, and sending processes about in different directions among the muscles, glands, vessels, and nerves, which are literally buried in its substance. The growth is generally attached more or less extensively to the vertebra, and, for this reason, cannot always be completely excised. The surface of the multilocular tumor is generally more or less tuberculated, dimpled, or nodulated, free from discoloration, and easily indented with the finger. The fluctua- tion is always distinct, although seldom uniform, for, while some portions of the growth are perfectly fluid, others, as previously stated, are semisolid, and, in great degree, devoid of elasticity. Occasionally the surface has a bluish tinge ; and, now and then, an instance is seen in which there is a remarkable enlargement of the subcutaneous veins, amounting almost to complete varicosity. The surface of the unilocular cyst is generally smooth. The diagnosis of the disease is deduced from the history of the case, the fluctuation, the absence of pain, and, when great doubt exists, by the cautious use of the exploring- needle. The existence of cholesterine is of great value, as this substance is never present in the fluid of a chronic abscess. The general health is never impaired, except when the tumor injuriously compresses the trachea and the great vessels and nerves of the neck ; a circumstance of rare occurrence. The congenital cystic tumor of the neck .sometimes disappears spontaneously, or under the influence of discutient remedies, of which mild solutions of chloride of ammo- nium and the dilute ointment of biniodide of mercury are the most reliable. Temporary relief may be afforded with the trocar. A radical cure can only be effected by iodine injections, the free division of the tumor, the use of a tent, the introduction of the seton, and excision, the latter of which, if I may judge from personal experience, is always the safest, provided the growth is not very bulky and does not send too many pro- cesses among the muscles, nerves, and vessels of the neck. In such an event, excision is not only exceedingly difficult and tedious, but full of risk. Now and then, however, an exception occurs, as in the case of a child, six weeks old, from whom I removed, in 1862, without an untoward symptom, an immense tumor of this kind, extending, on the one 362 INJURIES AND DISEASES OF THE NECK. CHAP. IX. hand, from above the ear to the clavicle, and, on the other, from the trachea near to the middle line of the neck behind. The cyst was multilocular, with extensive processes dipping in among the muscles. The seton is hardly a safe remedy in the treatment of the congenital cystic tumor of the neck ; more especially if it be of large size, or dips down extensively among the mus- cles, as it is liable to be followed by great difficulty of respiration and deglutition, in con- nection with severe constitutional disturbance. Injection with iodine is occasionally followed by similar effects. 9. Malignant Tumors—Malignant tumors of the neck, of the nature of medullary lymphoma and sarcoma, occasionally occur, generally commencing in the lymphatic glands, and capable of attaining an enormous bulk, as seen in fig. 271. They are nodulated in appearance, rather diffused than cir- cumscribed in shape, soft, and ap- parently fluctuating at some points, and hard at others ; the integument soon becomes adherent and discol- ored, to be followed by ulceration, with profuse discharge, and repeat- ed, exhaustive hemorrhage. Their growth is usually rapid, and this fact, together with the history of the case, and the rapid failure of the general health, is always sufficient to distinguish them from benign growths. The discrimination, how- ever, between these two forms of malignant disease is extremely dif- ficult without the aid of the micro- scope. Operative interference should be avoided when the tumor has con- tracted extensive and firm attach- ments, as is always the case when it is of large size, the great vessels and nerves often being included in its midst. Many of these growths, indeed, originate in the lymphatic glands along the carotid sheath, render- ing these vessels very liable to be wounded in their removal. Extirpation, however, may be attempted when the tumor is small and movable, but, even under these otherwise favorable conditions, it is very liable to return. The recurring tendency of sarcoma, after operation, is well illustrated in a case that came under my care in 1871, in a man, aged twenty-seven. One year and a half pre- viously, he noticed, after an attack of quinsy, a lump, of the size of a cherry, beneath the angle of the jaw, which remained stationary for sixteen months, when it began to enlarge until it attained the volume of a walnut with its hull. At this time, that is, on the 26th of June, it was removed by his family physician, but it immediately returned in the cicatrice and the subcutaneous connective tissue. On the 28th of August, I excised the new growth, which filled the space beneath the jaw, and was as large as a hen’s egg, along with the submaxillary gland, with which it w'as intimately connected. Another tumor of the same size soon appeared, which I removed on the 8th of November. It was seated over the parotid region, and differed from the former growth in its softer consistence and in the greater adhesion and discoloration of the skin. Both neoplasms proved to be small, round- celled sarcomas, the cells being closely packed, and containing large nuclei with bright nucleoli. Up to the present time, four months after the third operation, the patient con- tinues well. 10. Hypertrophy of the Sterno-mastoid Muscle In connection with the morbid growths of the neck, may be noticed a singular congenital disease, if so it may be termed, of the sterno-mastoid muscle, in which that muscle is converted into a hard, firm mass, of irregular outline, bearing a considerable resemblance to a tumor. The affection, which has been particularly described by Bryant and Holmes, in their treatises on the “ Surgical Diseases of Children,” is very uncommon, and presents itself as an innocent swelling, the result, apparently, of inflammatory deposits, involving the muscle, either in its whole length, or in the greater portion of its extent. The precise nature of the complaint is not well understood, as no opportunity has occurred, in any of the reported cases, of making Fig. 271. Sarcomatous Tumor of the Neck. CHAP. IX. TUMORS OF THE NECK. 363 a dissection of the parts. The probability, however, is that it is simply a congenital hypertrophy of the constituent elements of the mastoid muscle, developed under the in- fluence of irritating causes. The diagnosis is generally easy, and the affection commonly soon disappears under gentle sorbefacient applications. 11. Operations upon the Neck.—The operations necessary for the removal of tumors of the neck are often of the most difficult, perplexing, and bloody character. This is true alike of those of a benign and of a malignant structure, especially when they are large or deep-seated, involving important vessels and nerves, and forming strong attachments, not only to the muscles and aponeuroses, but also to the bones, especially the cervical vertebrae. In the superior part of the neck, they frequently extend high up into the parotid region, where they dip in between the ear and the lower jaw, sending processes about in every direction, some of which occasionally reach as far as the mucous membrane of the pharynx. On the other hand, a tumor of the face not unfrequently passes down into the neck, forming thus firm and intimate connections with the parts in this situation. In the inferior cervical region, a growth of this kind often extends beneath the clavicle, and sometimes even beneath the scapula. Fibrous and glandular formations are very prone to take this course, and the consequence is that they are generally extirpated with great difficulty, a long and elaborate dissection being necessary to effect their liberation. Occasionally the morbid mass is so completely buried among the muscles, vessels, and nerves, as to render their isolation absolutely impossible. When the pressure of the tumor is very great, and long continued, it may induce obliteration of the jugular vein, and even of the primitive carotid artery. Before commencing his operation, the surgeon should assure himself that the external jugular vein is not in the line of his incisions, as may always be readily done by the pres- sure of the finger, applied immediately above the clavicle. When injury to the vessel is unavoidable, the entrance of air may be effectually prevented by occluding it with a pin passed underneath it and secured with a ligature, to be retained or removed after the operation is over, according to the exigencies of the case. If it be necessary to divide the vein, it must be previously tied at its lower extremity. Unless the surgeon is well acquainted with the nature and habits of these growths, and also with the anatomy of the cervical region, he will find himself bewildered at every step of his progress, and be, probably, at length compelled to leave his task partially unfinished. When the growth is seated along the base of the jaw, the incision should, as a general rule, be curvilinear, in close proximity to the bone, as this will be the least likely to be followed by a disfiguring scar. Sometimes a crucial, T or Y-shaped incision is necessary. A similar proceeding is usually required in operating upon the inferior part of the cervical region. In front of the neck, the incision should usually be oblique, in the line of the sterno-cleido-mastoid muscle, and this course should generally be pursued whether the growth lie on the inside or on the outside of this muscle. In many cases, the tumor will be found to be so thoroughly tied down by it as to require its division early in the opera- tion. The deeper attachments should always, if possible, be severed with the finger, or with the handle of the scalpel, the separation being conducted from below upwards. If the point of the instrument is used for this purpose, great, if not irreparable, mischief may be caused. Sometimes the surgeon is reluctantly compelled to leave a portion of the morbid growth, owing to the extraordinary depth to which it passes, or to the nature of its attachments. In such an event, a ligature should be cast firmly around it before the main mass is liberated. It is very important during the after-treatment in all severe operations upon the neck, especially in those involving exposure of the windpipe, to keep the patient in a properly regulated atmosphere, in the same manner and for the same reason as in tracheotomy and laryngotomy. The contact of cold air is highly injurious, predisposing to the occurrence of pneumonia, one of the most fatal effects of such undertakings. All arteries should, as a general rule, be tied as soon as they are divided; or, if very large and deep-seated, before they are divided, and the large veins should be dealt with in a similar manner. Any veins that may be imbedded in the morbid growth and that can- not be separated by the cautious use of tl?e knife and other means, should be included in two ligatures, and divided in the interval. Unless these precautions be observed, there will be great risk of the entrance of air, and of the occurrence of hemorrhage, which would often be very copious, if not positively fatal. So far as my observation goes, it is never necessary, in any of the operations upon this region, to ligate, as a preliminary step, the common carotid artery. This artery, however, may occasionally require a ligature after the excision of the morbid growth is completed, especially when the bleeding vessels 364 INJURIES AND DISEASES OF THE NECK. CHAP. IX. are very deep-seated, and the hemorrhage cannot be controlled in the ordinary manner. I have on two occasions been obliged, under such circumstances, to resort to this expedient, in each with the happiest results. Great cai/e must be taken not to wound any important nerves, as the phrenic or pneu- mogastric. Experience has shown that no harm results from the division of the spinal accessory and cervical nerves, properly so called, or of the descending branch of the ninth pair. In a case of extirpation of the parotid gland, involving the structures of the neck, the late Dr. John H. B. McClellan, of this city, divided the pneumogastric nerve without any apparent injury to the patient. In order to effect thorough approximation of the sides of the wound, a matter of great importance after operations on the neck, the most efficient means is a soft, wet sponge, placed in immediate contact with the flaps, and confined by a muslin compress and a roller. The sponge thus used serves the double purpose of a compressing and of an absor- bent agent, at the same time that it excludes the air and supports the bloodvessels. In summing up the general characters of operations upon the neck, for the removal of morbid growths, the great points to be considered are, first, the difficulty of their execu- tion, and, secondly, their liability to be attended with profuse hemorrhage, injury to im- portant nerves, and the entrance of air into the veins. The after-treatment should always be conducted with special reference to the avoidance of erysipelas, pyemia, and diffuse inflammation. Despite, however, the closest and most skilful attention, the patient will not unfrequently perish. Cystic tumors of the neck are particularly difficult of extirpation. The embarrassment is always greatly augmented when the cyst is inadvertently punctured, so as to permit of the escape of its contents and the collapse of its walls. Such an occuri-ence may generally be effectually prevented by the free but very cautious use of the grooved director, layer after layer of the superimposed structures being divided, until the morbid growth is so com- pletely denuded as to admit of its easy enucleation with the finger or the handle of the scalpel. In old cysts of large size, the number of these adventitious investments is gen- erally surprisingly great, and hence, if the operator is not very guarded, he will be almost sure to penetrate the proper tunic before he is aware of it. No statistical inquiry has, I believe, been made to show the mortality of extirpation of tumors of this region. In a paper referring to wounds of the internal jugular vein, published in the American Journal of the Medical Sciences for January and April, 1867, Dr. S. W. Gross has found that this vein was injured thirty-seven times in the removal of tumors. The greater number of these growths were of a malignant nature, and their connections were deep and extensive, so that in seven not only the jugular vein, but the carotid artery also required deligation. In one case the pneumo- gastric nerve was divided, the patient, notwithstanding this untoward circumstance, making a good recovery, being the fourth instance of the kind on record. Of the 37 cases, 13, or 35 per cent., terminated fatally; the cause of death being the entrance of air in 4, exhaustion in 4, secondary hemorrhage from the vein in 3, and pyemia and bronchitis, each in 1. The infrequency of pyemia after operations of such magnitude is remarkable. SECT. VI ABSCESSES AND FISTULF.S OF THE NECK. There is no region of the body in which abscesses are so frequent as in the neck, or so difficult of diagnosis and treatment. Liable to occur at all periods of life, and under all conceivable circumstances, they may be common or specific, acute or chronic, superficial or deep, large or small, bold or stealthy in their origin and progress. Their favorite seat is the upper and lateral part of the neck. Among the more common causes of cervical abscesses are, exposure to cold or the sudden suppression of the cutaneous perspiration, disease of the teeth, gums, and lower jaw, and the exhausting and poisonous effects of measles, scarlatina, and typhoid fever. Scrofulous persons are particularly liable to their formation from the most trivial circumstances. A bad form of abscess of the neck occasionally arises from disease of the tongue, hyoid bone, larynx, trachea, fauces, or oesophagus. However, induced, cervical abscesses are commonly ushered in by more or less general disorder, attended with severe pain, swelling, and induration. When situated superficially, the skin becomes early discolored, assuming a purplish and congested appearance, and distinct fluctuation is soon perceptible. When, on the contrary, the matter is deep seated, the skin may for a long time retain its normal aspect, and fluctuation may either be CHAP. IX. ABSCESSES AND FISTULES. 365 entirely absent, or else show itself only as the fluid approaches the surface. Severe, ten- sive, throbbing pain usually attends the more aggravated forms of the complaint, the movements of the neck are greatly impeded, the patient swallows witli difficulty, and even the respiration may be seriously embarrassed, simply from the extension of the inflamma- tion or from the pressure of the accumulating fluid. Owing to the remarkable laxity of the connective tissue of the neck, and the great firmness of its aponeuroses, the tendency of these abscesses is to burrow exten- sively among the muscles, the pus often passing down below the clavicle and around the great vessels, windpipe, pharynx, and oesophagus. Such an event is particularly liable to occur in weakly, scrofulous children, the subjects of scarlatina, measles, smallpox, and typhoid fever, and also in old, broken-down, anemic persons, in whom the morbid action frequently spreads with extraordinary rapidity, the tissues readily yielding to its devastating influence. In general, the matter is finally evacuated through the skin, but cases are occasionally met with in which it bursts into the anterior mediastinum, the fauces, oesophagus, windpipe, the carotid artery, or even the internal jugular vein. In a paper published in the American Journal of the Medical Sciences for April, 1871, Dr. S. W. Gross, analyzed thirty-eight cases, including one under his own care, of communication between the cervical vessels and abscesses or open sores, from which it would appear that the large venous and arterial trunks are more liable to be opened than their branches. The internal jugular vein was involved in twelve, and the external jugular in one; in at least ten instances the accident occurred in children after an attack of scarlatina, while in two it was due to the extension of inflammation to the coats of the vessel from a scrofulous abscess and ulcer. All of the cases perished from hemorrhage, generally of a recurrent character, immediate death having taken place in three. Of the arteries, the common carotid was the seat of the lesion five times; the internal carotid three times; the subclavian once; the superior thyroid twice ; and the lingual, facial, and inferior thyroid, each once. In eleven instances the precise vessel was unknown. Of these twenty-five cases, the majority of which occurred in children debilitated by eruptive fevers, six were saved by ligation of the common carotid, one by tying the external carotid, and three by direct compression. All of the remainder were fatal, inclusive of two deligations of the common carotid, and one of the internal carotid. The treatment of these abscesses must be conducted upon general principles, due regard being had to their nature and to the condition of the system, which is often greatly dis- ordered, and, therefore, requires to be amended. A course of tonics and alterants will frequently prove highly efficacious. The best local remedies are leeches, blisters, iodine, cataplasms, and saturnine lotions. Matter should be evacuated early, by suitable incisions, made in such a manner as not to interfere with any important vessels, or to leave any disfiguring scars. When the healing process is sluggish, a healthful stimulus may be imparted to the sore by the application of nitrate of silver, or injections of iodine, sulphate of copper, or acid nitrate of mercury. The synovial burse in front of the neck, and the structures immediately over it, are liable to suffer from abscess, either as an independent affection or as a result of reflected irritation from the throat, windpipe, or lungs. The disease is sometimes so obscure as to elude detection during life. In general, however, there are more or less tumefaction, difficulty of swallowing, spasmodic coughing, and a sense of strangulation. An early in- cision is required, to prevent the abscess from busting into the windpipe. A congenitalJistule is occasionally met with in this situation. It is commonly single, incomplete, and so small as hardly to admit of the introduction of the finest probe. Of 65 cases, collected and analyzed by Dr. George Fischer, including 79 fistules, both sides of the neck being affected in 14, 20 were complete and 53 incomplete, the latter having no internal opening. In 47 instances the outer orifice was seated on the right side, and in 27 on the left, almost uniformly a few lines above the sterno-clavicular articulation. The internal aperture is generally found on the wall of the pharynx, in the vicinity of the great horn of the hyoid bone, the track itself being narrow, lined with mucous membrane, and lying parallel with the trachea. In a case of double fistule, described by Mayr, one of the canals communicated with the trachea, and the other with the oesophagus. Such an affection seldom requires surgical interference, as it is not often productive of any special inconvenience. A cure may, if necessary, be attempted by the use of a heated probe, or of a probe moistened with a solution of nitric acid. If this 366 INJURIES AND DISEASES OF THE CHEST. CHAP. X. fail, the parts should be freely divided, and healed from the bottom with the aid of a deli- cate tent. A very rare form of fistule, to which the term lymph Jistule may be applied, is some- times met with in the neck, generally at or near the middle line, discharging a thin, limpid fluid, possessing all the properties of ordinary lymph. The orifice leading to the fistule seldom exceeds the size of a common bristle. The affection is usually con- genital, and is evidently dependent upon the imperfect closure of one of the lymphatic vessels of the neck. The treatment is similar to that of congenital fistule described in the preceding paragraph. SECT. YII AFFECTIONS OF THE HYOID BONE. The hyoid bone, from its peculiar situation and relations, is liable to various diseases, some of which originate in its own structure, while others are communicated to it from the surrounding parts. These affections have been described with great care by Dr. Gibb, in his monograph on the Diseases of the Throat and Windpipe, and are deserving of special attention. Fractures and dislocations of the hyoid bone are treated of in the first volume. Inflammation of the hyoid bone may arise from external injury, or from the effects of syphilitic and other diseases. It generally begins in the fibrous covering of the bone, and occasions more or less swelling of the neck, severe pain, dysphagia, and difficulty of res- piration. l»y and by, matter forms, and, if not speedily evacuated, may cause extensive havoc among the surrounding structures, attended by an increase of all the local phe- nomena here alluded to. The treatment must be strictly antiphlogistic, with leeches, iodine, and blisters, to the neck, and an early and free incision, to afford vent to pent-up fluids. When necrosis occurs it may be limited to a particular portion of this bone, as to one of its horns, or it may affect one-half or even its entire substance, as in a case recorded by Rozart. The patient, a lady, aged thirty-six, was of a scrofulous habit, and had been ill for five years, when she coughed up the dead bone, and immediately recovered. A similar case has been described by Sprey. The disease is frequently associated with ulcer- ation of the larynx and throat. As soon as the bone is sufficiently isolated, it should be removed with the knife and forceps. The hyoid bone is sometimes eburnized, or converted into a hard, ivory-like substance; and Warren alludes to an instance in which the right horn was the seat of a conical exos- tosis, nearly three inches in length. In elderly subjects the thyro-hyoid articulations are sometimes completely ankylosed. Wounds of this bone are uncommon. They are generally the result of gunshot injury, or of violence inflicted in attempts at suicide, and are to be treated upon the same princi- ples as similar lesions of the larynx and trachea. A severe contusion is sometimes fol- lowed by serious consequences, as abscess, caries, and necrosis. CHAPTER X. INJURIES AND DISEASES OF THE CHEST. SECT. I WOUNDS OF THE CHEST AND LUNGS. Wounds of the chest, like those of the abdomen, necessarily divide themselves into external and internal, or those which affect the wall of the chest, and those which impli- cate its contents. They may, as in other parts of the body, be of various kinds, as incised, lacerated, punctured, or gunshot, and they may be either simple or complicated, according to the nature and amount of tissue involved in the injury. External wounds of the chest, unless accompanied by severe concussion, profuse hem- orrhage, or fracture of the ribs, are rarely attended with any particular danger, and require no other treatment than that which regulates the conduct of the practitioner in the management of wounds in general. When the lesion is considerable, it may be necessary, especially if the patient is harassed with cough, to adopt means for securing CHAP. X. WOUNDS OF THE CHEST AND LUNGS. 367 the quietude of the chest by the application of a broad bandage and the occasional exhi- bition of an anodyne draught; but under ordinary circumstances both these expedients may be dispensed with. Any foreign substance, as a splinter of wood, a ball, or a loose piece of bone, must, of course, be removed, either on the instant, or as soon as its situa- tion is rendered obvious. The direction which a ball sometimes pursues upon striking the chest, especially if it comes in contact with the sternum, spine, or ribs, is very remarkable. Thus, instead of lodging at or near the point of entrance, it has been known to make almost the entire circuit of the thorax, passing underneath the integument, and becoming arrested a short distance from the point of ingress, or, perhaps, issuing even at the same orifice, as has occasionally happened in military engagements. When this is the case, the course of the projectile is generally indicated by a reddish or purplish line, which will be more distinct in proportion to the size of the ball; and, in addition to this, there is not unfrequently a crackling sensation imparted to the finger as it sweeps over the chest in pursuit of the intruder, caused by the presence of air. In some instances the ball lodges between two ribs, perhaps splintering them, and finally effecting an entrance into their substance. When two openings exist in the chest, the probability is that the ball has escaped, and yet it is possible that a portion of it may have been cut off, and retained. The orifice of entrance is usually readily distinguishable by the fact that, if a bone has been struck, the fragments will be forced inwards towards the lungs, whereas they will be pushed outwards at the orifice of egress. When the missile comes in contact with a costal cartilage, it simply breaks it, without carrying any of its substance into the chest. Sometimes a bul- let perforates the lung, and lodges under the skin, opposite its point of entrance. When this is the case, the air may escape from the thoracic cavity into the subcutaneous connec- tive tissue, and be thus more or less extensively diffused over the body. External wounds of the chest are seldom attended with much hemorrhage ; it is only when the intercostal artery is laid open that there will be likely to be much bleeding, and in that event the vessel must, of course, be secured with the ligature. The operation, however, is generally difficult, if not impossible, owing to the deep situation of the ves- sel. When this is the case I should not hesitate to drill a small aperture into the rib, immediately above the artery, and pass a silver wire around its bleeding orifice. Such a procedure, although apparently harsh, would not involve any special risk from inflam- mation of the plenra. Lesion of the internal mammary artery is occasionally followed by hemorrhage into the anterior mediastinum. When the quantity of blood effused is so copious as to compress the heart and lungs, or to cause great exhaustion, the only thing to be done is to expose and ligate the vessel at all hazard. Wounds involving fracture of the ribs or sternum must be treated upon the same gen- eral principles as fracture of these bones without such lesion of the soft parts ; that is, the movements of the thorax must be controlled with the bandage, and cough and pain allayed by anodynes and appropriate antiphlogistic measures. The lungs are sometimes seriously, if, indeed, not fatally, injured without any apparent lesion of the walls of the chest. A young man, while riding, fell from his horse on his left arm. He complained of no pain, but twelve hours after lie was seized with alarming hemoptysis, and died in a few days. The dissection revealed an extensive laceration of the posterior part of the right lung, and a copious effusion of blood into the pleural sac, without any external sign of violence. A similar accident has occasionally been pro- duced by a fall from a scaffolding, and by the passage of the wheel of a cart, as in a case reported by Dr. Edward Hartshorne. The occurrence of such a lesion, sixteen cases of which have been collected by Professor Ashhurst, is easily explained by supposing that the lungs, at the moment of the accident, are forcibly distended with air, so that the walls of the chest, on being brought violently in contact with them, readily cause their rupture. A ball striking the chest, without leaving any other mark upon the skin than, perhaps, a slight weal, not unfrequently produces violent effects; primarily severe, if not fatal, shock, with more or less hemoptysis, and, secondarily, intense inflammation of the lung, or lung and pleura, followed, occasionally, by profuse empyema and an attempt on the part of the pent-up fluid to escape externally, its progress being sometimes denoted by the existence of air under the integument. Internal wounds of the chest are much more serious accidents than external ; they are generally made by balls and sharp-pointed instruments, as knives, dirks, lances, sabres, or bayonets, and are often attended with severe lesion of the contents of the thoracic cavity, terminating life either on the spot, or at a period more or less remote from the occurrence of the injury. Hence their effects may conveniently be arranged under two 368 INJURIES AND DISEASES OF THE CHEST. chap. x. heads, the primary and secondary ; the former including shock, collapse of the lung, hem- orrhage, and pneumothorax ; the latter, inflammation and its consequences, as accumula- tions of serum, lymph, and pus in the pleural cavity. Internal wounds of the thorax may be further divided into those which merely pierce its walls, without inflicting any injury upon its contents, and those in which the contents participate in the mischief. Of the former occurrence, the case of the man in London, whose chest was perforated by the shaft of a chaise, affords a memorable illustration. The shaft entered between the ribs on one side, and, passing behind the sternum, emerged at the opposite side without wounding the lungs or any of the large vessels. A rapid re- covery followed. Death from mere shock is by no means uncommon in wounds and injuries of the chest; cases of the kind are frequently met with both in civil and military practice, and their occurrence has occasionally been noticed where, upon dissection, no serious lesion has been detected to account for so untoward a result. The treatment of such cases does not involve anything peculiar, as it does not differ from that of shock from other causes. Our principal reliance must necessarily be upon sinapisms and stimulants, especially in the form of enemas, with opium, to calm the nervous system and sustain the heart’s ac- tion; but great caution should be observed in their use, particularly if there is reason to be- lieve that the depression is dependent, in part, upon intrathoracic hemorrhage, lest, by the induction of early reaction, the bleeding should be encouraged instead of being represssed. Collapse of the lung is much less frequent than was formerly supposed, and is not, by any means, a necessary effect of a penetrating wound of the chest. The occurrence will be most likely to happen when the wound is direct and of large size; under opposite cir- cumstances, and especially when the opening presents a valvular arrangement, or when the passage leading from it is long and devious, the air will And it difficult, if not im- possible, to enter the chest to such an extent as to counterbalance that in the lung, which will thus, consequently, retain its natural position. Even when the wound is of consider- able size, the organ is sometimes found to resist collapse, as is proved by the fact both that the respiration is unembarrassed and that the lung is seen moving to and fro beneath the aperture in the thoracic wall. Still more satisfactory proof is occasionally furnished by the protrusion of a portion of the lung across the wound in the chest, thus constituting what has curiously enough been called pulmonary hernia or pneumonocele. Collapse of the lung is always a serious occurrence, as the patient is thus generally in- stantly deprived of one-half the quantity of air which he was accustomed to breathe before the injury ; if both sides are similarly affected, the difliculty will, of course, be proportion- ately increased, although even then the case is not necessarily fatal, for both clinical ob- servation and experiments on the inferior animals have shown that the lungs, under these circumstances, so far from collapsing, may become so completely distended with air as to project from the thoracic cavity at each opening, and yet the subject make a very rapid and satisfactory recovery. It is not improbable that the state of the patient’s strength exerts considerable influence upon the production of collapse, the accident being more likely to take place when he is exhausted by shock and loss of blood than when he is able to command the free use of his respiratory muscles. In the former case, he is very much in the condition of a person who is partially asphyxiated, and, consequently, incapable of distending his lungs, which are thus easily collapsed by the accidental ingress of the smallest quantity of air; in the latter, on the contrary, his efforts, which are often very violent, enable him effectually to resist the encroachment, and even to force the lungs somewhat out of the chest. Collapse of the lung is characterized by excessive dyspnoea, the patient struggling vio- lently for breath, and throwing himself about in the greatest distress and anguish ; the ribs on the affected side are immovable, the respiratory murmur is completely absent, the voice is weak and indistinct, and percussion elicits an unusually clear resonance. With these symptoms are conjoined those of sudden and severe prostration, as excessive pallor of the countenance, a feeble, almost imperceptible pulse, and clammy sweats, followed by coldness of the extremities. When the chest is pierced without collapse of the lung, the air generally makes a pecu- liar noise as it rushes into the pleural sac; and, if the opening of communication is suffi- ciently large, the lung may be seen to move up and down in consonance with the egress and ingress of the air, filling, perhaps, the whole, or, at any rate, the greater portion, of the thoracic cavity. The voice is not materially changed, if at all, and the vesicular murmur is nearly natural, although the respiration is performed with great labor and difficulty. Soon after the accident, there will be an escape of blood at the wound at each CHAP. X. WOUNDS OF THE CHEST AND LUNGS. 369 effort at inspiration, and, if the pulmonary tissue has been injured, the patient will cough up blood, or, perhaps, have actual hemoptysis, especially if some of the larger vessels have been divided. A discharge of blood by the mouth, however, is not a positive evidence ot penetration of the lung, experience having shown that the mere concussion of the chest by a ball or shot is capable of producing it. The prognosis of penetrating wounds of the chest is exceedingly unfavorable. In many of the cases, life, as above stated, is destroyed on the instant, or, at all events, shortly after the infliction of the injury, either by shock or hemorrhage, or the two together. When both sides are pierced, death may take place from collapse of the lungs, although such an event is much less frequent than is commonly supposed. If the patient be so for- tunate as to escape from the immediate effects of the lesion, he will incur great risk of perishing from inflammation of the lungs and pleura ; or, surmounting this, from pyemia or hectic irritation. Gunshot wounds of the chest are generally much more dangerous than wounds inflicted with the lance, sabre, or bayonet, owing to the fact that they are attended with more laceration, and frequently also with the lodgment of the bullet and other foreign matter. A penetrating wound of the apex of the lung is not so dangerous as one of the root of this organ, as it is less liable to be followed by copious hemorrhage and severe inflammation. In the old mode of warfare, more than half of those who were shot through the chest died, but this ratio has been immensely increased since the introduction of the conical ball. The mortality from this cause in the Russian army at the siege of Sebastopol was most appalling, only 3 out of 200 having recovered. In the British army, on the contrary, during the same campaign, 27 out of 147 were saved. The fatality in this class of in- juries is, doubtless, much influenced by the mode of treatment and other attentions received by the wounded. The Russian surgeons relied chiefly upon the use of digitalis; the British, upon copious venesection. During our late war, in which bloodletting was almost entirely neglected, of 1272 penetrating wounds of the chest, 930, or 73 per cent., perished. The ball, in wounds of this kind, instead of penetrating the lung, is occasionally ar- rested in the pleural cavity, in contact with the upper surface of the diaphragm, as in the case of a young man, a patient of mine, who was injured by a pistol shot. The outer opening gradually closed, but violent inflammation soon set in, followed by copious sero- purulent effusion, terminating in death at the end of four weeks. No perceptible lesion could be discovered in the lung, showing that the ball, after passing through the thoracic wall, must either have rebounded upon touching that organ, or else dropped down into the chest by the force of its own weight. The treatment of penetrating wounds of the chest requires, in the first place, accurate closure of the orifice of communication, provided there are no contraindications; and, in the second, the employment of such measures as may tend to prevent the occurrence of severe inflammation of the pleura and lung, which is so liable to happen after ail injuries of this kind, even when the latter organ is not directly implicated. The treatment of hemorrhage will be considered under the head of hemothorax. Any foreign substance that may be present should promptly be removed, provided it is easily accessible; for the rule here, as in all other visceral cavities, is to refrain from officious interference. Nothing, in such a condition, can more clearly betray the ignorance of the surgeon than the introduction of the probe into the chest ; a careful exploration of the outer wound is always admissible, especially when suspicion exists that a rib has been fractured, or that a ball has lodged in one of the intercostal spaces. If a probe be required, the finger, if not too large, will always answer that object better than any- thing else. When a ball lies loose in the cavity of the chest, as in the case above mentioned, the result must almost necessarily be fatal. There is the merest possibility that it might be- come encysted, or buried in a mass of organizable lymph, and thus remain, at least for a time, a harmless tenant. I have met with cases of shot wounds of the chest where the ribs were so much splint- ered as to require removal with the cutting-pliers; but the instances demanding such a procedure must necessarily be uncommon, and, in general, the duty of the surgeon is limited to the extraction of the loose, or partially detached, fragments. Such cases, it need hardly be added, are extremely liable to prove fatal. If the lung is collapsed, an attempt may be made to draw the air out of the thoracic cavity with a large syringe, although such a procedure will generally be unnecessary, as the organ will of its own accord soon regain its natural position. If a portion of lung 370 INJURIES AND DISEASES OF THE CHEST. chap. x. protrude, or puff out through the wound, it should immediately be returned, and proper means taken to prevent a recurrence of the accident. If, on the other hand, the extruded structures are highly inflamed, or perhaps gangrenous, as must occasionally happen where proper treatment has been neglected, the only rational procedure is to excise the parts on a line with the skin, a stout ligature having previously been cast around them to guard against hemorrhage. In the case of a lad, eight years old, thus treated by Dr. Fordyce Grinnell, prompt recovery took place, the portion of lung cut off measuring four inches and a half in length by nearly three inches in width at its widest part. Any ten- dency to protrusion of the lung during the after-treatment must be counteracted by the ap- plication of graduated compresses. When the wound is very large, it should be closed with a suitable compress and ad- hesive strips, or collodion plaster. Cases occur in which, when the orifice is very capa- cious, occlusion may be effected by sliding the integument down over it from the parts in its immediate vicinity. Such a procedure would, of course, be objectionable when there is extensive injury of the bony case of the chest. Dr. Benjamin Howard, formerly of the army, recommends a plan of treatment in gun- shot wounds of the chest, which he calls “hermetical sealing.” It simply consists in cutting away the contused structures down to the ribs, so as to convert the wound into an incised one of an elliptical form, and in effecting close and accurate approximation with silver sutures, deeply inserted, at a distance of a quarter of an inch from each other. The dressing is completed by carefully wiping the surface, and then covering it well with shreds of charpie arranged crosswise, and thoroughly saturated with collodion. The ob- ject of the procedure is to exclude the air from the chest, and thereby diminish the chances of suppuration and other untoward occurrences. The histories of the cases in which this method was adopted, during our late war, show, according to Dr. Otis, that it is untrustworthy, only one case having recovered, and in that there was every reason to believe that the symptoms were aggravated by the treatment, and were only relieved by the profuse discharge of pus and blood on the spontaneous opening of the wound. When a ball, after having perforated the lungs, has lodged under the skin, the best plan is not to disturb it until the wound in the wall of the chest is healed, otherwise it may greatly increase the chances of inflammation. The only exception to this rule is where the injury is complicated with a comminuted fracture of the ribs, sternum, or ver- tebrae, requiring extraction of large splinters of bone or of other foreign substance. Collapse of the lung, partial or complete, is sometimes produced by an accumulation of blood within the chest, occurring immediately after the receipt of the injury. Should this be found to have proceeded from one of the intercostal arteries, the proper remedy will be the ligature, after which the blood may either be removed mechanically, or be permitted to drain off spontaneously, by making the patient lie upon the affected side, so as to render the wound, if possible, the most dependent part of the body. If, on the other hand, it is evident that it has been derived from the lung itself, the best plan will be to let it remain, in the hope that, by compressing the injured structures, it may serve as a hemostatic. When the lung retains its natural position within the chest, the inflammation conse- quent upon the injury soon causes it to adhere to the edges of the wound, and, in this manner, all communication between the exterior and the pleural cavity is generally speedily cut off; an occurrence which is one of the greatest safeguards that can possibly happen in such a case, and which should always, if practicable, be promoted by making the patient lie upon the affected side. If, on the other hand, the lung is collapsed, it may be so tied down by effused blood and inflammatory deposits as never to regain its original situation. To avert and moderate inflammation of the lungs and pleura? in wounds of the chest is one of the great objects of treatment, as this constitutes the chief source of danger when the patient survives the immediate effects of the injury. The principal agents for ac- complishing this are the lancet, tartar emetic and opium, purgatives, cupping, and counterirritants, especially epispastics. If the system has not been too much drained of blood by the accident, the bleeding should be both early and free, and repeated at short intervals until a decided impression has been made upon the disease; otherwise our chief reliance should be upon the use of tartrate of antimony and potassium, in union with ano- dynes, to allay pain and cough, and promote sleep. For controlling the circulation liberal use should also be made of veratrum viride, its effects being carefully watched, lest too much cardiac depression should arise. The bowels should be thoroughly moved with senna and sulphate of magnesium, or calomel and jalap ; blood should be taken by cups or leeches from the chest, over the seat of the morbid action ; and, if these remedies do not CHAP. X. WOUNDS OF THE CHEST AND LUNGS. 371 prove speedily successful, a large blister should be applied, and retained until complete vesication is produced. Many of these cases, however, either do not bear these depletory measures at all, or only to a very limited extent, and on this account not a little judg- ment is often required to determine when to employ or to reject them. Perhaps the best guide, in such an event, is the state of the pulse and of the countenance ; when the former is hard, full, and frequent, and the latter hot and flushed, lowering agents are plainly in- dicated, whereas, if the reverse be true, they should be refrained from, tonics and stimu- lants being used in their stead. Sometimes a kind of middle course is the most judicious. Penetrating wounds of the chest are extremely liable to be followed by serous, sero- sanguinolent, and purulent effusions, no matter what means may be adopted for their pre- vention. If the accumulation be trifling, it will generally disappear spontaneously, or under the influence of suitable local and constitutional remedies, as in ordinary pleurisy, or pleuro-pneumonia; but when it is abundant, means must be adopted for its removal, otherwise the patient will be extremely apt to perish. I have seen several cases of death simply from neglect of this precaution. The presence of fluid is denoted by the ordinary symptoms of thoracic effusion, of which absence of the respiratory murmur, dullness on percussion, excessive dyspnoea, harassing cough, and inability to lie on the sound side, are the most prominent and characteristic. If the accumulation is very great, there will be, in addition, partial effacement, and, perhaps, even bulging of the intercostal spaces, thus imparting greater certainty to the diagnosis. All doubt, of course, vanishes if the fluid escapes at the external wound. The formation of pus is generally preceded and ac- companied by rigors and hectic irritation. The proper treatment of this accident is sufficiently obvious. If the external wound has not yet closed, the body is placed in such a position as to render that the most de- pendent part, and it is seldom that any other procedure will be necessary. In a case under my charge, in which the chest liad been penetrated by a pistol ball, evacuation of the cavity could only be effected by placing the patient on his knees and elbows, at the same time raising the hips and lowering the head, thus making the orifice as dependent as possible, an operation which was repeated, for several weeks, at least three times in the twenty-four hours. He ultimately made an excellent recovery, with a collapsed lung. Before this expedient was resorted to, the fluid was occasionally drawn off with a syringe. When no opening exists, or when it cannot be made available for the purpose in ques- tion, a new one should be made, care being taken to select the most suitable part of the chest for furnishing a ready outlet to the pent-up fluid, and to avoid injury to the inter- costal arteries. Patency of the orifice is maintained by a proper tent, or canula, well se- cured to the side of the chest, lest it should slip into its cavity. Injuries of the lungs not unfrequently exert a very prejudicial secondary effect upon these organs, eventuating in the production of abscess, or the development of phthisis, the latter being more likely to take place when there is a hereditary tendency to this disease. Such occurrences cannot always be avoided, but the fact that they may happen should be borne in mind by the surgical attendant, as this will be one of the surest means of pre- venting them. Although balls and other foreign bodies, lodged in the lungs, occasionally become en- cysted, yet in the great majority of cases they ultimately produce extensive and fatal dis- organization of the pulmonary structures. The time at which this result occurs is very variable. In a case reported by Boyer the ball was retained for twenty years. A man, aged thirty-five, shot at the battle of Novi, died at the end of seven years, the bullet being found near the base of the left lung, in a distinct membrane, surrounded by indurated tissue. His health, after he had recovered from the more immediate effects of his wound, remained tolerably good for four years, when he was seized with an increase of dyspnoea, nocturnal cough, and hectic irritation, with pain in the chest, and inability to lie on the right side. He had no other sign of pulmonary disease, but finally died completely ex- hausted. In a case related by Dr. M. II. Houston, a piece of coarse domestic linen, evi- dently the patch of a bullet, about two inches and a half in length by two in width, when unrolled, was found in the left lung, twenty-five years after its introduction. The cavity in which it lay was opposite the fifth intercostal space, near the spinal column ; it was lined by a smooth, tough membrane, and communicated with several of the bronchial tubes, into one of which the foreign substance projected, thus keeping up the cough and irritation which had so long annoyed the patient. The ball, along with a piece of rib, had been extracted immediately after the receipt of the injury. In the chapter on gun- shot wounds, allusion is made to a case where an ounce bullet was found in the right lung, in a distinct cyst, forty-five years after its introduction. In a few fortunate instances, the 372 INJURIES AND DISEASES OF THE CHEST. CHAP. x. foreign body was ejected during a violent paroxysm of coughing, excited by its presence, as in the case of a soldier, reported by Dr. Geiger, of Ohio. A Minie ball, weighing three-fourths of an ounce, had entered the chest at the lower margin of the seventh rib, and lodged in the lung, from which it was expelled by the mouth nearly three years after the accident, the man making an excellent recovery. Arnott found a piece of iron hoop in the lung fourteen years after its entrance; and in a case reported by Guillon a part of a fencing foil had remained in the chest for a still longer period without any suspicion of its presence. Penetrating wounds of the thorax occasionally remain fistulous almost for an indefinite period. Such an event will almost certainly arise when the pulmonary and costal pleune fail to adhere for some distance around the more dependent parts of the external orifice, thereby forming a kind of pouch, in which the matter, furnished by the sac, is allowed to accumulate instead of passing off as fast as it is poured out. The manner in which the pouch is usually emptied is by the patient placing himself in a particular posture favora- ble to the escape of its contents; but as this is often irksome and inadequate, it is seldom that the case receives the requisite atten- tion, and hence many years often elapse before a cure is finally ef- fected. The proper remedy is a counteropening, made at the most dependent portion of the sac, so as to admit of ready drainage, both during recumbency and in the erect posture, the puncture being prevented from closing by a tent or canula. In a case which was under my care, some years ago, I pierced the chest through the fifth intercostal space, directly over the pericardium, on account of an ab- scess from a wound made with a hatchet between the second and third ribs, and soon succeeded in effecting obliteration of the adven- titious cavity. In a second case, under my charge in 1872, I excised, as seen in fig. 272, a portion of rib two inches long, and inserted a silver canula to afford an outlet for an abscess, the result of gunshot injury received twenty years previously. Professor T. G. Richardson, of New Orleans, in several similar cases, the first of which occurred in 1861, has effected excellent cures by trephining the rib over the most dependent portion of the sac. The obliteration of the cavity in these affections, which is generally followed by a remarkable retrocession of the wall of the chest, is greatly promoted by free drainage, and by the diligent use of weak astringents and detergent injections. Another unpleasant secondary effect of wounds of the chest is necrosis of the ribs and sternum, the exfoliation of which is generally a work of time and suffering, months not unfrequently elapsing before complete riddance of the disease can be effected. The exist- ence of the lesion is usually indicated by a puffy and painful swelling of the part, by a foul discharge, and by the appearance of one or more cloacae, leading from the surface to the dead bone below. As soon as the bone is found to be loose, it should be removed. Cases occur in which, during the progress of gunshot wounds of the chest, fragments of bone, the result of fracture of the ribs, vertebrae, or sternum, either alone, or in union with portions of the patient’s dress, are coughed up. Such instances are uncommon, and they are by no means always followed by recovery. Secondary hemorrhage in wounds of the lungs sometimes arises at a very remote period, owing, apparently, to the imperfect cicatrization of the affected tissues. Under such cir- cumstances, indeed, any severe bodily exertion, as lifting a heavy weight, sneezing, laughing, loud talking, or straining at the water-closet, may reopen the vessel, and cause extravasation of blood. A case has been reported, in which a soldier died instantly of internal hemorrhage, brought on by throwing a ball in a game of nine-pins, two months after he had, as was supposed, perfectly recovered from a wound of one of the lungs. Fig. 272. Counteropening in Abscess of the Chest. CHAP. X. HEMOTHORAX. 373 SECT. II HEMOTHORAX. The hemorrhage which succeeds wounds of the chest, constituting what is called hemo- thorax, may proceed either from the lung, or from some artery in the wall of the thorax, as an intercostal, or a branch of the internal mammary ; not unfrequently it is derived from both these sources. The quantity of blood poured out varies from a few ounces to several quarts, and hence its effects upon the lung and system may either be very slight or ex- ceedingly severe ; perhaps, in the latter case, causing death by exhaustion within a few minutes after the accident, or putting life in jeopardy, at a more remote period, by inflam- mation and various deposits. The symptoms of intrathoracic hemorrhage are such as denote loss of blood in other parts of the body, with the addition of respiratory embarrassment occasioned by the mechani- cal compression of the lung. The countenance is deadly pale, the pulse small, quick, and tremulous, the surface cold and clammy, the breathing oppressed, the head giddy, the mind anxious. Thirst and restlessness generally exist in a high degree ; the patient experiences a sense of weight in the chest, and is unable to lie on the sound side ; the tho- racic walls emit a dull sound on percussion ; and if the effusion is large, there will be com- plete absence of vesicular murmur, with a tendency to flattening of the intercostal spaces. Blood usually escapes at the external wound, and, in the event of injury of the pulmonary tissue, is also discharged by the mouth, either in a pure state, or mixed with frothy mucus. Hemoptysis, however,.is not always present in penetrating wounds of the lung. I have seen a number of cases where it was entirely wanting. When blood escapes from the chest into the subcutaneous connective tissue along the spine, it is apt to gravitate towards the loins, giving rise to an ecchymotic appearance of that region, which some, as Valentin, Larrey, Louis, and others, have been led to regard as pathognomonic of hemothorax, or effusion of blood. into the pleural sac. This state- ment, however, must be received with some allowance ; for it has been shown, on the one hand, that this phenomenon is often entirely wanting in hemorrhage of the chest, and, on the other, that it may be present simply as a consequence of a bruise or contusion, when there has been no injury of this cavity. The blood in hemothorax is variously disposed of; when the quantity is small, it is gene- rally absorbed, followed, probably, by some adhesive action of the pleura; if large, it will not only violently compress the lung, but, assuming the solid form, be sure to excite severe inflammation, eventuating in serous and other effusions, which thus greatly com- plicate and aggravate the original difficulty. Instances occur in which, along with the extravasated blood, there is a considerable accumulation of air, thus combining hemothorax with pneumothorax, and, of course, increasing the urgency of the symptoms and the dan- gers of the case. It will thus be perceived that the prognosis of intrathoracic hemorrhage is always serious, except in the minor and more unimportant cases. Death may occur within a few minutes after the accident, or the patient may recover from the primary effects, and perish from the secondary, particularly from the mechanical compression of the lung and the irritation which the blood excites by acting as a foreign body, The treatment of this form of hemorrhage is by no means satisfactory, since it is based upon speculation rather than any well-defined principles. The patient should lie on the affected side, and the wound be kept open, unless the escape of blood is so excessive as to threaten serious, if not fatal, exhaustion, when it must be promptly closed. The head and shoulders should be elevated, ice applied to the chest, and acetate of lead and opium freely given internally either alone or with ergot and aconite. The drink should be cool- ing and acidulated, and the diet restricted to the most simple articles. When the blood proceeds from the lung, a circumstance, however, which cannot always, or, perhaps, even generally, be ascertained, the most judicious plan, probably, will be to let it remain, in the hope that it may exert a favorable hemostatic action upon the wounded part; but, as soon as all apprehension is over in regard to a recurrence of the bleeding, as it generally will be in five or six days, the effused fluid should be evacuated by operation, either by enlarging the original wound, or, if this be situated unfavorably, by making a free opening through one of the intercostal spaces at the most dependent portion of the chest, or wherever the results of percussion and auscultation may unite in locating the extravasated substance. The respiratory organs must be incessantly watched, to pro- tect them from harm, the slightest tendency to inflammation being promptly averted with the lancet, tartar emetic, calomel, and opium, along with thorough and early vesication of the chest. 374 INJURIES AND DISEASES OF THE CHEST. CHAP. X. SECT. Ill PNEUMOTHORAX. Pneumothorax is caused by injury of the substance of the lung, admitting of an escape of air into the pleural cavity, and, in some cases, also into the posterior mediastinum, and thence, by the cervical vessels and nerves, into the subcutaneous connective tissue of the neck, trunk, and extremities. But in order that the latter occurrence may happen, there must not only be a wound of the lung, but likewise of the costal pleura. When these two conditions coexist, it is easy to perceive how the air in the pulmonary vesicles may, during the expansion of the lung, be forced into the connective tissue beneath the lining membrane of the thoracic cavity, and thus constitute what is denominated emphy- sema. Collections of air in these situations may be caused by injury inflicted upon the lung, through the walls of the chest, especially if the wound is very small, oblique, or valvular, thereby interfering with the outward escape of the fluid; or they may form independently of any external wound, in consequence of the laceration of the pulmonary tissues by a piece of broken rib, or the sudden and violent compression of the lung during a fall of the body from a considerable height, although such an event must be extremely rare. When the accident is caused by the laceration of an air cell or a small bronchial tube, the air, passing into the posterior mediastinum, travels along the structures in this situation, until it reaches the fascia at the upper part of the thorax, when it diffuses itself over the neck and limbs, first along the sheaths of the vessels and nerves, and then through the connective tissue generally. Emphysema of the connective tissue of the trunk occasionally occurs without pneumo- thorax, as when a portion of lung that has become firmly adherent to the wall of the chest has been injured by the end of a broken rib being driven into its substance. In such a case, which is ,also one of extreme infrequency, the air may readily escape from the wounded organ into the connective tissue beneath the costal pleura, and from thence into that of the trunk and extremities, but cannot obtain access to the thoracic cavity. The symptoms denotive of pneumothorax are gene- rally of a very decisive nature. Percussion of the chest affords a remarkably resonant, or hollow, drum-like sound, wholly dissimilar from that which is elicited in any other disease, and, therefore, of itself characteristic of the presence of air; the vesicular murmur is either much diminished, or entirely absent; the breathing is more or less embarrassed ; the voice is feeble ; difficulty is experienced in lying on the affected side ; and the respiration in the sound lung is puerile. The symptoms of emphysema are also distinctly marked. The puffy, colorless, and elastic swelling, crackling under pressure, and commencing at a particu- lar part of the chest, either at the wound, or, if there is none, opposite a broken rib, and gradually spreading in different directions is an unmistakable sign of the ex- istence of air beneath the integument. The air, in con- sequence of the permeable nature of the structure in which it is lodged, may readily be pushed from one place to another, especially soon after it begins to make its appearance; and occasionally travels with astonishing rapidity over the greater portion of the body, destroying all dis- tinction of the chest, neck, and face, thus inducing the most unseemly and frightful de- formity, as seen in fig. 273. The treatment of pneumothorax and emphysema is very simple. Tn general, the air in the pleural cavity will be rapidly decomposed and absorbed ; should it prove trouble- some, by causing serious respiratory difficulty, it may be let out slowly by means of a delicate trocar, introduced so as to make a valve-like aperture, which should be closed immediately after with adhesive strips, supported by a compress and bandage. Emphy- sema is usually easily controlled by compression ; but if it should threaten to become very extensive and inconvenient, or, if it actually be so when advice is demanded, the most prompt and effectual remedy will be a moderately free incision at the seat of injury, or a number of little punctures in different parts of the body. Fig. 273. Geueral Emphysema of the Whole Sur- face, after Wound of the Kight Side of the Chest. CHAP. X. HYDROTHORAX AND PYOTHORAX. 375 SECT. IV HYDROTHORAX AND PYOTHORAX. Under these names may be described those collections of serum and of pus which super- vene upon acute and chronic pleurisy, whether the result of accident or of disease. Col- lections of this kind are extremely common, and are of great surgical interest, from the fact that they may generally be removed by a very simple and safe operation. In acute pleurisy, large quantities of serum are frequently poured out in an astonish- ingly short time, especially when the disease is of great extent and of unusual violence. The fluid is generally thin, colorless, and intermixed with lymph ; sometimes it is of a reddish hue, from the presence of hematin, while at other times it is found to be re- markably yellowish, and of a thick, viscid consistence, not unlike copal varnish or fresh olive oil. It is very seldom that genuine pus is poured out in acute pleuritis, yet such cases are sometimes met with, and that, too, at an early period of the disease. I have seen several instances, chiefly in young, plethoric children, in which one of the thoracic cavities was literally filled with purulent fluid in less than a fortnight from the commencement of the disease. The water in chronic pleuritis is generally much more abundant than in the acute dis- ease, often amounting to a number of quarts, if not to several gallons. It is also more thick and turbid than in acute attacks, being usually of a light lemon color, and of a somewhat oleaginous consistence. Sometimes it is of a greenish or reddish hue, and cases occur in which it contains blood and pus. The fluid, when drawn off, and allowed to stand for some time, generally separates into two parts; one, thin and viscid, like serum, occu- pying the top; the other, which consists of fragments of lymph and albumen, resting at the bottom. This disunion not unfrequently takes place in the cavity of the chest during the sojourn of the fluid. Large portions of lymph are often intermixed with this fluid ; and instances are met with in which it consists almost entirely of pure pus. When this is the case, the fluid is generally more or less fetid ; sometimes, indeed, almost insupportably so. The quantity of pus is occasionally enormous, amounting, perhaps, to several gallons. When the dis- ease is of long standing, the matter may be partly contained in separate cavities among the layers of adventitious membranes which are so liable to form under such circumstances. I have repeatedly met with cases of chronic pleurisy in which three or four such cavities existed ; some being filled with pus, some with serum, and some with a mixture of these fluids and of blood. Old thoracic accumulations occasionally contain gas and various kinds of concretions, especially fibrous and fibro-cartilaginous. The effects which these various effusions exert upon the lung are generally very dis- tressing, if not most disastrous, compressing and condensing its substance, so as to render it unfit for the purposes of respiration. When the quantity of fluid is very great, the organ is sometimes reduced to a mere cake-like mass, hardly as large as the hand, lying in the back part of the chest, by the side of the spinal column. In this condition, it is occasionally bound firmly down by bands of lymph, so that, even if the fluid is ulti- mately gotten rid of, it remains incapable of expansion. Very frequently, also, espe- cially in protracted cases, the pulmonary tissues become thoroughly solidified, in conse- quence of the mechanical compression to which they are subjected, thus rendering them hopelessly impervious to the air. The pleura, in chronic inflammation, is usually very much thickened from interstitial and surfacial deposits, and closely adherent to the surrounding parts. The diagnosis of these collections is founded mainly upon three circumstances; first, the history of the case ; secondly, the changes in the configuration of the thorax; and, lastly, the alterations in the respiratory functions. 1st. The history of the case will show whether the effusion is the result of traumatic or of constitutional causes ; if the latter, whether the consequence of ordinary pleurisy, pleuro- pneumonia, or tubercular disease; finally, whether the affection is acute or chronic, open or latent. 2d. Whenever the pleuritic effusion is unusually copious, it sensibly encroaches upon the chest, so as to cause a very manifest enlargement of the corresponding side ; the inter- costal spaces are not only abnormally widened, but perhaps thrust considerably beyond the level of the ribs. The diaphragm is also more or less depressed, and the heart is thrown out of its natural position, either to one side or down towards the stomach. The extent of the dilatation of the chest varies in different cases, but rarely exceeds two inches. The best way of determining it is to measure both sides with a graduated tape, carried from a 376 INJURIES AND DISEASES OF THE CHEST. chap. x. central point of the sternum, under the mamma, to the spinous process of the correspond- ing vertebra. The eye alone, however, is often quite sufficient to detect the difference, even although it be comparatively slight. When the intercostal spaces are much dis- tended, and there is at the same time great wasting of the tissues, fluctuation may occa- sionally be detected. 3d. The effects exerted by these effusions upon the respiratory sounds and movements are generally of an unmistakable character. The alteration of the vesicular murmur is always in direct ratio to the quantity of fluid, being deep and feeble when it is moderate, but entirely wanting when it is very abundant, except, perhaps, along the spinal column, where it may still be somewhat audible over a space of a few inches in extent. When old adhesions exist between the pulmonary and costal pleurae, as often happens in the upper part of the chest in tubercular disease, the fluid, unable to compress this portion of the lung, may allow it to receive a certain quantity of air after respiration has ceased everywhere else. No friction sound is ever present when there is much fluid in the chest. To produce such an effect, it is necessary not only that the two pleurae should be rough- ened with lymph, but that they should rub more or less against each other. iEgophony exists only when the effusion is moderate, or only a few lines in depth ; hence, it is not present either in the very early or in the more advanced stages of the disease. Finally, during certain movements of the body, especially if suddenly made, a splashing noise may occasionally be heard within the chest, resembling that produced by agitating a cask partly filled with watei’. Dullness on percussion is always present when there is much effusion ; commencing at the lower part of the chest, from which it gi’adually ascends as the fluid mounts upwards, and changing with the position of the patient. The symptom, however, considered by itself, is of no diagnostic value, inasmuch as it always attends solidification of the lungs, in whatever manner induced. When the pleuritic effusion is blended with the exti-ication of gas, percussion elicits a remarkably clear, tympanitic sound. The most impoi’tant functional symptoms, especially in chronic pleuritic effusions, are hectic fever, rapid emaciation, pain in the chest, troublesome cough, a sense of tightness and oppression, great dyspnoea in ascending a flight of stairs, and inability to observe re- cumbency. If the patient lies down at all, he lies on the affected side, on his back, or in an intermediate posture. Collections of water, or of water and pus, in the pleural cavity, occasionally find their way out to the external surface; generally through one of the intercostal spaces, as in two cases which have been kindly shown to me by Professor Da Costa. Sometimes the discharge takes place through the bronchial tubes. Le Dran, Andral, and others have recorded instances in which it was evacuated through the diaphragm. When the patient survives such an event, the track is lined by false membi-ane, and often remains fistulous for a long time. But a spontaneous opening is a rare occurrence ; and hence, as the fluid, when existing in large quantity, cannot be l’endered amenable to the absoi’bents, the only remedy is to evacuate it by operation, otherwise it will inevitable destroy the patient. In the milder forms of the affection, as when the fluid exists in small quantity, and is mainly of a serous nature, removal of the deposit may sometimes be effected under the influence of sorbefa- cient remedies, as the application of blisters and tincture of iodine, and the exhibition of mercury, either alone or in union with iodide of potassium. Sti’apping the chest more or less firmly with adhesive plasters, as originally practised by Professor John B. Biddle, is occasionally serviceable in promoting the absorption of the effused fluid, the strips being sometimes carried completely round the chest so as to compel the patient to breathe solely with the aid of the diaphragm and abdominal muscles. Thoracocentesis, or tapping the chest, although occasionally performed by some of the older sui’geons, was not placed in its true light until within the last thirty or forty years. In this country attention was first prominently directed to the subject by Dr. Henry I. Bowditeh, of Boston, in a seines of papers which have honorably associated his name with this department of pathology and practice. From the results of his cases and of those of other observers, it is evident that the operation, when pi’opei’ly performed, is not only perfectly safe, but generally eminently successful, the issue being always more favorable, other things being equal, in pi-oportion to the shoi’tness of the time that has elapsed since the commencement of the disease, the excellence of the general health, and the absence of purulent matter. When the patient is much exhausted from protracted suf- fering and serious organic disease, the chances of recovery will, of course, be much lessened. The operation of tapping the chest, is very simple. The instruments which are required are a scalpel and a long, slender trocar, furnished with a stopcock, fig. 274, to prevent the entrance of air into the serous sac. The patient being comfortably propped up in bed, a small incision is made through the in- tegument, previously rendered tense, just above the upper margin of one of the ribs, generally the sixth, about midway between the sternum and spine, or just posterior to the digitations of the great serrated muscle. When the fluid points externally, the punc- ture is made at the most prominent and dependent portion of the swelling. The trocar is then thrust boldly through the intercostal space, penetrating the muscles and pleura, as well as any false membranes that may be adherent to its surface. The trocar being now' withdrawn, the fluid will come away in a full stream, a suitable vessel having been provided for its reception. A large gum-elastic bag or beef’s bladder, secured by a nozzle to the extremity of the canula, will be found to be the most eligible article for the purpose. When it is filled, the stopcock is shut until the bag can be re- attached, and thus the operation is continued until the cavity is completely emptied. Upon withdrawing the canula, the integument immediately resumes its natural position, and thus effectually occludes the puncture. The edges of the outer wound are ap- proximated by an adhesive strip, which is the only dressing required, the bandage being objectionable on account of its constricting effects. The flow of the fluid is sometimes impeded by flakes of solid matter and by the pres- ence of false membrane, necessitating, in the former case, the use of the probe, and in the latter the reintroduction of the trocar. Thorough evacuation is sometimes greatly facili- tated by the employment of the gum elastic catheter. Change of posture, coughing, a full inspiration, and straining, as if at stool, often greatly promote evacuation. The instrument now usually employed for evacuating fluids from the pleural sac is Potain’s aspirator, with which the operation may be performed with great facility and safety, more especially when the fluid is of a purely serous character. When it is mainly composed of pus, intermixed with flakes of lymph, the trocar answers much better, as it is much less liable to be clogged. The operation is generally well borne, especially when the patient is slightly under the influence of anaesthesia, which also, in great measure, prevents the cough that is otherwise so apt to attend it. If the patient becomes faint, his head should be gradually lowered, and free use made of brandy. The former of these precautions will usually be required anyhow, with a view to complete clearance of the chest. As the fluid flows off, the lung, if not adherent or solidified, steadily expands, and at length regains its natural volume. If the accumulation has been very great, the operation will probably be obliged to be re- peated several times before a final cure can be effected. The after-treatment is very sim- ple ; opium is given to allay cough and pain, and the system is supported by good diet and milk punch. When the case is very tedious, the fluid manifesting a strong tendency to reaccumulate rapidly after each operation, the cure may be expedited by the use of a sil- ver tube provided with a proper valve, and by the occasional injection of some slightly stimulating lotion, or simple tepid water, and the daily application of dilute tincture of iodine to the walls of the chest, which is generally preferable to a blister. In several cases of pyothorax healed by me in this manner, the result was most satisfactory, a per- fect cure being effected in each in less than two months. When a spontaneous opening arises in the chest in empyema, it will usually be found to be altogether inadequate for effectual drainage, both on account of its small size and its vicious site. In such a case, a counteropening, or a puncture in some more eligible situa- tion, should be made ; for it is very desirable that the matter should have an opportunity for escaping as fast as it is formed. A similar procedure may occasionally be required after the operation of tapping. The use of a drainage-tube may, under such circumstances, be of service, but it must be employed with care and vigilance, otherwise it may act as an irritant, and so be productive of harm. Thoracocentesis is sometimes attended with injury to the lung, the point of the instru- ment being thrust into its substance. Such an accident, which, however, is seldom followed by serious consequences, will be most liable to occur when the organ has con- tracted firm adhesions. The intercostal artery is easily avoided by making the puncture in the lower part of the intercostal space, at a considerable distance from the inferior margin of the upper rib. The chances of serious hemorrhage in this operation are so slight that in 820 recorded cases it caused death only in one. The occurrence of fatal CHAP. X. HYDROTHORAX AND PYOTHORAX. 377 Fig. 274. Trocar for Tapping the Chest. 378 INJURIES AND DISEASES OF THE CHEST. chap. x. shock is extremely uncommon. Much outcry lias been made about the risk of the entrance of air during the operation, but I am not aware of any case that has proved fatal, or that has led to any serious detriment from this cause. Of 498 cases of this operation, collected by Gunther, in 18G1, 302 were cured, 149 died, 16 were improved, 19 recovered with a fistulous opening, and of 12 the result was unknown. Of 132 cases analyzed by Dr. John A. Brady, of Brooklyn, 79 were cured, 14 were relieved, and 37 ended fatally; in 1 the result was not known, and in 1 no bene- fit followed. In a number of the patients that died, the disease had committed irremedi- able ravages before recourse was had to the operation. Of the 37 fatal cases, 11 were carried off by phthisis. Dr. Bowditch, in a communication with which he kindly favored me in March, 1882, stated that he had, up to that time, operated upon 236 persons 370 times, and had never met with any evil results; nor had he witnessed any immediate bad effects from thorac- otomy, performed with a view of establishing a permanent opening in the chest, although in some of the patients who died a long time afterwards the wound was still unclosed. The ages of the patients varied very greatly, some being under five years and others nearly eighty. Dr. A. L. Mason, in 1882, published an analysis of 200 cases of primary pleurisy treated in the Boston City Hospital, in 70 of which the chest was tapped 122 times with no unfavorable effects which could justly be ascribed to the operation. On the contrary, the good effects were generally great and permanent. The operation had to be repeated twice in 14 of the cases, thrice in 6, four times in 7, and six times in 1, in which, how- ever, the fluid had become purulent. The fluid was usually of a translucent serous character, and the quantity, drawn off at one tapping, varied from a few ounces to eleven pints, as many as three quarts being removed in many instances without inconvenience. The instrument usually employed was the pneumatic aspirator, inserted in the seventh, eighth, or ninth intercostal space below the angle of the scapula. Sometimes the fluid was allowed to drain off through an India-rubber tube. Of the above cases, 96 were dis- charged well, 6 nearly well, 18 much relieved, 69 relieved, 2 not relieved, and 4 dead; a result eminently complimentary to the operation and to those in charge of the general treatment. In 1877, Dr. John G. Blake, of the Boston City Hospital, reported the results of 19 cases of empyema in which a permanent opening was made in the chest by an incision two inches long, between the seventh and eighth ribs, a little inside the scapula and in the direction of the axillary line, this point being selected as admitting of the most ready drainage, and being most easy for the patient. The edges of the opening were kept apart either by an ordinary drainage tube, a gum-elastic catheter, or a silver canula provided with a valve. The cavity containing the pus was washed out with carbolized water only when the fluid was offensive, not in ordinary cases; and the after-treatment was of a strictly supporting nature, with anodynes to relieve cough and promote sleep. Under this management 10 of the 19 cases recovered, 4 were relieved, 1 was rapidly improving, and 4 died, one of them from causes entirely unconnected with the operation. Dr. Blake con- demns the use of anaesthetics, except in very rare cases, as unsafe in this operation, a conclusion in which every sensible practitioner must certainly concur ; and he alludes to two instances in which their administration was followed by death. Incipient phthisis and long-existing pyothorax might be supposed, he says, to contraindicate the perform- ance of the operation, and yet, even under such apparently desperate circumstances several astonishing cures have been witnessed by him. Dr. Blake does not place any particular confidence in the antiseptic treatment in empyema. In chronic cases, with a view of affording a free outlet for the matter and allowing the chest to contract permanently, a portion of one or more ribs may be excised. Of 8 cases recorded by Estlander, in 1881, 2 died, and 6 recovered, in four of which the opening remained fistulous. Children recover from the effects of empyema much more readily than adults. Dr. Bowditch, to whom we are so much indebted for having pointed out the proper treatment in this affection, declares that children almost always get well; he is opposed to operative interference when there is well-marked phthisis, and his experience is, that injections are not required when the pus is perfectly pure, the results of his observations agreeing, in this respect, with those of Dr. Blake. Finally, the removal of the fluid from the pleural cavity, whether by medicine or oper- ation, is always followed, especially in cases of empyema, by a remarkable contraction of the corresponding side of the chest, which generally remains during life, except when the CHAP. X. PULMONARY ABSCESSES AND CAVERNS. 379 patient is very young, and the lung regains its full expansion, when it sometimes nearly entirely disappears. Tapping of the chest is sometimes rendered necessary on account of the existence of hydatids in the cavity of the pleura, as in a case recorded by Dr. Reginald Southey, of London. The patient, a man, thirty-one years old, had suffered from a variety of anom- alous symptoms, somewhat resembling neuralgia and hysteria, attended with cough, dys- pnoea, and pain in the chest, when a marked projection appeared on the right side of the spine, extending into the interscapular region. A puncture made with an exploring needle gave vent to a large quantity of puriform fluid, with some relief. Subsequently, a free incision was made between the sixth and seventh ribs, and a soft, loose, jelly-like mass, recognized as a part of a hydatid, was extracted. It was about the size of a pig’s bladder, and seemed to have formed in the sac of the pleura, above the diaphragm, with- out any connection whatever with the liver. A speedy recovery took place. Collections of pus are liable to form in the anterior mediastinum, sometimes as an effect of cold, but more commonly of external injury, as a blow or fall upon the chest, or of fracture, caries, or necrosis of the sternum. The principal symptoms are, severe pain, great tenderness on pressure, and difficulty of respiration with inability to lie down. Vio- lent rigors sometimes attend ; and fever, of a remittent or intermittent character, is usually present throughout. The diagnosis must necessarily be obscure. The matter commonly points at an intercostal space by the side of the sternum ; occasionally it bursts into the pleural cavity, and then genei’ally induces death by inflammation, pyemia, or hectic irritation. For the relief of this affection, La Martiniere proposed tapping the sternum; but such an operation could only be justifiable when the abscess has been caused by caries, necro- sis, or fracture of this bone, and then, of course, there should be no hesitation about its performance. Ordinarily, the surgeon waits until the matter points, when evacuation is effected with the lancet. Trephining of the sternum might be required for the removal of a foreign body in the anterior mediastinum. SECT. V PULMONARY ABSCESSES AND CAVERNS. Surgery, in its triumphant march, not satisfied with invading the thoracic cavity in search of pent-up fluids, has lately boldly planted itself upon the lung itself, and already boasts of a number of successes. To Professor Mosler, of Greifswakl, the profession is indebted for the brilliant conception of opening this new route to the operator’s knife. In this country the subject was first prominently brought to notice by Dr. Fenger and Dr. Hollister, of Chicago, in an elaborate and exhaustive paper in the American Journal of the Medical Sciences for October, 1881. Professor Pepper had also called attention to it in a clinical lecture, illustrated by the recital of an interesting case. The operation of opening the lung would seem to be proper in all cases in which there is a cavity in this organ requiring drainage, whether the result of abscess, gangrene, or tubercular disease, provided the constitution is not so far undermined as to forbid inter- ference. It is well known that persons occasionally make astonishing recoveries, despite the great disadvantages under which they labor, when affected with abscess or gangrene. In such cases surgery proposes to aid recovery by making an incision through the wall of the chest directly over the cavity in the lung, to evacuate the pent-up fluid, always of a highly offensive character, to wash out the sac, and, by means of the drainage-tube, to prevent reaccumulation, so invariably productive of local and constitutional irritation. The treatment, in other words, which it aims to accomplish is precisely similar to that pursued in abscess and gangrene occurring in any external part of the body. The pro- priety of surgical interference in lung cavities caused by the softening of tubercular mat- ter is not so apparent, but even here conditions may arise which may render the use of the knife perfectly proper. The great misfortune in most of these lung troubles is that, when an operation is agreed upon, the time has passed for doing any good, except, perhaps, in the most transient manner. Several examples are recorded in which the chest was opened for the extraction of echinococci from the lung. One such case, with a successful issue, has been reported by Fenger and Hollister, in a man thirty-four years of age, who, not- withstanding the most unfavorable symptoms at the time of the operation, made a perfect recovery. It is self-evident that, before any operation is agreed upon, every possible pains should be taken to establish an accurate diagnosis. This can be done only by a thorough ex- 380 INJURIES AND DISEASES OF THE CHEST. chap. x. amination of the chest by auscultation and percussion, and a careful consideration of the general symptoms, aided by the exploring-needle. Abscess and gangrene of the lung are always preceded by pneumonia, by chills and profuse sweats, by excessive prostration, by elevation of temperature, and, in a word, all the phenomena incident to such occurrences. When an abscess opens into a bronchial tube profuse purulent expectoration is an invari- able symptom, attended with pectoriloquy and increased resonance of the chest at the seat of the disease. The excessive fetor of the breath and of the discharges which accom- pany gangrene afford unmistakable evidence of the existence of that disease. The diagnosis of echinococcus must necessarily, from the very nature of the complaint, be very obscure, especially in its earlier stages. When the cyst bursts into the bronchial tubes, so as to admit of a microscopic examination of the expectorated fluid, any doubt that may have been previously entertained in general promptly vanishes. Before this event, the disorder may be suspected, but nothing more, when there has been protracted and more or less severe lung trouble, attended with hemorrhage, frequent cough, pain in the chest referable to one particular spot, and increased by bodily exertion, gradual wast- ing of the flesh and strength, hectic irritation, and dullness on percussion, with absence of the respiratory murmur. The booklets of the echinococcus are always characteristic. In cases of doubt a small aspirator may be employed as an aid to the diagnosis. An ordi- nary exploring-needle, or hypodermic syringe, may be of service in locating the precise spot of the abnormal cavity, especially when it is near the surface of the lung. Supposing that there are no contraindications, and that the point of election has been settled by a careful examination of the chest, an incision, varying in length from an inch to one inch and a half, is made through the corresponding intercostal space, at the most dependent part of the cavity, close along the upper border of the rib, down to the pleura and thence through the lung tissues, until the object is satisfactorily accomplished. Any bleeding vessels should be promptly ligated, and oozing arrested with hot water, Pag- liari’s styptic, or Monsel’s salt, aided, if necessary, by a sponge compress. The cavity is washed out freely at first twice, and then thrice, a day with a very weak antiseptic lotion of carbolic acid, chloride of zinc, thymol, or permanganate of potassium, a drainage- tube being retained in the passage to conduct away any fluid as fast as it is secreted. A soft, gum catheter is, on the whole, the best, although a silver canula formed like a trachea tube, provided with a valve, is generally more convenient, as it is more easily kept in place. Occasionally a counteropening may be required, as when the surgeon has failed to reach the bottom of the cavity in the first instance. In some cases, indeed, it may be neces- sary even to remove a portion of rib in order to effect thorough drainage. The after-treatment is conducted upon general principles, and every effort made to sus- tain the patient’s strength by anodynes, tonics, and stimulants. Time alone can determine the value of this operation. SECT. VI WOUNDS OF THE HEAKT, PERICARDIUM, AND LARGE VESSELS. Wounds of the heart may be of an incised, punctured, or gunshot nature, according to the character of the vulnerating body; and their gravity is generally such as to lead very speedily to fatal results. Severe lesions are sometimes inflicted upon this organ without any serious injury of the integument, or any solution whatever of its continuity, as in fracture of the ribs and sternum, in which some of the fragments are driven into its substance, or so rudely pressed against its surface as to cause more or less contusion. Wounds of the heart may be limited to the walls of the organ, penetrate its cavities, or affect its partitions. In the first case, they may be said to be superficial; in the other two, deep, and, consequently, of a more serious character. Experience has shown that those parts of the organ which are least protected by the sternum and ribs are those which are most liable to be injured. Of 401 cases, analyzed by Dr. George Fischer, the right ventricle suffered in 123, the left in 101 ; the right auricle in 28, the left auricle in 13; the apex in 17 ; the base in 2 ; the interventricular septum in 7 ; both ventricles in 26 ; the entire heart in 16 ; the right heart in 4; the left heart in 5, and the coronary artery in 2. In 57 cases, the locality of the wound was uncertain. In gunshot wounds of the heart, the ball may lodge in the walls of the organ, or in the interventricular septum, as in the interesting case related by Professor Carnochan. At other times, but this, also, is extremely rare, it may penetrate one of the cavities of the heart, and then fall into the inferior cava, descending, perhaps, nearly as far as the bifurcation of that vessel. Of this occurrence, a remarkable example is afforded by the CHAP. X. WOUNDS OF THE HEART. 381 unique case reported by Dr. Simmons, of a young man who, after having received a pis- tol-shot in his chest, died at the end of ninety-seven hours, without having given any evidence whatever of being wounded in the heart. Upon dissection, however, an open- ing, pretty firmly closed by blood and plasma, was discovered in the upper part of the right ventricle, the inner surface of which exhibited a lacerated appearance, but no appre- ciable lesion existed in any other portion of the organ, and it was only by accident that the ball was detected in the inferior cava. In this class of wounds, the heart is occasionally fatally injured without any apparent lesion of the walls of the chest. At the last siege of Antwerp by the French, a number of cases occurred in which this viscus was severely contused and ruptured, and yet the closest scrutiny failed to detect any external evidence of the mischief. In some of these cases, death happened instantaneously, while in others it was preceded by violent pneu- monia, or by a copious effusion of blood into the pleural sac. Professor Holmes, of Mon- treal, has recorded a curious instance in which the right ventricle of a young man con- tained a transverse linear opening, large enough to admit the finger, without any wound in the pericardium, leading to the inference that this membrane had been driven before the ball into the heart, while the latter was forcibly distended. The ball was found loose in the cavity of the chest. Several similar examples have been observed by other practitioners. Wounds of the heart are often complicated with other injuries, as fractures of the ribs and sternum, and wounds of the lungs, diaphragm, and large vessels. Of 22 cases of accidental rupture of the heart, in which the precise seat of the lesion was noted, analyzed by Mr. Gamgee, 12 occurred on the right side and 10 on the left; 8 of the former affecting the ventricle, and 4 the auricle, while of the latter 3 involved the ventricle, and 7 the auricle. The pericardium in half of the cases was intact. Such an occurrence can only be explained on the assumption that the ventricle was dilated at the moment of the percussion. Laceration of the heart from external violence not unfre- quently occurs without leaving any trace of injury upon the skin. The symptoms of wounds of the heart are often so obscure as to be of very doubtful diagnostic value. In general, they are such as indicate severe shock, whether from mere nervous depression or from loss of blood, which is often exceedingly profuse. The patient is faint, anxious, and deadly pale ; the pulse is small, frequent, and irregular ; the surface is cold and clammy; the pupils are dilated; the voice is feeble and indistinct; and the respiration is laborious, and often interrupted by sighs. The pain is usually very severe, especially in the region of the sternum ; and, upon applying the ear to the heart, a pecu- liar noise is perceived, similar to that which is heard in aneurismal varix, or during the passage of blood from an artery to a vein. Although the patient is usually very much exhausted by the shock consequent upon a wound of this organ, cases not unfrequently occur in which he is able to walk or run a considerable distance before he falls down or expires. These symptoms are, obviously, not pathognomonic ; for they may be caused by various other lesions, as a wound of the lungs or large vessels. Important information may often be derived from a consideration of the situation and direction of the wound. Thus, if a knife, sabre, or ball has entered the chest on the left side, between the fourth and fifth ribs, about two inches from the sternum, and the patient is in the condition above de- scribed, there will be strong reason for concluding that the heart has been laid open, especially if the external wound has pierced the pleura. Probing, in such cases, can be of no use in any respect, and should, therefore be avoided. The prognosis of wounds of the heart is generally, although not invariably, unfavorable. Much will depend, in every case, upon the nature of the injury, especially its extent and direction. Sometimes a single shot is sufficient to cause death almost instantaneously, as happened in the case of a youth, seventeen years of age, from whom the accompanying sketch, tig. 275, was taken, and who was hit in the chest by a stray shot, passing through the left ventricle, near its middle. When a ball or knife takes an oblique, tortuous course among the muscular fibres of the heart, their contraction may be such as to close the track made by the vulnerating body until a clot is formed, and so oppose, in great measure, the effusion of blood, thereby affording the wound an opportunity of under- going repair. However this may be, there are numerous instances upon record which serve to prove that recovery is by no means impossible. Thus, Dr. Randall, of Tennes- see, has reported the case of a negro boy, who died sixty-seven days after having been wounded in the chest with a load of shot. The lesion was followed by severe inflamma- tion of the lungs, but there was no indication that the heart had been injured, and the lad was thought to be convalescent, when he suddenly died from over-indulgence in eating. 382 INJURIES AND DISEASES OF THE CHEST CHAP. X. Upon dissection, five shot were found in the heart, three in the base of the ventricle, and two in the bottom of the auricle; the wounds in the walls of the organ were all firmly healed, and the sur- faces of its cavities exhibited no trace of former suf- fering. In the case of a soldier, mentioned by Fournier, a musket ball was discovered in the right ventricle of the heart, in contact with its septum, six years after he had been shot. Dr. Balch found a ball in the lower part of the wall of the right ventri- cle of a man eighteen years after he had been wounded. He recovered from the immediate effects of the injury in six weeks. Dr. F. M. Holly, of Connecticut, in 1878, met with a case in which a small ball was imprisoned for fifty-five days, when it unexpectedly caused death while the man was at work in a field. In the case of Poole, recorded by Dr. Carnochan, the probability is that recovery would have taken place if the man had been more careful of himself, and had not been otherwise hurt. He died eleven days after the acci- dent; and the dissection showed that the bullet, which was one-third of an inch in diameter, was enveloped in a delicate cyst, as it lay firmly imbedded in the muscular septum, mid- way between the apex and base of the ventricles, a quarter of an inch beneath the surface. The cause of death was inflammation of the heart and pericardium, the latter of which was so enormously distended with sero-sanguinolent fluid as to encroach greatly upon both lungs. In a case of gunshot wound of the chest, reported by Professor Sayre, the ball tore open the pericardium in such a manner as to expose the contused heart, and yet the patient made an excellent recovery. Some remarkable instances have been recorded of persons surviving a considerable length of time after the heart had been transfixed by foreign substances. Thus, Ferrus has narrated the particulars of the case of a man who lived tor twenty days with a skewer traversing his heart; and Mr. Davis mentions one of a boy who lived upwards of a month with a piece of wood, three inches long, in the right ventricle. Of 30 examples of punc- tured wounds of this organ, collected by Dr. Purple, of New York, 2 survived twenty-five days. In one of these the injury, inflicted with a penknife, opened the coronary artery, and in the other the heart was pierced at six different places by a saddler’s needle. Of 401 cases tabulated by Dr. Fischer, 103 died immediately; 199 consecutively; 50 recovered, and in 49 the termination is not given ; 33 of the recoveries were proved by post-mortem inspection, but in the remainder the wound was only conjectured from the symptoms. Deducting the uncertain cases, of 352 wounds of the heart, 217 were incised with 30 cures; 51 gunshot, with 7 recoveries, in four of which the balls remained in the organ; 47 lacerated and ruptured, with 3 cures; and 37 punctured, with 10 recoveries. The majority of the incised wounds were made by knives, daggers, and poniards, while four-fifths of the punctured were due to needles. The cause of death in wounds of the heart is hemorrhage, shock, or compression of the heart by effusion of blood within the pericardium, if it occur soon after the accident, and inflammation and its consequences, if it occur more remotely. Mere contusion of the heart is occasionally sufficient to destroy life, as in a case men- tioned by Nelaton, in which the anterior wall of the right ventricle was bruised and slightly lacerated by a pistol ball, death occurring at the end of twenty-four hours. The ball was found in the pericardium, which was filled with bloody serum. The treatment of wounds of the heart must be conducted upon general principles. It the patient is found to be in a swooning condition, a drink of cold water, with an abund- ance of cold air, may be allowed, and the head and shoulders should be laid low in order to promote the access of blood to the brain. If the shock is excessive, sinapisms are ap- plied to the spine and extremities, and an injection of turpentine or ammonia given; but all internal stimulants are, if possible, avoided, lest, by favoring untoward reaction, they should increase hemorrhage and the tendency to inflammation.. Protracted depression is rather to be desired than avoided. Hence, the treatment, for the first two or three days, should be as much as possible of an expectant nature. Opium should be given largely to relieve pain, which is often very severe, but, above all, to tranquillize the wounded organ, the tumultuous action of which cannot fail to exert a most injurious influence upon the Fig. 275. Shot Wound of the Heart. CHAP. X. WOUNDS OF THE HEART. 383 reparative process. It should be combined with aconite and acetate of lead, to augment its sedative influence, and to increase the coagulability of the blood. When inflammation is set up, the chief reliance must be upon the lancet, antimony, calomel, opium, mild pur- gatives, and revulsives, especially large blisters, with elevation of the head and shoulders. The chest should be supported with a broad flannel bandage; and, after the more acute symptoms have subsided, recourse should he had to small doses of iodide of potassium and bichloride of mercury, to promote the absorption of effused fluids. The patient must take great care of himself during convalescence, as well as for a long time afterwards. Foreign bodies should be removed, if easily accessible, otherwise they should be per- mitted to remain, in the hope of becoming encysted, as happened in some of the cases above mentioned, and in many others recorded by different writers. The late Mr. Cal- lender, of London, in 1872, successfully extracted from a man, thirty-one years of age, by an incision through the skin and connective tissue over the fifth intercostal space, a needle one inch and nine-tenths in length, embedded for nine days in the heart near its apex. Wounds of the 'pericardium, uncomplicated with lesion of the heart, are occasionally observed, and their occurrence is probably more frequent than is generally supposed. A number of interesting cases of recovery from such injuries have been reported, their former existence having been satisfactorily established by examination after death, months, if not years, after their infliction. Thus, of 51 cases tabulated by Fischer, 22 recovered, three of which were verifled after death from other causes. Of 32 incised wounds, 19 were fatal; of 7 gunshot injuries, only 2 died; of 3 punctured wounds, all perished; and of 9 lacerated and ruptured wounds, 5 died. Wounds of the pericardium necessarily give rise to inflammation, the presence of which cannot always be recognized by the usual signs of that disease, as the friction sound may be entirely absent in consequence of the interposition of a large quantity of blood between the membrane and the heart. When much fluid exists, whether it be pure blood, or serum, the precordial region will necessarily sound dull on percussion, and often become preternaturally prominent, in the same manner as the thorax in pleuritic effusion. The pulsations of the heart are irregular, tumultuous, and obscure, and the patient finds it difficult, if not impossible, to lie on his back without suffering from swooning, and a sense of impending suffocation. In a case which I saw with Dr. Knapp, auscultation for many days together afforded a peculiar lapping sound, similar to that made by a dog in lapping water, as if the heart had been splashing about in a fluid. In my private collection is a specimen, kindly presented to me by Dr. J. W. Coles, of the Navy, in which a common sewing needle, nearly two inches in length, is encysted jn the pericardium. No history could be obtained of the case, as the man, who was twenty- two years of age, was moribund at the time of his admission into the hospital. An old cicatrice existed on the right side, between the sixth and seventh ribs, immediately ex- terior to their junction with the cartilages, probably the result of a former attempt at self- destruction. The pericardium was everywhere closely adherent, thus rendering it highly probable that the needle had been introduced a considerable period before death, caused by perforative ulceration of the lower extremity of the descending colon. In a case recorded by Dr. Fischer, a ball was encysted in the sac of the pericardium for fifty-two years. Wounds and ruptures of the pericardium must be managed upon the same general prin- ciples as similar injuries of the heart. Wounds of the large vessels of the chest are sufficiently common, and are, perhaps, still more frequently fatal than those of the heart. Their symptoms and treatment require no especial attention here. A rare case of recovery from a stab in the ascending aorta with a knife, has been re- corded by Dr. Heil. The patient, a Bavarian soldier, died of pneumonia, upwards of a year after the accident, when the wound, which had penetrated all the coats of the vessel, was found to be closed by a firm cicatrice. Guattani and Pelletan each describe an in- stance in which a wound of the aorta was followed by a false aneurism, the patient of the former surviving the accident several years, of the latter upwards of two months. No case, so far as I know, of recovery, from wound or rupture of the vena cava, has been met with. Blumenbach refers to an instance, observed by Lentin, in which a person lived for many months, although in a very feeble state, after laceration of the thoracic duct. 384 INJURIES AND DISEASES OF THE CHEST. CUAP. X. SECT. VII HYDROPERICARDIUM. Ilydropericardium is of surgical interest only in connection with the operation of para- centesis, admissible as a dernier resort, if the accumulation be large, and other treatment unavailing. The fluid, which may be strictly serous or sero-purulent, varies in quantity from a few ounces to upwards of a gallon. When the inflammation which precedes and accompanies its formation is unusually severe, it is not unfrequently intermixed with flakes of lymph and even pure blood, either liquid or coagulated. The quantity of puru- lent matter thrown out in chronic pericarditis is sometimes enormous. In a case ob- served by Dr. Wright, of Baltimore, in a man, thirty-three years of age, it amounted to four quarts. The diagnosis of this affection, in cases likely to fall into the hands of the surgeon, is, in general, not difficult. Whenever there is a considerable accumulation, whether the result of acute or chronic disease, the precordial region will be found to be dull on percus- sion, and to be abnormally prominent; not universally, as in pleuritic effusion, but over a circumscribed space of about four or five inches in length by three to four in width. It is seldom that the distension is so copious as to simulate empyema. In a case observed by Dr. Corrigan the projection extended as high up as the first rib, and yet no difficulty was experienced in the diagnosis. Occasionally the fluid can be detected on each side of the sternum and even in the epigastrium. The action of the heart is irregular, tumul- tuous, obscure, and perceptible beyond the ordinary limits. In general, it is accom- panied by a peculiar undulatory or wave-like motion, owing to the fact that some beats are stronger than others. “ The impulse,” says Hope, “ does not accurately coincide with the sound of the ventricular contraction, as the heart has to remove the interposed fluid before it can impinge against the thoracic walls; the first sound is dull and remote, in consequence of the intervention of the fluid; finally, the sensation communicated to the hand and stethoscope is that of an impulse transmitted through a fluid, and not of an organ striking the ribs immediately.” When the accumulation is very great and the action of the heart feeble, there may be an entire absence of impulse. If, superadded to these phenomena, there is constant orthopnoea, with frequent paroxysms of swooning, lividity of the countenance, and a feeble, irregular state of the pulse, no reasonable doubt can be entertained respecting the true nature of the disease. Nevertheless, it should not be forgotten that an enormous accumulation may occasionally exist, and yet the patient hardly experience any uneasiness. The affection with which hydropericardium is most liable to be confounded is empyema or hydrothorax. Errors of diagnosis may also arise from sarcomatous or lymphomatous growths in the mediastinum and from a serous cyst between the lung and the heart. Paracentesis of the pericardium, originally proposed by Riolanus, in 1653, was first successfully executed by Romero, of Barcelona, in 1819. It may be performed with a trocar of medium size, or, what is, perhaps, in the main preferable, with a bistoury, care being taken, in either case, not to wound the heart or to permit any air to enter the pleural sac. It will be safest, as a general rule, to select the most prominent portion of the swelling. Camper directs the puncture to be made between the fourth and fifth ribs; Romero, between the fifth and sixth ; Desault, between the sixth and seventh. Larrey’s advice is to effect penetration between the seventh rib and the ensiform cartilage. Skoda and Schuh each had a case, in one of which the pericardium was pierced through the third intercostal space, and in the other through the fifth. It will thus he seen, not to cite other names, as, for example, those of Senac, Skielderup, and Richerand, that it is impossible to lay down any definite precept as it respects the place of election. My own opinion is that a preliminary incision should be made, of a valve-like character, at the most prominent part of the swelling, within an inch of the sternum, on the left side, and that the distended sac should then be pierced with a trocar of medium size, furnished with a stopcock, to prevent the ingress of air. Great care must be taken not to interfere with the intercostal and internal mammary arteries. In a case of purulent pericarditis, in a boy ten years of age, Rosenstein recently incised the sac under antiseptic precautions, two drainage tubes were introduced, and the lad was well in nineteen days. The most satisfactory statistics of paracentesis of this cavity are those collected by Dr. John B. Roberts of this city. Rejecting as doubtful all the operations performed prior to 1860, he finds that the number of reliable cases from that period to 1881 inclusive was 49, of which 19 recovered and 30 died, affording thus a mortality of 61.2 per cent. In addition to these cases, there were 4 in which no fluid was obtained; in 2 of these the CHAP. X. WOUNDS AND RUPTURE OF THE DIAPHRAGM. 385 heart was punctured, and no fluid existed, and in the other 2 the fluid was not reached, because the trocar became entangled in the thickened or adherent pericardium. Dr. Roberts, who has paid much attention to the subject, is of opinion that the most eligible point for aspiration of the pericardium is the fifth intercostal space, immediately above the sixth rib, about two inches and a half to the left of the middle line of the ster- num in the adult, and somewhat nearer to that bone in the child. In selecting this spot no risk will be incurred of injuring the internal mammary artery, the heart, or any other important structures. The aspirating trocar preferred by Dr. Roberts is represented in fig. 27G. The vacuum should always be attached to the instrument as soon as the point Fig. 276. Roberts’s Aspirating Pericardial Trocar. is buried beneatl) the skin, in order that the flow of fluid may indicate the moment the pericardium has been penetrated. In this country the operation was first performed by Dr. John C. Warren, in 1852, the patient leaving the hospital well in a few weeks. SECT. VIII WOUNDS AND RUPTURE OF THE DIAPHRAGM. Wounds of this musculo-tendinous septum possess but comparatively little practical in- terest, for not only is their diagnosis extremely difficult, but, even when their nature is ever so well understood, little can be done for their relief. Moreover, they are not only exceedingly dangerous in themselves, but they are often, if, indeed, not generally, com- plicated with serious lesion of the contents of the chest or abdomen, thus greatly increas- ing the risk. Wounds of the diaphragm are generally inflicted with the knife, dirk, sabre, or sword. Their extent is, of course, very variable, and they may be either single or multiple. Oc- casionally a severe lesion of the diaphragm is produced by the sharp point of a fractured rib, with or without external wound. Gunshot injuries of this septum are sufficiently common in military engagements. Laceration of the diaphragm is occasionally met with, generally as the result of a severe fall, in which the person, as he alights, receives the blow upon the chest or abdomen, the septum being, perhaps, rendered unusually tense at the moment by a forcible inspiration. The accident may also be caused by the passage of the wheel ot a carriage, or by the body being tightly squeezed between two hard and resisting ob- jects, as the buffers of a railway car. In a case, mentioned by Mr. Pollock, the rupture was due to spasmodic contraction in an effort which the man made to save himself from falling. The left side of the diaphragm suffers incomparably more frequently in this accident than the right, and the fleshy portion than the tendinous. The rent is nearly always longitudinal, or in the direction of the muscular fibres. The signs of an injury of the diaphragm that is not immediately fatal are generally very equivocal. The most reliable, in a diagnostic point of view, are excessive shock, with great pallor of the countenance, difficulty of respiration, which is performed mainly with the aid of the intercostal muscles, pain in the region of the diaphragm, increased by motion, pressure, and expansion of the chest, intense precordial distress, and irregu- larity, smallness, and feebleness of the pulse. In some cases the pain extends into the shoulder, along the course of the phrenic nerve. When the shock is conjoined with co- pious hemorrhage, the sufferer is generally completely collapsed, and often dies without an effort on the part of the system at reaction. The direction of the wound sometimes affords important diagnostic information. When the opening in the diaphragm is capa- cious, the stomach and even a large portion of the bowel may escape into the chest, thrust- ing the lung high up into its cavity, and thus proportionately diminishing the size of the abdomen. The cause of death in wounds and rupture of the diaphragm is usually shock, or shock combined with hemorrhage. An instance has been reported by Mr. Wheelwright, in which a rupture of the diaphragm, caused by a fall from a coach, proved fatal from iiemor- 386 DISEASES OF THE JAWS, TEETH, AND GUMS. CHAP, xi. rhage. The extravasated blood filled the left cavity of the thorax. If the patient survives the immediate effects of the injury, he will be likely to perish from the resulting inflam- mation, which often extends far among the neighboring structures. When recovery occurs, the edges of the abnormal opening become gradually rounded off and callous, and the opening itself may, if not very large, be closed by adhesions of the thoracic and ab- dominal viscera. Wounds of the diaphragm are liable to be followed by phrenic hernia, attended with protrusion of the stomach, or stomach and bowel, into the thoracic cavity. In a case of extensive rupture of the diaphragm, related by Devergie, in which the stomach and colon were found in the chest, the person survived the accident nine months, and then died of another disease. Death, after such an injury, may occur from strangulation of the dis- placed viscera at a more or less remote period after its infliction. Thus, in an instance reported by Dr. Smith, in which the diaphragm had been punctured by a sharp-pointed weapon, the man died three months afterwards from strangulation of the protruded stomach. The treatment of these lesions does not differ, in any respect, from that of injuries of the chest and its contents in general. Reaction is promoted by the usual means ; if there is no copious hemorrhage, the external wound is closed with suture and plaster, otherwise it is kept open, the patient lying on the affected side, in order to favor drainage; any ten- dency to excessive inflammation is counteracted by general and local bleeding, while cough and pain are allayed by anodynes administered in full doses. CHAPTER XI. DISEASES AND INJURIES OF THE JAWS, TEETH, AND GUMS. SECT. I AFFECTIONS OF THE SUPERIOR MAXILLARY BONE. The superior maxillary bone differs from most of the other pieces of the skeleton, in having a large cavity, denominated the antrum of Highmore. This chamber which is very diminutive in young subjects, is situated in the body of the bone, and is lined by a reflection of the mucous membrane of the nose, with the middle meatus of which it com- municates by an opening, which, in the recent state, hardly equals the volume of a crow quill. Owing to this peculiarity of structure, the diseases of the superior maxillary bone are of a much more complicated character than those of the inferior, although they are, per- haps, not any more frequent. The most important affections of the bone and the chamber of Highmore are wounds, inflammation, abscess, cystic and various kinds of solid tumors, especially the sarcomatous and carcinomatous. 1. Wounds Wounds of the sinus may be inflicted through the cheek, the alveolar process, the roof of the mouth, or the orbit; and in their character they may be in- cised, punctured, or gunshot. The bleeding is always slight, and the treatment of the accident involves no particular principles. Sometimes a wound in this situation is complicated by the presence of a foreign body, which maintains irritation, and impedes the cure. A middle-aged man, a patient of Di*. Donne, of Kentucky, had the antrum per- forated with a small dirk-knife. The instrument entered at the orbit, w'ounding the eye, and breaking off' in the cavity of the bone, from which it was extracted more than two years afterwards through the roof of the mouth, its situation being indicated by a black spot a short distance from the first and second molar teeth. In gunshot wounds of the face, the ball sometimes lodges in the maxillary sinus, as in the cases recorded by Ravaton and Dupuytren. Joubert met with an instance in which a nail wras driven, head foremost, into this cavity by a bullet, and Beclard has reported one in which the ferule of an umbrella was firmly implanted in it. All such accidents are necessarily followed by more or less inflammation and discharge, and their true nature can, in general, be determined only by the introduction of a probe along the fistulous openings which accompany them. When the foreign substance is retained, it must be searched for, and, if possible, ex- tracted. The same mode of management is necessary when a tooth or fragment of bone is forced into the cavity. CHAP. XI. AFFECTIONS OF THE SUPERIOR MAXILLARY BONE. 387 2. Inflammation Inflammation of the lining membrane of the maxillary sinus is un- common. It may be developed under the influence of various causes, of which the most frequent are external injury, suppression of the cutaneous perspiration, a syphilitic taint of the system, the inordinate use of mercury, and, above all, the irritation produced by a loose, carious, or necrosed tooth. Occasionally the disease is propagated from the mucous membrane of the nose, by mere continuity of structure. The principal symptoms are pain, of a fixed and severe character, a sense of weight and heat, pulsation, aching of the molar teeth, and, in violent cases, fever. The cheek is often tender on percussion, and the integument sometimes pits on pressure. An increased discharge, of a thin, watery, and fetid nature, from the corresponding nostril, is occasionally present. The pain generally extends to the surrounding structures, as the teeth, nose, orbit, and forehead. The above symptoms, which are always less marked in the chronic than in the acute form of the malady, are not diagnostic, and the practitioner should, therefore, always institute a most thorough examination before he finally decides on their value. It is of great importance that this disease should be early recognized and properly treated, as its tendency, when neglected or mismanaged, is to run into suppuration and other mischief. Diseased teeth, or stumps of teeth, are, of course, removed, even when it is not very apparent that they are the cause of the inflammation. If the symptoms are severe, blood is taken from the arm, and by leeches from the cheek or the alveolar pro- cess ; the bowels are freely evacuated with senna and Rochelle salt; and the action of the heart is still further depressed, if necessary, by the exhibition of antimony and dia- phoretics, the latter of which are particularly indicated when the inflammation has been induced by cold. Fomentations and the application of steam are often beneficial in assuaging pain and relieving morbid action. 3. Abscess—The formation of abscess in the antrum is denoted by an increase of the local and constitutional suffering, described as attending inflammation. The pain becomes more violent, and assumes a throbbing, pulsatile character, darting about in different direc- tions, and being accompanied, in most cases, by a feeling of weight and tightness at the focus of the morbid action. Aching sensations are perceived in the teeth, nose, and fron- tal sinuses ; and there are often severe rigors alternating with flushes of heat. By and by, an erysipelatous blush appears on the cheek ; the surface pits on pressure, and is exquisitely painful on the slightest touch. On raising the lip, the gum over the large grinders is found to be abnormally red and tumid, evincing the same increase of disease here as in the other situations. When the natural outlet of the sinus is not obstructed, there is often, especially during recumbency, an escape of pus from the corresponding nostril, which, together with the symptoms just narrated, leaves no doubt respecting the true nature of the complaint. The matter in this disease is rarely abundant, except in the chronic form, when it may amount to several ounces. It is generally of a thick, cream-like consistence, of a yellow- ish-green color, and highly fetid, apparently from its long retention. In the more violent grades of the disorder it is often intermixed with flakes of fibrin. In chronic abscess, the lining membrane usually undergoes serious structural changes, becoming thickened, floc- culent, and even ulcerated, at the same time that the walls of the antrum are expanded in every direction. Chronic abscess of the antrum is generally caused by dental irritation, or caries of the jaw-bone. In a very remarkable case, related by Professor Baum, each cavity was dis- tended with purulent matter, from the lodgment of a tooth in its interior. The lining membrane was excessively thickened, but the osseous walls were greatly attenuated, and cracked like parchment under pressure. The patient was a woman, thirty-eight years old, and the disease, which had commenced in early life, had produced horrible deformity of the face. The treatment of abscess of the antrum is conducted on the same principles as in abscess of the soft parts. The rule is to afford a free outlet to the pent-up fluid ; if possible, before the occurrence of serious structural change. Such a step is not neglected even when there is no material obstruction in the natural orifice of the sinus, the insufficiency of this, from its elevated, and, consequently, unfavorable position, being well known. As the abscess is frequently directly dependent upon the irritation of a decayed tooth, or as some of the teeth are likely to become involved in the disorder, the safest and most expeditious way of affording relief is to extract the affected tooth, the fang of which often projects into the sac of the abscess, and only requires removal in order to let out its contents. If the open- ing thus made be inadequate, it may easily be enlarged by means of a trocar, fig. 277, a triangular perforator, the little drill, fig. 278, constructed upon the principle of a trephine, DISEASES OF THE JAWS, TEETH, AND GUMS. CHAP. XI. the corkscrew-like instrument, fig. 279, or the four-edged perforator, fig. 280. Patency is carefully maintained, by means of a gold or platinum tube attached to a rubber or me- tallic plate, until the mucous membrane has regained its normal functions; an occurrence which is always greatly expedited by the use of mildly astringent or detergent injections, Fig. 277, Fig. 278 Fig. 279 Fig. 280. Perforation of the Antrum. Pope’s Antrum Drill. Corkscrew-like Per- forator. Coleman's Four- sided Perforator. as chlorinated sodium, carbolic acid, or nitrate of silver, and suitable constitutional mea- sures. The tooth usually selected is the middle grinder, especially if it be diseased. When the abscess points at the alveolar process, the puncture may be made there, but with a result much less promising of ultimate success. The site of a tooth that has been long extracted should never be selected for the operation, as the bone at that place is always abnormally solidified. Alveolar Abscess may be caused by external violence, by the effects of cold, or by dis- ease of a tooth, and is characterized, at first, by the ordinary phenomena of inflammation, which, as the tendency to suppuration advances, gradually increases in violence, until the suffering becomes almost insupportable. The pain is throbbing or pulsatile, the swelling great, the tenderness exquisite. The matter, usually small in quantity, is excessively fetid, and of a thick, yellowish appearance. Its tendency to point varies. When it is far back, as in the situation of the wisdom tooth, it generally burrows between the bone and muscles, and escapes at the angle of the jaw, preceded and accompanied by great swelling, pain, and constitutional disturbance. In front, in the incisor and canine regions, it insinuates itself between the bone and periosteum of the hard palate, opening, perhaps, at length upon the surface of the soft palate. An abscess at the side of the jaw- bone, along the course of the grinders, may send its contents into the mouth, or evacuate itself through the cheek, face, chin, or upper part of the neck. An abscess connected with the upper incisors sometimes finds an outlet through the nose. The treatment of an alveolar abscess is by timely and free incision. In the early stage of the disease, leeches, free purgation, and other antiphlogistic means are advisable, with diaphoretic anodynes to allay pain and promote sleep. Lead and opium lotions are pref- erable, as local applications, to poultices and warm fomentations, which have a tendency to invite the matter to the surface, and thus produce further mischief. 4. Effusions of Blood.—It is not improbable that considerable effusions of blood occa- sionally occur in the maxillary sinus, either as a consequence of external injury or of nasal hemorrhage, the blood passing into the sinus across the small aperture of communi- cation. However this may be, it would not be likely, of itself, to be productive of any CHAP. XI. AFFECTIONS OF THE SUPERIOR MAXILLARY BONE. 389 serious mischief; the most it could do would be to provoke suppuration. In such an event, the same treatment would be required as in ordinary abscess of the sinus. 5. Fistule of the Maxillary Sinus—The antrum of Highmore is occasionally the seat of a fistule, caused by external injury, by operations upon the jaw, or by the abnormal projection of the fang of a tooth. The passage, which is usually short and narrow, is generally situated in the alveolar process, although sometimes it is found on the cheek or on the roof of the mouth. Almost always solitary, it is sometimes multiple, and may then open both externally and internally. The diagnosis is commonly sufficiently easy, an escape of pus or of pus and mucus, and the existence of a small aperture either on the cheek or in the mouth, readily admitting a fine probe, being the most reliable phenomena of the presence of the disorder. A fistule in this situation often disappears spontaneously with the removal of the excit- ing cause. It is only when the opening is very large, as when it has been produced by the loss of a considerable portion of bone, that it will be likely to create trouble. In such a case, the contraction of the abnormal passage may be greatly promoted by attention to cleanliness and by the use of stimulants, aided, occasionally, by the gentle application of a heated iron. When the fistule opens upon the cheek, and refuses to yield to the ordi- nary measures, a cure may be hoped for by freely paring its edges, and then carefully uniting them with the twisted suture, the parts around being well raised. 6. Atrophy The upper jaw is sometimes atrophied, so as to give the antrum and, of course, also the cheek, a peculiarly hollow, sunken, or depressed appearance. Such an effect may be produced by external injury or by a diseased tooth, but it may also, as in a remarkable case reported by Mr. White Cooper, arise spontaneously, or, more properly speaking, without any obvious cause. In this case, the change seems to have beenowing to a gradual retrocession of the anterior and superior walls of the maxillary sinus, with a corresponding diminution of its cavity. The affection was unaccompanied by pain, but the patient, a female, aged twenty-eight, labored under constant epiphora, and was seriously disfigured in consequence of the peculiar state of the cheek. The nasal fossa was some- what lessened in size, and the mucous membrane preternaturally dry. When Mr. Cooper first saw the case, it had already been in progress for seven years. 7. Neuralgia There is a form of neuralgia of the jaw-bones, which, so far as my information extends, I was the first to describe in 1870, although, judging from the great suffering which attends it, it had doubtless been observed by other practitioners. Its seat is in the remnants of the alveolar process of edentulous persons, or in the alveolar structure, and in the overlying gum, and is met with chiefly, if not exclusively, in elderly subjects. It is also more common in the upper than in the lower jaw. The part affected is usually very small, often not exceeding a few lines in extent. The soft tissues around do not seem to suffer, at least not in the same degree, as is so frequently the case in the more ordinary forms of neuralgia of the jaws and face. On the contrary, the morbid action is generally limited to the osseous structure. In rare instances there may possibly be some involvement of the gum, which is nearly always exceedingly hard and dense, grating more or less under the knife, and adhering with extraordinary firmness to the atrophied alveolar process beneath. The pain is generally paroxysmal, appearing in fits and starts, very much as in ordi- nary neuralgia, the slightest causes being sufficient to provoke it, as talking, mastication, the contact of hot or cold fluids, deglutition, or mental excitement. Sometimes it is mo- mentary, coming and going with the rapidity of lightning ; occasionally it lasts for hours together, and cases occur, although they are rare, in which it continues, with but little mitigation, for an indefinite period. The pain varies in character. Thus, it may be sharp and darting, dull, heavy, aching, boring, or gnawing. Pressure generally relieves rather than aggravates it. Now and then, when it is uncommonly severe, there may be more or less spasm of the muscles of the face, but this is rare. The pathology of the affection seems to be compression of the minute nerves distributed through the wasted alveolar process, dependent upon the encroachment of osseous matter upon the walls of the canals in which they are naturally inclosed. In the normal state, the nervous current passes along without any hindrance, but in this condition of the canals in question its transmission is interrupted, and more or less pain, known as neural- gic, is the consequence. That this explanation is true does not, I think, admit of any reasonable doubt. The osseous structure, as previously stated, is always uncommonly hard, from the deposit of new substance, which imparts to it almost an ivory-like consistence. 390 DISEASES OF THE JAWS, TEETH, AND GUMS. CHAP. XI. The disease usually comes on gradually, and proceeds from bad to worse, until, in many cases, the suffering is rendered nearly intolerable. The general health, at first unaffected, is eventually materially impaired; the appetite is deranged ; the countenance wears an anxious expression ; the sleep is disturbed and unrefreshing; the bowels are habitually constipated ; digestion is imperfectly performed ; the extremities are almost constantly cold, and there is terrible depression of spirits. Loss of sleep, fatigue, exposure to cold, irregularity of diet, mental distress, and, in short, whatever has a tendency to lower the vital powers is sure to aggravate the pain and to prolong the paroxysms. Sometimes the disease is, apparently, of a malarial origin, the attacks coming on periodically, as in intermittent fever. In all the cases under my charge, a prompt and radical cure was effected by the free excision of the offending portions of bone with a stout knife, or with the forceps deli- neated in fig. 281. Quinine, chalybeate tonics, arsenic, and kindred articles are fre- quently of service in perfecting the cure. Fig. 281. Forceps for Cutting Away tlie Alveolar Process in Neuralgia of the Jaw. 8. Tumors—The upper jaw is extremely liable to various kinds of morbid growths, which generally originate in the antrum or the alveolar border of the bone, and in rare instances from the facial and zygomatic surfaces of its body or the palatine process. The relative frequency of their occurrence, as deduced from an examination of 542 cases col- lected by Weber, Gurlt, and Billroth, is in the following order: Carcinoma, 200; sar- coma, 211; osteoma, 36; cystoma, 46; fibroma, 20; chondroma, 15; gelatinoid pol- yps, 7 ; melanotic sarcoma and carcinoma, 5 ; and angioma, 2. Carcinoma, however, figures too largely in the list, doubtless from its having been frequently confounded with medullary sarcoma, and I am disposed to believe that the latter embraces rather more than one-third, and carcinoma less than one-third, of all neoplasms of the superior maxilla. a. Cystic Tumors—Cystic tumors of the upper jaw are by no means uncommon, and they may occur either in the antrum, in the cancellous tissue of the alveolar process, or between the plates of the palatine process, as in a rare case mentioned by Dupuytren. In the first of these situations they constitute the so-called dropsy of the sinus, which was formerly supposed to depend upon occlusion of its natural outlet, and the consequent retention of its secretion, a mode of production, however, which is exceedingly problema- tical and has never been verified by post-mortem inspection. They are often developed in connection with impacted, or misplaced teeth, when they are known as dentigerous cysts; but, as was originally pointed out by Giraldes, in 1853, and subsequently confirmed by the investigations of Marchant, Luschka, Virchow, and other observers, the most fre- quent immediate cause of these formations is cystic degeneration and enlargement of the glandular follicles which stud the mucous membrane, and are especially conspicuous on the inner wall of the chamber in the vicinity of its outlet. They may now and then be traced to simple serous cysts arising from the periosteum of the fangs of the teeth, and making their way into the antrum, as in three interesting cases recorded by Dr. Fischer, of Ulm. In one of the patients, in whom the sinus was enlarged at the expense of its facial wall, frequent puncture gave vent to a serous fluid, and each operation was followed by the disappearance of the bulging of the cheek. Examination of the bone, on the death of the man from dysentery, disclosed the antrum completely filled by a shut sac, which contained a yellowish, watery fluid, and was connected with the second molar tooth. Its wall, one-eighth of a line in thickness, was smooth and polished on its internal surface, and was in close contact with, but not attached to, the mucous lining of the chamber. Cysts of the antrum may be solitary or multiple, their volume, in the latter event, as represented in fig. 282, from Giraldes, ranging from that of a pea to that of a pigeon’s CHAP. XI. egg. Their contents are of a sero-albuminous char- acter, of a whitish, pale-yellowish, or brownish color, and of a thin, watery, or glairy consistence, not un- frequently intermingled with flakes of flbrin, epithe- lial debris, blood corpuscles, and crystals of choles- terine. Sometimes the cyst suppurates, and thus gives rise to an abscess, attended with great pain and excessive constitutional disturbance. In cases of long standing, the cyst wall is occasionally very much thickened, and rugose on the surface, or even calcified, as in an instance of the dentigerous form of the affection referred to by Mr. Heath and Mr. Salter. These growths are capable of acquiring a large bulk, expanding the walls of the antrum in every direction, and thus causing the most hideous defor- mity of the corresponding side of the face. The cheek bulges out as an immense protuberance, the nose is thrown out of shape, the eye protrudes from its socket, the nostril is completely occluded, and there is a great depression of the palate, along with excessive embarrassment in mastication, articulation, and even deglutition. Their most important diagnostic signs are, their slow, painless development, their crack- ling feel, or the fact that they are soft at some points and hard at others, the absence of any tendency to ulceration and enlargement of the neighboring lymphatic glands, and the excellence of the general health. When doubt exists, the exploring needle may clear it up. The affection is occasionally witnessed in young subjects, but is most frequent in middle age. The cystic tumor of the alveolar process is much more frequent than that of the antrum, its usual situation, being, according to personal observations, the internal and inferior ex- tremity of the canine fossa, where it may attain the volume of a hen’s egg, or even of a small orange. It is usually single, although there may be several sacs, either closely connected together, or separated by osseous septa. The anterior wall of the tumor is composed of a thin, elastic, crackling, parchment-like shell, and is easily penetrated by a sharp instrument, the puncture giving vent to its contents, which are serous, sanguinolent, or of a glairy, mucilaginous nature. This, in fact, is the best diagnostic sign of the mor- bid growth. The disease is always tardy in its progress, and manifests no disposition to extend among the adjacent structures. In 1860, an old man, a patient of Dr. Piper, was brought to my College Clinic, on account of a cystic tumor situated in the areolar tissue, immediately above the lateral incisor and cuspid teeth. It was about the volume of a lime, and distinctly fluctuated under pressure, its anterior wall crackling like parchment. Its contents were of a serous character. The tumor being opened with a stout knife, its secreting surface was freely touched with chromic acid, a tent being afterwards intro- duced to keep up the irritation. Healthy granulations soon sprung up, and in less than two months the cavity was completely obliterated. The treatment of these cystic growths is easily comprehended. In the more simple forms, as in the case just mentioned, the object is readily attained by opening the sac fully, and exciting obliterative action by means of tents and stimulating injections. When the antrum is affected, the management of the case is based upon the same principles as that of abscess, evacuation of the contents of the chamber being effected at the most dependent portion of the tumor. The palate bulging, the opening is made there; or a decayed tooth is extracted, and the fluid is allowed to drain off along the resulting chan- nel, widened, if necessary, by artificial means. Gradually the osseous cyst contracts, and, reaccumulation being prevented, it is eventually obliterated, the process being often advantageously expedited by the use of mildly astringent injections. If the cure be very tardy, in consequence of the great bulk of the tumor, or the presence of an imbedded tooth, or multiple cysts, it will be well to cut away a portion of its outer wall and remove the offending substance, care being taken not to injure the integument of the face. When the tumor is of a large size and of long standing, thorough extirpation alone will be likely to afford relief. j3. Polyps—It is rare to meet with polyps of the maxillary sinus. A great variety of morbid growths, having scarcely any points of resemblance, have been described under this name, much to the detriment of sound pathology and practice. The term, AFFECTIONS OF THE SUPERIOR MAXILLARY BONE 391 Fig. 282. Cysts of the Antrum. 392 DISEASES OF THE JAWS, TEETH, ANI) GUMS. CHAP. XI. however, should be restricted to those gelatinoid or vesicular growths which, being developed from the mucous membrane, are closely allied to cystic tumors, and are similar to soft polyps of the nose. Luschka met with these formations five times in sixty autopsies, and Forster, Billroth, and Virchow have delineated striking examples of tiie affection. Polyps of the antrum rarely acquire large dimensions, and, therefore, seldom call for surgical interference. They have, however, been observed to attain considerable bulk, when they either protrude into the nasal cavities or expand the walls of the sinus. Under these circumstances, the symptoms and treatment do not differ from those of cystic disease. y. Vascular Tumors—A tumor, having all the properties of an anastomotic aneurism, is occasionally developed in the maxillary sinus. It is difficult to determine whether it takes its rise in the mucous membrane of the sinus, or in its bony walls. However this may be, it appears to consist essentially in an enlargement of the branches of the internal maxillary artery, which interlace with each other in every conceivable manner, and thus form a tumor of an erectile character, similar to mevus of the face. As the affection progresses, the walls of the antrum are absorbed, and the morbid growth is thus placed immediately beneath the skin, feeling like a soft, spongy mass, and exhibiting a bluish, purple, or modena color. Its pulsation, which is synchronous with the contraction of the left ventricle, is very distinct under the finger, and may generally be seen at some distance. When the tumor is very large, it encroaches upon the eye, nose, and mouth, and is pro- ductive of great deformity. The prominent symptoms of the disease are, its steady increase, its tendency to encroach upon the surrounding parts, its soft, spongy consistence, its pulsatile movements, and the livid discoloration of its surface, both external and internal. The attendant pain is usu- ally slight, and the general health is seldom impaired, until after the establishment of nasal hemorrhage, which is sure to set in sooner or later, and which is often profuse and draining in its effects. If the tumor be seen early, or, rather, if it be recognized before it has attained any considerable bulk, the proper procedure would be to expose it by a careful dissection, and effect its destruction with the actual cautery, the Vienna paste, or acid nitrate of mercury. Perhaps a portion of the growth might be constricted with the ligature, as in the operation for the radical cure of hemorrhoids. When it has attained a large size, ligation of the common carotid artery, as proposed and practised by the late Professor Granville S. Pattison, may be tried, although, it must be confessed, with but a faint pros- pect of success. 8. Fibrous Tumors—Pure fibrous tumors of the upper jaw are not very common, but, in connection with the lower maxilla, they constitute the larger proportion of all fibromas of the osseous system. Taking their origin in the soft layer of the periosteum or the lining membrane of the Haversian canals, they usually spring from the facial surface or the alveolar border of the bone, in the latter of which they constitute fibrous epulis. They are also developed in the antrum, either as pyriform or polypoid outgrowths, or, as more frequently happens, as lobulated tumors, which evince a great disposition to expand its walls in every direction, project into the nose, protrude the eye, cheek, and hard palate, and, finally, perforate or disintegrate the bone, which is ultimately lost in the new product. The fibrous tumor of the upper maxilla almost always contains small masses of hyaline cartilage and spicules of bone, the latter element often being so predominant as to entitle it to be called osteoid fibroma. The osseous proliferation of the periosteum, indeed, may invade the fibrous tissue to such an extent as to convert the growth into an osteoma, and many exostoses, doubtless, arise in this way. On the other hand, but very seldom, numerous cartilaginous nodules are interspersed through the mass, giving rise to lobu- lated tumors, which are appropriately termed chondroid fibromas. In addition to these transformations, cysts or cavities, containing various kinds of fluids, are sometimes inter- spersed through its substance, and serve to give the growth a mixed character. In rare cases, the tumor is composed of pure, dense, compact, interlacing fibrous tissue, which creaks under the knife, and has a very feeble circulation. Its volume, although generally small, sometimes equals that of the fist; it manifests no malignant tendency, and rarely returns after extirpation. Its attachment is usually by a broad, ill-defined base, but now and then it is by a narrow pedicle, similar to what is observed in fibrous polyp of the nose. Middle-aged persons are its most frequent subjects. CHAP. XI. AFFECTIONS OF THE SUPERIOR MAXILLARY BONE. 393 Fibrous tumors of the superior maxilla are distinguished from sarcomatous and carcino- matous formations, first, by the tardiness of their growth ; secondly, by their globular, ovoidal, or pyramidal shape; thirdly, by their circumscribed character, or indisposition to ramify through the surrounding parts; fourthly, by their firm, unyielding consistence; fifthly, by their painlessness; and, lastly, by the absence of contamination of the neighboring lymphatic glands. There is, moreover, little tendency in such tumors to ulceration ; the mucous membrane of the mouth retains its florid appearance; and there is much less sanguinolent discharge from the nose than in carcinoma. The general health is not deteriorated, and the countenance is free from that sallow and dejected expression which forms so striking and characteristic a feature in malignant disease. A fibroma of the antrum, or on the exterior of the bone, may occasionally be ap- proached by the mouth, the outer wall of the cavity being opened just above the roots of the teeth. When the wall is very thin and soft, the operation may be performed with the knife ; when the reverse is the case, it may be necessary, in addition, to use a gouge and mallet. The cheek is, of course, detached from the bone for some distance as a preliminary measure. I have, on several occasions, enucleated fibrous tumors from the antrum in this way with very satisfactory results, and the plan should always, if possible, be adopted in preference to any other, as it is unattended with disfigurement of the face. It will also be well to remove the portion of the bone to which the growth is attached. When the morbid growth is uncommonly large, it is generally necessary to attack it through the cheek, as in the extirpation of malignant tumors. Little hemorrhage usually accompanies such operations, provided the tumor is not opened in the dissection. A fibroma, or osteoid fibroma, occasionally springs from the alveolar border of the upper jaw, in connection with the periosteum, or with the lining membrane of the socket of one of the teeth, when it is termed fibrous epulis. Arising generally, according to my observation, in one of the molar alveoli, epulis originally consists of a small, fleshy- looking tubercle, situated at the side of one of the teeth, which, in time, becomes dis- placed, loose, and ultimately drops out. During its progress, which is slow and painless, it advances into and carries the gum before it, and forms a mass of a dense, firm consist- ence, of a florid color, of an irregularly rounded shape, somewhat like a mushroom, its point of attachment being usually much smaller than its free extremity. The surface is smooth and regular, although it may be lobulated, and it is liable to ulceration, when the growth becomes painful, not unfrequently bleeds more or less copiously, and is the seat of a constant, offensive discharge. Fibrous epulis is composed of a dense, white, shining, interlacing tissue, the fibres of which are interspersed with delicate osseous spicules, which pass into its interior from its attachment to the alveolus. The glands of the gum are sometimes much enlarged. Its volume rarely exceeds that of a walnut, and, although it almost always grows downwards towards the buccal side of the jaw, it may perforate the alveoli and protrude into the antrum. The tardiness of its development, its firm, elastic consistence, its comparatively small bulk, and the freedom from contamination of the neighboring lymphatic glands, are the signs by which it is distinguished from sarcomatous and carci- nomatous epulis. Fibrous epulis being a benign affection and showing little disposition to local return after extirpation, its management may be restricted to thorough removal of the socket from which it springs ; but, if several cavities be involved, the excision of the alveolar border of the bone, and cauterization of the exposed surface with the hot iron may be necessary. If the substance of the jaw be deeply involved, the only way to deal with the malady is to remove a portion embracing its entire thickness, and reaching for some distance beyond the limits of the morbid mass. Violent hemorrhage sometimes accom- panies such operations, as in a fatal case reported by Billroth, in which the blood, coagu- lated by Monsel’s solution, gained access into the windpipe, and necessitated the operation of tracheotomy. e. Cartilaginous Tumors Chondroma of the upper jaw must be ranked among the rarest of these neoplasms. I have myself never met with an example, but cases have been recorded by Morgan, Beck, Partridge, O’Shaughnessy, Heath, Buck, and others, in which it was developed between the periosteum and the bone, its most common sites being the facial surface and the nasal process. With the exception of a case, referred to by Rindfleisch, in which the growth was the seat of numerous clefts, thus imparting to it a papillary or cauliflower-like appearance, I am not aware of an instance of pure cartila- 394 DISEASES OF THE JAWS, TEETH, AND GUMS. CHAP. XI. ginous tumor of the antrum. Dolbeau and Trelat have described an osteoid chondroma of the sinus; Giraldes met with a myxomatous chondroma; and Mr. Stanley lias delineated a remarkable example of sarcomatous chondroma, in a lad sixteen years of age, which involved both cavities, as well as the left orbit, extended into the skull and left nasal cavity, and protruded into the pharynx. The maxillary and pharyngeal portions of the tumor were of the nature of fibrous sarcoma. Chondroma of the superior maxilla is capable of attaining enormous dimensions, as in a case of successful operation by Mr. O’Shaughnessy, in which the tumor was nearly as large as the patient’s head, and weighed four pounds. Such a growth is seldom dis- tinguished during life from some of the other formations incident to the jaw. The diag- nosis is based mainly upon the firm consistence of the tumor, its tardy and painless development, its appearance at an early age, and its indisposition to ulceration. The general health is not materially impaired as long as the patient retains the power of de- glutition. These features, however, are not characteristic of the cartilaginous tumor, as they are also common to fibrous and osseous growths. f. Osseous Tumors.—The superior maxilla is liable to exostosis. The morbid growth, varying infinitely in regard to its size and form, is most common in old and middle-aged subjects; it may appear upon any part of the bone, and, gradually augmenting in volume, may at length involve its entire extent. It is strictly a local affection, the result generally of external violence, or of a syphilitic taint of the system ; and rarely, if ever, degenerates into malignant disease. An exostosis is easily recognized. Its chief peculiarities are, its excessive hardness, its slow growth, its freedom from pain, the absence of disease in the surrounding structures, and the unimpaired state of the general health. There is no discharge of blood, mucus, or pus, no tendency to ulceration, no alteration, at least not for a long time, in the skin of the face, or in the lining membrane of the mouth ; the principal inconvenience is from the size of the morbid growth, which is occasionally enormous, and from its consequent interference with the functions of the adjacent parts. When doubt exists, a small explor- ing needle, introduced at various points of the tumor, will at once decide the question. Osseous tumors of the antrum have been recorded by Manz, Hilton, Stanley, Duka, Schott, Seutin, Michon, Despres, Sir Astley Cooper, and Sir James Paget. They are most common before the thirtieth year; usually develop from the inner wall of the sinus ; and during their progress encroach upon the orbital wall, and dislocate the eye upwards and outwards. Their removal may readily be effected through the facial surface of the superior maxillary bone. Instead of an outgrowth, the osseous tumor may occur in the form of general or partial hypertrophy of the bone. An interesting case of hyperostosis of the entire superior maxilla, along with its ascending process, in a girl, fifteen years of age, has been reported by Mr. Stanley. The affection included every part of the bone, and caused complete obliteration of the antrum. Other examples of diffused hypertrophy, or “ osseous leon- tiasis,” in which, in addition to the superior maxilla, other bones of the face were in- volved, thus giving rise to great deformity, have been recorded by Howship, Sir Astley Cooper, Gruber, and Bickersteth. Partial hyperostosis of the alveolar border of the bone, depending upon the irritation of an inverted tooth, is occasionally met with. An instance of the kind, the only one I have ever seen, fell under my observation in 1843, in a young lady, aged twenty-one. The enlargement, which had been first noticed two years and a half previously, and which was about the volume of a large hickory-nut, occupied the alveolar process of the left jaw, and was of a hard, firm consistence, free from pain and soreness, unaccompanied by disease of the gum, or derangement of the general health, and formed at the expense mainly of the outer plate of the bone. Upon sawing into the tumor, it was found to be occupied by a cuspid tooth, a little smaller than natural, but well grown, with the crown reversed, or directed upwards towards the antrum of Highmore. The parts soon healed, with hardly any defect, save what resulted from the extraction of the canine tooth, which was deemed necessary as a preliminary step. Little, if, indeed, anything, is to be accomplished in this disease by medical treatment. When the tumor is young and small, the external and internal use of iodine may be ser- viceable in diminishing, and even in eradicating it. A mild mercurial course, conjoined with the internal exhibition of iodide of potassium, is indicated when it is dependent upon a syphilitic taint of the system. A growth of this kind has been known to drop off spon- taneously ; but such an event is not to be looked for, nor, as before stated, is much to be expected from therapeutic agents. In general, nothing short of extirpation will answer, and this, fortunately, is usually readily accomplished by the ordinary means. 395 CHAP. XI. rj. Sarcomatous Tumors By far the most frequent of all tumors of the upper jaw, whether developed from the soft layer of the periosteum or from the medulla, are the sarcomatous, which may spring from the body of the bone or from its alveolar border, con- stituting in the latter situation sarcomatous epulis. Periosteal sarcoma of the body of the superior maxilla is principally observed in young adults, in connection with its external surface and the orbital and facial boundaries of the antrum. Usually composed of fasciculated, spindle-celled tissue, intercalated with a few giant cells and radiating spicules of bone, the latter of which are sometimes so numerous as to entitle it to the name of osteoid sarcoma, it gives rise to a dense, firm, smooth, ovoidal or globular swelling, which is now and then traceable to injury, is of slow and painless growth, and presents on section the gross appearances of osteoid fibroma, from which it is almost indistinguishable without the aid of the microscope, and between which and exostosis it appears to hold an intermediate position. The softer forms of the affec- tion, consisting of small round or spindle cells, however, increase rapidly and attain large dimensions, thereby imitating carcinoma in their general features, as is represented in fig. 283, copied from a photograph of a lad fourteen years of age, an out-door patient at the Jefferson Medical College Hospital. The tumor grew very rapidly unattended with pain or hemorrhage, and attained its present size in less than three months. The lymphatic glands beneath the jaw were greatly enlarged. When seated be- tween the periosteum and the facial sur- face of the bone, the tumor, covered by the distended, but otherwise unchanged, periosteum, mucous membrane, and in- tegument, generally proceeds outwardly, elevating the ala of the nose, the lip, and cheek, although it may produce absorp- tion of the bone and penetrate the antrum. When, on the other hand, it originates in the maxillary sinus, its disposition is to fill that cavity and protrude into the nose, mouth, pharynx, and even the skull. In this situation periosteal sarcoma occa- sionally presents a papillary or cauliflower- like appearance, rendering it liable to be mistaken for epithelioma, as in a case de- scribed and delineated by Mr. Christopher Heath. The soft, friable, morbid growth occupied the left antrum of a man, seventy-six years of age, projected into the nose, pushed out all of the teeth of the corresponding jaw, and was attended with a constant purulent discharge, but no pain. Central, myelogenic, or myeloid sarcoma, which includes a variety of epulis, designated by ISelaton as the encysted intraosseous, is, according to my observations, less common in the upper than in the lower jaw. Rarely witnessed after the fortieth year, it is most fre- quent between the ages of fifteen and twenty-five, and often appears soon after the second dentition. Arising, as a rule, in the spongy substance of the internal and inferior extre- mity of the canine fossa and the medulla between the anterior molar alveoli, its structure essentially consists of very numerous giant cells, contained in an apparent stroma of spin- dle-celled tissue, although a small round-celled or glious basis is not infrequent. At its commencement, the plates of the bone, by the addition of new osseous matter from the periosteum, form a more or less perfect capsule for it, but this, in part, finally disappears through disintegration and absorption, thereby permitting the mass to make its way into the antrum, the nose, or the mouth, through the alveolar or palatine process. In rare instances, the soft tissues of the cheek and lip are invaded and perforated, when the tumor assumes a malignant aspect, and bears a close resemblance to medullary carcinoma. The myeloid tumor of the jaw is distinguished from fibroma and periosteal sarcoma by the early age at which it appears, its more rapid growth, its elastic, parchment-like feei, its lobulated outline, and a sense of fluctuation after it has in great measure undergone the cystic degeneration. In some cases it is highly vascular, the vessels being so much enlarged as to impart to it a distinct pulsation, rendering it liable to be mistaken for AFFECTIONS OF THE SUPERIOR MAXILLARY BONE. Fig. 283. Encephaloid Sarcoma of the Upper Jaw. 396 DISEASES OF THE JAWS, TEETH, AND GUMS. CHAP. XI. anastomotic aneurism. On section, the surfaces are found to be succulent, shining, soft, and easily broken down, and to present a modena, brownish-red, or greenish tint. The tissue, rarely interspersed with osseous spicules, usually presents under the microscope a predominance of giant cells, although the soft, gelatinous forms of the affection consist mainly of spindle cells. The treatment of the sarcomatous tumor of the body of the upper jaw does not differ fx-om that of fibrous growths. When small, the portion of the bone from which it arises should be freely excised, whereas, in the case of the myeloid tumor, the mere cutting away of the anterior wall of its capsule, and freely scraping the cavity in which it lies, generally suffice to prevent repullulation. When, on the other hand, the mass has ac- quired a large bulk, and involves the greater portion of the bone, the entire jaw must be sacrificed. Sarcomatous epulis may arise from the alveolo-dental periosteum of a socket or from the medulla cells of the enlarged Haversian canals. In the former case, it is usually com- posed of closely aggregated spindle cells, intermixed with bundles of fibrous tissue, spi- cules of bone, and a few giant cells, whence it may not improperly be termed osteoid fibro-sarcoma; while, when it originates in the medulla, it may more appropriately be called myeloid or myeloplaxic sarcoma of the alveolar border of the bone, since giant cells predominate in its structure. The general features of sarcomatous epulis do not differ from those of the purely fibrous variety, to which, indeed, osteoid fibro-sarcoma is closely allied, although there is a form of the latter which, being composed almost entirely of small round or spindle cells, is quite soft and vascular, and, therefore, pursues a more rapid course, and is more disposed to local return. Myeloid epulis is not so firm and re- sistant as the periosteal growth, and it usually attains a larger size. The distinction, however, between fibrous and sarcomatous epulides is almost impossible before their ex- tirpation. In all the cases of sarcoma of the alveolar border of the jaw-bones that have fallen under my observation, and their number has been considerable, the repullulating disposi- tion has been most remarkable, although I have never known it to give rise to lymphatic involvement or similar deposits in the internal organs. Hence, the only remedy for the affection is early and thorough excision, not of the tumor, or of the parts from which it grows, but of the portion of the bone in which it has its origin. Although periosteal epulis is sometimes developed in a socket, and may be removed by extracting the tooth from the membrane of the root of which it springs, yet this simple operation, combined with the superficial shaving off of the growth, as advised by some surgeons, is worse than useless. The only way is to deal it at once an effectual blow by sawing out a piece of the jaw, embracing its entire thickness, and reaching some distance beyond the limits of the mor- bid mass. I have never known a case in which any other procedure did the least good. In treating epulis, we should not lose sight of the fact that it is an affection, not so much of the gums as of the jaw-bone; and, therefore, anything short of the removal of this, at the site of the disease, is an absurdity. 6. Carcinomatous Tumors By far the most common, as well as the most formidable, of the carcinomatous affections of the upper jaw are encephaloid and epithelioma. Scir- rhus is extremely infrequent. I have never seen an instance of it, but, if it should ever occur here, it would be most likely to show itself in advanced life, as a hard, firm, solid tumor, slow in its progress, and characterized by sharp, lancinating pain. It would not attain as great a bulk as the softer forms of carcinoma, nor would it be so liable to fungate and bleed. Of primary colloid and melanosis of the upper jaw, we are almost entirely ignorant. There are no signs by which encephaloid can be discriminated from epithelioma. Both are soft and medullary; grow rapidly, and soon acquire a large bulk; usually occur after the twentieth year; and have the same sources of origin. Possessing so many features, clinical and anatomical, in common, any distinction that may be attempted to be drawn is exceedingly difficult, if not impracticable. Hence, it will be understood that both forms of carcinoma are included in the following remarks. Carcinoma occurs here, as elsewhere, in both sexes, and in all classes of individuals. It is most common after the fortieth year. It is not known what influence, if any, occu- pation, temperament, climate, and other circumstances exert upon the development of this disease. In all the instances of it, except one, that have fallen under my observation, it arose without any obvious cause. The disease usually begins in the cavity of the antrum, in connection with the glands of the mucous membrane, or it may originate in the mucous glands of the gum and palate. In the first case, it generally progresses until it fills up the whole sinus, after which it AFFECTIONS OF THE SUPERIOR MAXILLARY BONE. 397 CHAP. XI. encroaches upon the bony parietes of the cavity, pushing them out in every direction, and thereby pressing them against the surrounding structures. As the external wall is ex- tremely thin, in fact a mere shell, in the natural state, the morbid growth commonly ad- vances more rapidly in this direction than in any other, forming thus, frequently at an early stage, quite a large tumor on the cheek. By and by, as it proceeds in its develop- ment, it extends towards the nostril, partially, and sometimes completely, occluding the corresponding cavity; upwards towards the door of the orbit, compressing and ultimately protruding the ball of the eye, or even penetrating the skull through the ethmoid bone ; downwards towards the palate, displacing the tongue, and diminishing the mouth; and backwards towards the fauces, impeding mastication, deglutition, speech, and respiration. At this stage of the disease the countenance is most hideously disfigured, and the patient is an object well calculated to excite commiseration. The appearances here described are well seen in figs. 284 and 285. Fig. 284. Fig.285. Carcinoma of the Antrum, Encroaching upon the Face. Carcinoma of the Antrum, Encroaching upon the Mouth. The overlying integument and mucous membrane are generally sound in the earlier stages of the complaint; but after a certain period, varying from several months to a year, they assume a livid and congested appearance, and at length yield to ulcerative action. The consequence is a fungating and rapidly spreading sore, the seat of a thin, sanious, muco-purulent, or sanguinolent discharge, very abundant, excessively fetid, and highly irritating. Pure blood often proceeds from it; sometimes very small in quantity, at other times so copious as rapidly to undermine the strength, and bring on hectic fever, with exhausting night-sweats. In the later stages of the disease, when ulceration has set in, the lymphatic glands of the temple, behind the ear, and under the jaw, occasionally become enlarged and contami- nated, and finally give way from overdistension. This immunity of the glands is peculiar to carcinomatous diseases of the upper jaw, doubtless for the reason that the antrum is poorly supplied with lymphatic vessels. The countenance assumes a peculiar cadaverous expression ; the patient rapidly loses flesh and strength; colliquative diarrhoea supervenes; the pain is excessive; and death finally occurs from exhaustion. The progress of the malady is variable; sometimes very rapid, at other times quite tardy. I have seen death produced by it in less than six months from its commencement; and, on the other hand, I have met with cases in which the fatal event did not take place under four years. I he affection, according to my experience, is usually more rapid here, as elsewhere, in the middle-aged than in old persons. The tumor, after removal, exhibits, under the microscope, squamous and cylindriform epithelium, contained in a soft, alveolar basis-structure. That portion which occupies the antrum is commonly very soft and pulpy, resembling, at least faintly, both in color 398 DISEASES OF THE JAWS, TEETH, AND GUMS. CHAP. XI. and consistence, a section of the brain. The osseous structure is broken down and disorganized, quite vascular, and so porous as to be easily cut. In the majority of cases, the morbid growth is remarkably vascular, as it is pervaded in every direction by large vessels, the walls of which are exceedingly brittle, and, therefore, liable to yield under the slightest impulse. It is owing to this circumstance that these tumors frequently attain such an enormous bulk, and that, when ulceration sets in, they are so liable to fungate and bleed. The diagnosis of carcinoma of the superior jaw, however commencing, is usually not difficult. The rapid growth of the tumor, its steady encroachment upon the adjacent parts, its soft and elastic feel, the livid aspect of' its buccal portion, and its sharp, darting pains, readily distinguisli it from all other formations. In the later stages of the affec- tion, the fungous character of the ulcer, and the sanious, sanguinolent, or bloody dis- charges, together with the sallow and cadaverous state of the countenance, and the en- largement of the neighboring lymphatic glands, leave no doubt about its nature. The exploring needle will at once inform us as to the consistence of the morbid product, and the nature of its contents. If the mass have undergone the cystic degeneration, an es- cape of serum, or muco-sanguineous fluid, will afford the necessary intelligence, and ena- ble us to shape our course accordingly. Carcinoma of the jaw seldom coexists with malignant disease in other parts of the body. The affection, in fact, in the great majority of instances, is more local in its cha- racter than when it invades other tissues or organs. It is, doubtless, owing to this cir- cumstance that excision of the disease, especially in its earlier stages, when it is, as it were, incapsulated in the bone, is occasionally successful, although in general the progno- sis is most unfavorable. Carcinoma of the alveolar border of the superior maxilla, in the form of epithelioma, or, occasionally, of melanosis, usually begins in the glands of the gum, from which it gradually extends to the bone, and constitutes carcinomatous epulis. Arising generally in the vicinity of the molar teeth, it consists of a florid or purplish mass, with a firm, elastic base, and a coarsely granular, papillary, cleft, or cauliflower-like surface, which soon ulcerates, manifests a great tendency to bleed, and is the seat of severe pain, with a fetid, sanious discharge. The affection is peculiar to advanced life. The cervical lym- phatic glands almost invariably enlarge, and the constitution evinces signs of contamina- tion, early in the disease, the duration of life from the time of its first appearance often not exceeding eight months. These features, along with the possibility of expressing a juice and a soft, cheesy substance, are sufficient to distinguish carcinomatous from fibrous and sarcomatous epulides. The prognosis of this affection, if removed in its early stages, is favorable. When, however, it has attained considerable volume, excision of the entire bone is indicated. Under these circumstances, partial extirpation will be sure to be fol- lowed by repullulation, not only at the cicatrice but also in the neighboring glands. EXCISION OF THE UPPER JAW. Excision of the upper jaw is required chiefly in malignant disease, and under such circumstances it may be necessary to remove, at the same time, portions of the malar, turbinated, ethmoid, and sphenoid bones, which are often involved in the morbid action. A part of the upper jaw was removed by Acoluthus, as early as 1693 ; but the honor of first extirpating the whole of it is due to the late Dr. Jameson, of Baltimore, who achieved the enterprise successfully in 1820. The patient, during the operation, should always be placed recumbent, especially if the tumor is of considerable bulk, and a good deal of time is required to effect its removal. The head and shoulders should be well elevated, and the face inclined towards the oppo- site side. Very few persons, whatever may be their courage or fortitude, can bear the shock and fatigue of an undertaking of such magnitude in the sitting posture. This pre- caution is the more necessary if an anaesthetic be given, as I always do in such cases. The mouth during the operation is cleared of blood with the finger, or a sponge-mop. I have never found it necessary, in any of my operations on the upper jaw, to secure the carotid artery, as a means of preventing hemorrhage. Indeed, it is surprising that such a procedure should ever have been recommended, much less practised, by any one. My experience is that there are no structures in the body, of the same extent, in their natural and diseased conditions, the removal of which is attended with so little hemor- rhage. No skilful surgeon now even employs compression of the carotid artery in these operations, and, as to tying that vessel as a means of security against loss of blood, noth- EXCISION OF THE UPPER JAW. 399 CHAP. XI. ing, it seems to me, could be more unnecessary. The chief danger from hemorrhage is in the subcutaneous arteries, especially the facial and its branches, and these are always readily controlled by the ligature. The deep-seated arteries, involved in tumors of the upper jaw, seldom bleed much, if care be taken to keep beyond the limits of the diseased tissues. If this precaution be neglected, the hemorrhage may be copious, if not exhaust- ing. The oozing which takes place from the osseous surface, after the exsection is com- pleted, generally speedily ceases of its own accord from the contact merely of the air; when it does not, it is usually easily arrested by compresses wet with hot water, or a saturated solution of subsulphate of iron. The actual cautery can only be required when the vessel is inaccessible to the ligature, or when a portion of the disease has unfortunately been left behind. In operations upon the upper jaw, unattended with loss of the alveolar and palatine processes, the escape of blood into the throat may generally be effectually prevented by previous plugging of the posterior nares. The direction, extent, and number of the incisions through the soft parts must neces- sarily vary with the situation and volume of the tumor. In all these respects, much must be left, in every case, to the judgment and experience of the operator. When the mor- bid growth is comparatively limited, and seated upon the anterior, or antero-lateral, as- pect of the jaw, we shall generally be able to dispense with external incisions altogether, as the object may readily be accomplished simply by dissecting off the lip from its attach- ments to the bone, and holding it out of the way with a finger or blunt hook. The sur- face of the tumor having thus been thoroughly denuded, the bone is attacked with the pliers, and severed fairly beyond the line of the disease. By this procedure, which is admirably adapted to the more simple forms of morbid growths, the operation is divested of much of its severity, and not followed by any deformity of the features, save what re- sults from the caving in of the integument. © © When the tumor involves the body of the jaw, and is of considerable bulk, the plan w'hich I usually adopt, is to make one long, curvilinear incision, extending across the most prominent part of the tumor, from the commissure of the lips towards the zygomatic process of the malar bone, terminating within a few lines, half an inch, or an inch, of the external angle of the eye, according to the exigencies of the case. In this manner are formed two flaps, the upper of which is convex, and the lower concave, which are then carefully dissected up by bold and rapid strokes of the knife, and held out of the way by trustworthy assistants, who, at the same time, take care to compress the bleeding vessels. The space which this procedure affords is, in general, quite sufficient for the easy removal of the entire tumor, however large or extensive its connections. In my own cases, it has always an- swered the purpose most thoroughly. Should it, however, be inadequate, it can readily be increased to the requisite extent by carrying the knife hori- zontally along the inferior border of the orbit, as far over as the nose, as exhibited in fig. 286, from a patient affected with encephaloid disease of the antrum, whom I attended with the late Professor Pancoast. In making the first of these incisions, the facial artery is necessarily divided, and, in the second, the superior maxillary nerve, together with many of the branches of the portio dura of the seventh pair. In consequence of the injury thus sustained, the parts supplied by these nerves re- main a long time paralyzed, although ultimately the face regains, in some degree, its accustomed power and expression. When the tumor, or enlargement, occupies the anterior and upper portion of the jaw, the exter- nal incision may extend vertically upwards by the side of the nose, from the free border of the lip to a level with the orbit of the eye. This will ena- ble the operator to detach the wing of the nose, and to remove, if necessary, the ascending process of the jaw-bone, the lachrymal bone, the inferior turbinated bone, and even the vomer as I have been compelled to do in several instances. Fig. 286. Lines Indicating the Course of the Knife in Exci- sion of the Upper Jaw. 400 DISEASES OF THE JAWS, TEETH, AND GUMS. CHAP. XI. When the antrum is mainly implicated in the disease, two incisions, representing the form of an inverted rj, are necessary, the vertical limb corresponding with the ascending process of the maxillary bone, and the horizontal one with the inferior border of the orbit. When the tumor is not very large, access may readily be obtained by making a vertical incision through the upper lip, and dissecting away the ala of the nose, as practised by O’Farrall, Syme, and other surgeons ; a method which I have myself repeatedly followed with great advantage, as it respects the resulting scar. Whatever may be the form and direction of the incisions they should be sufficiently ex- tensive to afford ready access to the diseased mass. Nothing can be more embarrassing, or display greater defect of judgment in the operator, than a want of room in a case of this kind. The necessary incisions having been made, and the flap dissected up, the next step is to remove the tumor. As a preliminary measure, two teeth, one in front and the other behind, must be extracted, to make room for the play of the saw and other instruments. As a general rule, this part of the operation should be performed as soon as the patient is fairly under the influence of the anaesthetic, and, consequently, prior to the division of the soft structures. If done after that, it is liable to occasion delay and annoyance. The separation of the jaw is generally the work of a few minutes. The limits of the disease being usually well defined, care must be taken to keep on the outside of them, for the twofold purpose of avoiding hemorrhage and removing the whole of the morbid struc- tures. For executing this part of the operation there should be at least three pairs of pliers, of different shapes and sizes, figs. 287, 288, 289, as one is rarely sufficient for the Fig. 287. Fig. 288, Fig. 289. purpose. There should also be at hand several chisels, small saws, a lenticular, and a stout scalpel, the handle of which should terminate in a steel point, that it may be used as a scraper or cutter, as may be found most expedient. When it is desired to remove the entire jaw, the saw or pliers should be successively carried through the alveolar process in front, and the horizontal plate behind, close to the middle line, as far back as the corresponding portion of the palate bone, the mucous membrane of the roof of the mouth having previously been divided with the scalpel, to prevent it from being bruised and lacerated. Next, the instrument is to be applied to the malar bone, at or near its junction with the maxillary, and finally, to the nasal process, which is generally divided on a level with the lower margin of the orbit. The orbital plate of the jaw-bone is commonly left intact, at least in part, as it rarely participates in the morbid action. Should it do so, however, it should be cautiously removed with the chisel and knife, lest the eye and its appendages be injured. All that now remains to be Different Forms of Bone-forceps used in Excising the Jaws. CHAP. XI. EXCISION OF THE UPPER JAW. 401 done is to sever the tumor at its junction with the pterygoid process and palate bone; and here, again, the chisel and knife will come into excellent play. Occasionally the bones, after having been pretty well divided, may be forcibly wrenched from their bed by grasp- ing them firmly with the lion forceps of Fergusson, represented in fig. 290. The main Fig. 290. Clawed Forceps. tumor having been removed, the parts are carefully sponged, and any remnants of dis- eased substance that may appear are cleared away with the lenticular, gouge, and other suitable instruments. It is seldom that more than three or four ligatures will be needed. To stop the oozing of blood from the deep portion of the wound, and counteract the sinking in of the cheek, the bony gap should be well stuffed with lint, wet with a saturated solution of subsulphate of iron, or Pagliain’s styptic. The external wound is closed with the twisted suture, or with this suture and the interrupted, and supported by a compress, secured by a roller, passed around the head and chin in the form of the figure 8. When the tumor is attached to the base of the skull, or skull and posterior nares, as it may be when it is of a fibrous or sarcomatous nature, the operation is one of great diffi- culty, and in more than one instance the patient rapidly sunk from the effects of shock and hemorrhage. Removal of this bone has occasionally been effected through the mouth without any external incision, as in a case of sarcoma recently communicated to me by Dr. Mastin, of Mobile. The operation, however, although not necessarily bloody, is always tedious, and does not, in my opinion, admit of that thorough clearance of the morbid structures, so desirable in such a severe procedure. Excision of the entire upper jawr is not dangerous. I have performed it upwards of twenty times without a single loss. Of 17 cases, collected by Hutchinson, from the prac- tice of the London Hospitals, 14 were successful ; and of 10 operations performed by Esmarch the result was equally flattering in 8. The tables of Ileyfelder show that death ensued 26 times in 112 complete excisions of one jaw, and 36 times in 187 partial exci- sions. Of 12 excisions of both bones, 5 died. Excision of both superior maxillary bones was originally performed, in 1824, by David L. Rogers, of New York, and next, in 1844, by Dr. J. F. Heyfelder, on account of carcinoma. The operation has since been repeated by Maisonneuve, Deitz, Jungken, Rogers, Yon Langenbeck, and other surgeons. Dieffenbach, in 1848, removed the greater part of both upper jaw-bones, along with the palate and malar bones. When such an operation becomes necessary, access to the diseased structures may readily be obtained by two curvilinear incisions, extending from the commissures of the lip to within a short distance of the outer angle of the eyes. The after-treatment is strictly antiphlogistic ; and, as the great danger to be appre- hended is erysipelas, every means should be used to avert its occurrence. The pins are removed at the end of the third or fourth day, when the edges of the incision will gene- rally be found to be perfectly united. I have repeatedly seen wounds, eight and nine inches in length, close by the first intention after these operations. The patient soon becomes accustomed to his loss ; and the function of deglutition, at first so difficult and annoying, is gradually performed with its original facility. Even the faculty of mastica- tion is regained much more rapidly than one, unacquainted with the compensating powers of nature, might be led to suppose. The deformity of the face is often comparatively tri- fling ; and the defect in the mouth may usually be remedied, in the more favorable cases, by artificial means. It is surprising how much, even in a short time, the cavern contracts, and how all the surrounding and associated parts accommodate themselves to their new relations. When the tumour is sarcomatous or carcinomatous, it is almost certain to return, how- ever thoroughly it be extirpated. In the non-malignant formations, on the contrary, 402 DISEASES OF THE JAWS, TEETH, AND GUMS. chap, xi. there is no reason to apprehend a relapse, any more than in the same class of affections in other parts of the body. TUMORS OF THE SPHENO-MAXILLARY FOSSA. As a kind of an appendix to the morbid growths of the upper jaw, I may here briefly describe what are known as tumors of the spheno-maxillary fossa. These tumors are of various kinds, as the fibrous, vascular, osseous, sarcomatous, and carcinomatous, all of which are capable of acquiring a considerable bulk, and of penetrating, during their devel- opment, the base of the skull, and thus destroying life. Their diagnosis is, therefore, of the greatest importance, especially as most of them may be easily and safely removed in the earlier stages of their existence. The precise point of origin of these morbid growths is variable ; in general, they spring from the pterygoid process of the sphenoid bone, from the body of this bone, or from the superior rhaxilla. However this may be, they always advance, at first, in the direction of the least resistance, which is above and below the malar bone, where they, consequently, soon slightly elevate the cheek and temple. In time, they cover the whole exterior of the upper jaw, distend the temporal fossa, and penetrate the orbit through the spheno-maxil- lary fissure, pushing the ball of the eye upwards and somewhat forwards. They also gradu- ally force their way through the spheno-palatine foramen into the posterior nares, driving the mucous membrane before them, and thus occasioning more or less obstruction of the nose. The facial portion of the morbid growth usually presents a remarkably constricted appearance, owing to the situation of the malar bone. The resistance of the pterygoid fascia effectually prevents the tumor from descending into the cervical region. Severe pain is generally experienced, especially when the mass is of large size, and, in that event, there is also great difficulty in opening the mouth. The fibrous tumor of the spheno-maxillary fossa is characterized by its slow develop- ment and great firmness; the. vascular, by its softness, by its deceptive sense of fluctua- tion, and by its marked diminution under pressure. The osseous tumor, besides being rare, grows very tardily, and seldom attains a large bulk. Its great feature is its exces- sive hardness. The carcinomatous tumor is distinguished here, as everywhere else, by the rapidity of its formation, by its unequal consistence, and by the great volume which it is capable of attaining. Perforation of the cranium cannot be diagnosticated with certainty, inasmuch as it may occur without inducing any symptoms. Youth and middle age are the periods of life most liable to these different morbid growths. The extirpation of these tumors can only be effectually accomplished by the removal of the greater portion of the malar bone with the saw or pliers. The incisions through the integument should be shaped in such a manner as that, while they afford free access to the morbid mass, they may not lead to any undue deformity. The temporal muscle must, of course, be divided, either partially or completely. The attachment of the growth is usu- ally by a comparatively small pedicle. No serious embarrassment need be anticipated from hemorrhage, especially if the tumor be kept free from the knife. In the case of an old woman, under the charge of Dr. P. Heron Watson, of Edinburgh, in 1868, in which a large fibrous growth occupied the pterygo-buccal region, extirpation was successfully effected, with hardly any loss of blood, by an incision carried from the free margin of the lip to the mental prominence, and thence along the base of the bone to the lobe of the ear, after which the lower jaw was divided opposite the bicuspid tooth, and turned out nearly at a right angle with the zygoma, so as to expose the pterygoid region and the greater portion of the tumor, which was then carefully liberated from its attach- ments to the muscles of the jaw and pharynx, the carotid arteries, internal jugular vein, and the deep cervical nerves. After the large wound was sponged out, and the bleeding checked, the jaw was restored to its natural position, the severed ends being connected together by silver wire. Rapid recovery ensued. SECT. II AFFECTIONS OF THE INFERIOR MAXILLARY BONE. The lower jaw-bone is subject to various affections, of which the principal are abscess, caries, necrosis, phosphorus disease, deformity, ankylosis, and different kinds of tumors. 1. Chronic Abscess The lower jaw, like other bones, is liable to the formation of a circumscribed abscess, small in size, slow in its progress, lined by a distinct membrane, and filled with thick matter, the affected tissue being much increased in bulk and density. The disease, observed chiefly in young subjects, may be caused by external injury, by CHAP. XX . AFFECTIONS OF THE INFERIOR MAXILLARY BONE. 403 cold, by the action of phosphorus, or by the irritation of decayed teeth. The symptoms are generally obscure, the most prominent being a gradual enlargement of a particular portion of the bone, with a sense of excessive hardness, more or less tenderness on pres- sure, and fits of acute pain, recurring at variable intervals, with difficulty of separating the jaw and of masticating, and gradual failure of the health. The treatment consists in exposing the abscess with the trephine and evacuating its contents. If the textural lesions are very great, complete excision of the affected parts may be necessary. Fig. 291 exhibits the ramus of the left lower jaw, which, along with the coronoid process, was the seat of a central abscess. Under the supposition that it was a solid growth —for there were no symptoms pointing to suppuration—I removed it by disarticulation and resection, when it was found to contain nearly three ounces of thick, yellow mat- ter. The inner wall of the bone above the attachment of the internal pterygoid muscle was porous and covered by thickened periosteum, while the outer plate was normal. The interior of the abscess was lined by a membrane. The patient, nineteen years of age, had received a blow at the seat of the disease, twelve months previously. 2. Caries Caries of this bone does not require any par- ticular notice, as it is neither frequent in its occurrence, nor peculiar in its character. Various causes may induce it, as external injury, the irritation of a decayed tooth, mercuri- alization, or a scorbutic, strumous, or syphilitic taint of the system. Whenever it takes place, the nature of the ex- citing cause should, if possible, be traced out, and the case treated accordingly. 3. Necrosis Necrosis is also uncommon, being wit- nessed principally as a result of profuse ptyalism, especially in young and weakly persons, of a strumous temperament or syphilitic taint. Large por- tions of the bone, along with the corresponding teeth, were often destroyed by this cause in this country, where mercury used to be given with such a profuse and daring hand. I have known cases, where, from the effects of salivation, more than one-half of the bone perished and finally sloughed away. The inflammation which precedes and accompanies the necrosis frequently involves the soft parts, producing extensive mortification, and the most horrible deformity of the features. Another bad effect is the permanent closure of the jaw by the new inodular tissues, which are generally not only extremely firm, but exhibit the same tendency to contraction as the inodular tissues of a burn. The poor suf- ferer, in consequence, is often unable to move the bone in the slightest degree, except, per- haps, a little, laterally, and he has the greatest difficulty in feeding himself. I have seen many cases in which the power of mastication was utterly destroyed, and where the food was obliged to be chopped as finely as possible before it could even be introduced into the mouth. Articulation is, of course, impeded, and the patient, if young, must necessarily suffer in his education. Necrosis is always easily distinguished by the denuded state and whitish appearance of the affected bone, by the existence of purulent discharge, and by the excessively fetid state of the breath. The part, when struck with the probe, emits a peculiar ringing sound, very different from that of healthy bone. The treatment consists in attention to clealiness and the removal of the sequester. To fulfil the first intention, free use is made of chlorinated washes, along with such remedies as may have a tendency to improve the general health. The dead bone may be with- drawn with the fingers, or, with the fingers and forceps, the latter being always handled with the greatest care and gentleness. When the piece is very large, the operator may be compelled, as a preliminary step, to cut the gum, or even to divide the dead bone itself with the saw or pliers, but an external incision will seldom be required in any case, how- ever extensive. When the whole of the lower jaw is necrosed, the proper procedure is to divide it at the chin, and to draw out each half separately, the knife being employed wherever it may be necessary on account of the resistance of the soft structures. When these precautions are used, and the operation is postponed until the sequestration is entirely, or at least measurably, completed, I feel satisfied that there will seldom be any need of interfering with the skin. The whole lower jaw, affected with necrosis, was thus removed by I)r. George McClellan in 1823. Fig. 291. Chronic Abscess of the Lower Jaw. 404 DISEASES OF THE JAWS, TEETH, AND GUMS. CHAP. xx. 4. Phosphorus Disease Within the last thirty years, the attention of the profession has been called to a singular species of necrosis of the lower jaw dependent upon the injurious effects of the fumes of phosphorus in the manufacture of lucifer matches. In this country, it was first noticed by Dr. James R. Wood, wbo gave an account of it in the New York Journal of Medicine for May, 1856, accompanied by the history of a case in which he removed the entire lower maxillary bone for the cure of this disease. In order to produce its specific impression, it would seem to be necessary that the vapor should come in immediate contact with the periosteum, or the alveolar process of the bone ; hence it is alleged that those only who have carious teeth are liable to suffer from it. There are, however, some pathologists who assert that the phosphorus is absorbed into the system, and that its effect upon the jaw is altogether secondary, acting very much in the same manner as mercury. However this may be, the disease is essentially inflammatory, and gradually terminates in a loss of vitality, sometimes so extensive as to involve the entire bone. Its approaches are usually slow and insidious, the parts feeling merely somewhat tender and painful, as so often happens in slight toothache. The disease, in fact, is at first quite subacute. By and by, however, it acquires new activity, and then rapidly accomplishes its work, the local and constitutional disturbance being excessive, especially if ab- scesses form, and the mortification extend to the soft parts. Under such circumstances, it is not uncommon for the patient to die. Of 91 cases of this affection, observed by Yon Bibra, Billroth, and Salter, both jaws were affected in 5, the lower in 49, and the upper in 37. What is remarkable is that, while the inferior bone is not unfrequently involved in its entire extent, in the superior the necrosis is generally limited to the aveolar border or to this border and the palatine process. The treatment of the disease, in its earlier stages, is the same as in periostitis from any other cause; by leeches, incisions, astringent and detergent lotions, and general antiphlogistic means. Tonics will be demanded when there is profuse suppuration, or when the morti- fication extends to the soft parts. In the latter case, the best topical remedy will be dilute nitric acid, acid nitrate of mercury, or nitrate of silver, with chlorinated washes. Surgical interference is required when the dead bone has become measurably detached; it may be removed entire, or piecemeal, according to circumstances. In general, the operation may be satisfactorily performed without any external incision, even when the whole bone is involved, as in an instance reported by Dr. Charles S. Boker, of this city; Dr. William Hunt, of the Pennsylvania Hospital, in a similar manner, removed nearly the entire bone; and Dr. Hutchison, of Brooklyn, in 1872, excised the whole of the upper jaw along with the malar, in a girl eighteen years of age, on account of phospho- rus disease. When the periosteum remains intact, the jaw may be almost completely re- produced, as in the interesting cases recorded by Geist, Billroth, Wood, Langenbeck, Thomas Smith, myself, and many others. In general, however, there is an imperfect development of the chin-portion of the bones interfering thus seriously with its contour, apparently due to the action of the genio-hyo- glossal muscles. In order to prevent this occurrence, when the entire jaw is implicated, the operation should be performed at two different times, the anterior portion being allowed to remain for six or eight weeks after the removal of the body and branches. Another im- portant point, as suggested by Billroth, is not to interfere with the osteophytes which form around the necrosed bone, inasmuch as they serve as centres for the formation of new osseous tissue. 5. Deformity A very unseemly deformity of the lower jaw is occasionally produced by an elongated condition of it; it is generally caused by the dragging exerted upon the bone by the vicious cicatrice of a burn, or by the pressure of some tumor, as a hypertro- phied tongue, but instances occur in which it is congenital. The change produced in the position of the front teeth by the habit of sucking the thumb in childhood is well known. The enlargement is generally, if not always, associated with a peculiar oblique or hori- zontal direction of the jaw and teeth. Besides the disfigurement which it occasions, such a defect is necessarily attended with more or less inconvenience in mastication, and in the retention of the saliva. For the slighter forms of this deformity, especially in young subjects, systematic compression sometimes answers a good purpose, made, as first sug- gested by Professor Humphry, of Cambridge, and now generally practised by dentists, with a belt of India-rubber, attached to a suitable head-piece, and passed around the chin in such a manner as to bear more or less firmly upon the elongated and depressed portion of the bone. The adjoining cut, fig. 292, from Coleman, admirably fulfils the indication required of such a contrivance. The entire apparatus is composed of elastic webbing. In fig. 293, from Stellwagen, the straps are provided with buckles, by which the degree of CHAP. XI. AFFECTIONS OF THE INFERIOR MAXILLARY BONE. 405 tension my be regulated at pleasure, while the lower one is so arranged as to draw the chin directly backwards. When this treatment fails, the ingenious operation devised by Dr. Hullihen, of Virginia, consisting in the excision of a V-shaped portion of the bone on each side, may be resorted to. In one case in which this was done, the result was most gratifying, although the distortion had been unusually great. Fig. 292. Fig. 293. Chin Retractor as Constructed of Webbing. Chin Retractor Provided with Buckles. 6. Congenital Fissure—A congenital fissure of the lower jaw is an occasional, but very uncommon, occurrence, generally, if not invariably, situated at the centre of the bone and accompanied by fissure of the lips and chin. I have never met with an instance of the kind, and the only one of which, surgically considered, I have any knowledge was recently reported by Dr. Thorndike, of Boston. In this case the fissure extended through the jaw and lip along the middle line as far as the upper part of the neck. None of the hard and soft parts were wanting ; the tip of the tongue was tied down by the tissues in front of the hyoid bone, the saliva dribbled constantly away, and whenever the woman opened her mouth the ends of the bone projected at the sides of the gap like two horns. The operation performed by Dr. Thorndike consisted in separating the tongue, and bringing it forward into the mouth, in sawing off the liorn-like projections of the jaw and uniting the bone with wire sutures, in dissecting up the soft structures on each side of the fissure, and, after refreshing the edges, tacking them together with silk thread, a new lip being made by sliding the integument of the face forward toward the middle line. Finally, the front teeth of the upper jaw were extracted, as they were large and protruding, followed, in due time, by the insertion of an artificial plate. The wound healed by the first inten- tion, the fissure being entirely obliterated, and the woman’s appearance greatly improved. 7. Ankylosis of the Jaw This distressing affection, which may be produced in a variety of ways, may exist in such a degree as to render the patient entirely unable to open his mouth or to masticate his food. The most common cause, according to my ob- servation, is profuse ptyalism, followed by gangrene of the cheeks, lips, and jaw, and the formation of a firm, dense, unyielding inodular tissue, by which the lower jaw is closely and tightly pressed against the upper. Such an occurrence used to be extremely frequent in our Southwestern States, during the prevalence of the calomel practice, as it was termed, but is now, fortunately, rapidly diminishing. Children, of a delicate, strumous constitution, worn out by the conjoint influence of mercury and scarlatina, measles, or typhoid fever, are its most common victims ; but I have also seen many examples of it in adults and elderly subjects. In the worst cases, there is always extensive perforation of the cheeks, permitting a constant escape of the saliva, and inducing the most disgusting disfigurement. Secondly, the affection may depend upon injury, as a severe sprain or concussion, or arthritic inflammation, leading to a deposit of plastic matter, and the conversion of this 406 DISEASES OF THE JAWS, TEETH, AND GUMS. CHAP. XI. substance into fibrous, cartilaginous, or osseous tissue. I have met with a number of such cases ; several in very young subjects. Thirdly, the immobility is occasionally produced by a kind of osseous bridge, extend- ing from the lower to the upper jaw, or from the lower jaw to the temporal bone. Such an occurrence, however, is uncommon, and is chiefly met with in persons who have suf- fered from chronic articular arthritis. Finally, immobility of the jaw may be caused by the pressure of a neighboring tumor, espe- cially if it occupy the parotid region, so as to make a direct impression upon the temporo- maxillary joint. However induced, the effect is not only inconvenient, seriously interfering with masti- cation and articulation, but is often followed, especially if it occur early in life, by a stunted development of the jaw, exhibiting itself in marked shortening of the chin, and in an oblique direction of the front teeth. When complicated with perforation of the cheek and destruction of the lips, the patient has little or no control over his saliva, and is so horribly deformed as to render him an object at once of the deepest disgust and the warmest sympathy. Treatment—The treatment of ankylosis of the jaw must depend upon the nature and situation of the exciting cause. The milder forms, such, for instance, as arise from arthritis, generally yield to constitutional means, aided by leeches and blisters, and fol- lowed by properly conducted passive motion. To relieve the affected joint of pressure on the inflamed surfaces, Dr. Goodwillie, of New York, strongly recommends the use of an interdental splint, the posterior part of which is slightly raised so as to form a fulcrum on which the back tooth of the opposite side rests. The chin is supported by a rubber trough, which is attached to a skull-cap, furnished with elastic bands, by which the whole apparatus is secured, and the necessary degree of extension maintained. When the difficulty in the joint is occasioned by the formation of fibrous bands, the only thing that can be done is to break up the adhesions, upon the same principle as in ankylosis of any other joint. For this purpose, the patient being thoroughly influenced by anaesthesia, the jaw is forcibly depressed, either by a wedge made of hard %\ood, or by the instrument sketched in fig. 294, depicted by Scultetus, in his well-known work, the Armamenta- rium Chirurgicum, and reintroduced to the notice of the profession by Dr. Mott. Constructed on the lever and screw principle, it may be employed with great advantage in nearly all cases of ankylosis of the jaw, not only for breaking up the adhesions within the articulation, but also for maintaining the separation afterwards. Owing to the remarkable tendency in the parts to reunite, the instrument must be daily used for many months, if not for several years. Menwhile, sorbefaeient lotions should frequently be rubbed ever the joints, and every precaution taken to keep down inflammation. The annexed sketch, fig. 295, exhibits an instrument, which, as a mere lever for sepa- rating the jaw, and breaking up morbid adhesions, is superior to that of Scultetus, which it closely resembles in its mode of action. It diffuses its pressure more widely and equably over the teeth, and is, therefore, less liable to fracture and dislocate them. When the immobility depends upon the presence of inodular tissue, the proper remedy is excision of the offending sub- stance, an operation which is both tedious, painful, and bloody, and, unfortunately, not of ten followed by any but the most transient relief, owing to the tendency in the parts to reproduce the adhesions, however carefully and thoroughly they may have been removed. There is the same remarkable disposition in these cases to the contraction and regenera- tion of the inodular tissue as in burns and scalds. During my residence in Kentucky, I had a large share of such cases, and, although I never failed to make the most thorough work, not unfrequently repeating the operation several times at intervals of a few months, very few of them were permanently relieved. After the excision is effected, the patient must make constant use of the wedge, wearing it for months and years, so as to counter- Fig. 294. Scultetus’s Lever for Separating the Jaws. Fig. 295. Lever for Separating the Jaws. CHAP. XI. AFFECTIONS OF THE INFERIOR MANILLARY BONE. 407 act the tendency to reclosure. Any pieces of dead bone, and loose or ill-placed teeth that may be present, should always be removed prior to the operation upon the soft parts. Immobility of the lower jaw, caused by the formation of an osseous bridge, connect- ing this piece with the upper jaw, may be remedied by the removal of the adventitious substance, by means of the saw and pliers. Sometimes, however, such a procedure is rendered inexpedient, on account of the long duration and excessive firmness of the ankylosis, and the large quantity of the new osseous tissue. When the closure is of long standing, it occasionally becomes necessary to divide the masseter muscles, as they are often found, when this is the case, to be permanently con- tracted. The operation, performed, of course, subcutaneously, requires some care, lest important vessels should be divided. When the muscles are extensively contracted, form- ing a hard, immovable mass on each side, the only rational procedure is to cut away the greater portion of them, and to prevent reclosure of the mouth by the use of the wedge. When the ankylosis depends upon the presence of strong cicatricial tissue, a useful degree of motion may frequently be obtained by the removal of a small section of the lower jaw immediately in front of the contraction. Such an operation, originally sug- gested by Professor Esmarch, has been repeatedly performed with very excellent results, the first successful case having occurred in the hands of Dr. Wilms, of Berlin, in 1858. Mr. Heath, in his Prize Essay on the Diseases and Injuries of the Jaw, has collected a number of examples, including several of his own, in which the operation was performed by Continental and British surgeons. The object in removing a portion of bone is to establish a false joint; and, although, if proper care be not taken, the chasm in the bone may ultimately be filled up with new osseous tissue, the relief afforded is so marked that, if it be regarded merely as a temporary expedient, the procedure is one which no surgeon should hesitate to undertake. Professor Rizzoli, of Bologna, instead of cutting out a sec- tion, simply divides the bone. His first operation was performed in 1857, and he subse- quently had three other successful cases. In none of these cases was there any external incision, the section of the jaw having been effected with powerful forceps within the mouth. It is hardly necessary to say that the operation of Esmarch is decidedly prefer- able to that of the Italian surgeon, as holding out a better chance of permanent relief. Simple division of the bone is more especially adapted to cases of contraction within the mouth without loss of substance of the cheek. For the cure of ankylosis of the temporo-maxillary articulation, one of two things may be done—neither, it must be confessed, very promising, nor easy of execution—either to exsect the condyle of the jaw at the joint, or to cut through the ramus underneath the masseter muscle. In a case of complete synotosis of the lower jaw on the left side, the result of rheumatism, in a girl seven years of age, under my charge in 1874, I exsected the condyle along with a portion of the neck of the bone, and succeeded in establishing excellent motion. The parts were exposed by a curvilinear incision in front of the ear, with hardly any loss of blood. The condyle was prized out of its socket by means of the instruments depicted at figs. 305 and 306. Grube, in 1863, in a case of complete anky- losis, broke the neck of the bone by means of a straight chisel introduced through the mouth, and effected a cure by the formation of a false joint, the treatment having been materially facilitated by the subcutaneous division of the masseter muscle some months subsequent to the original operation. It has been proposed, when both condyles are firmly ankylosed, to remove the entire jaw, but such a procedure would not only be ruth- less but unnecessary, as the patient can generally contrive to articulate and feed himself without much trouble even when the teeth are pretty firmly locked. The gap in the cheek, left by salivation, and so often accompanying closure of the jaw, may be filled up by a flap borrowed from the neighboring integument, and carefully stitched in place. The adjoining sketches, figs. 296, 297, exhibit the manner of perform- ing such an operation. 8. Tumors Morbid growths of the lower jaw are more common than those of the superior, and spring either from the interior of the bone, its surface, or its alveolar bor- der, constituting, in the last situation, epulides, which may be fibrous, sarcomatous, or carcinomatous, and do not differ, in any respect, from those of the upper jaw. Whether peripheral or central, they generally attain much larger dimensions than corresponding tumors of the superior maxilla, the sarcomatous and cartilaginous, especially, giving rise to hideous deformity, projecting on the sides and front of the neck, and into, and almost filling, the mouth and pharynx, widely separating the jaws, stretching the mouth, dis- placing the tongue, and pressing upon the epiglottis, thereby interfering with, if not finally abolishing, articulation, mastication, deglutition, and respiration. 408 DISEASES OF THE JAWS, TEETH, AND GUMS. CHAP. XI. From its superficial relations and its isolated position, tumors of the lower jaw are more readily diagnosticated than those of the other bones of the face. When they arise in the interior of the body or ramus, they are usually inclosed in a bony or periosteal case, or in a capsule composed of both structures, which is developed principally at the expense of the Fig. 296. Fig. 297. Plastic Operation on the Cheek. external surface of the bone, the projection on the inner side being comparatively insig- nificant. This osseous shell, which surrounds the smaller growths, is somewhat loosely referred, even in standard works, to expansion of the plates of the bone, but this is an error, inasmuch as the cancellous and compact structures are absorbed, at the same time that the new osseous material, which furnishes the cyst-wall, is poured out by the soft layer of the periosteum. In the larger tumors, the periosteum ceases to proliferate, so that the inclosing capsule is for the greater part membranous. It is best marked in the cystic, myeloid, and cystic cartilaginous tumors, and is usually so thin as to fluctuate at some points, and crackle like parchment at others. The periosteal or peripheral tumors, on the other hand, are not provided with a bony capsule, but it is not at all uncommon to find them pervaded by osseous spicules and plates, giving rise to the so-called osteoid fibromas, carcinomas, and sarcomas. The carcinomatous tumors of the lower jaw may readily be distinguished from the innocent formations by their progressive, rapid, and painful growth ; by their soft, pulpy, or elastic feel; by the early involvement of the submaxillary glands, with adhesion to, and infiltration of, the surrounding parts; by the enlargement of the subcutaneous veins; by early ulceration and the appearance of fungous masses either at the exterior or at the alveolar border of the bone; and by the usual signs of constitutional contamination. Sarcomatous tumors develop more slowly, but, when once aroused into action, their growth is more rapid, and they soon attain a greater bulk. Their consistence is, equally with carcinoma, usually soft and elastic, but all of the other signs are wanting, although ulceration may set in late. Even that portion of a central sarcoma which makes its way into the mouth through absorption of the alveolar border of the bone, is not the seat of central ulceration. The sore, if present at all, is due either to overstretching of the mucous membrane, or external causes, and is superficial and non-fungating. Tumors of all descriptions, with the exception of gelatinoid polyps, are more commonly seated in and on the lower than the upper jaw. The following statistics of 611 cases, from the tables of Weber, Gurlt, and Billroth, show the relative frequency of their occurrence, although the number of examples of carcinoma, doubtless from errors in diag- nosis, is too large, while that of sarcoma is too small: Carcinoma, 236 ; sarcoma, 252 ; osteoma, 26; cystoma, 26; fibroma, 25; osteoid chondroma, 18; chondroma, 24; angi- oma, 2 ; and melanotic sarcoma and carcinoma, 2. a. Cystic Tumors The cystic tumor of the lower jaw is usually seated in the alveolar border of the bone, and resembles, in every particular, the alveolar cyst of the superior maxilla. It not unfrequently arises within the substance of the bone, where it may attain the volume of an orange ; but, in this situation, it differs from cystic disease of the antrum CHAP. XI. AFFECTIONS OF THE INFERIOR MAXILLARY BONE. 409 in originating in the cancellous structure of the bone, and not in the glandular follicles of a lining mucous membrane. As the anatomy and symptoms of the central cystic tumor of the lower jaw do not differ from those of cystic disease of the alveolar border of the upper jaw, they do not require further consideration here. It is seldom that this tumor requires removal of the affected bone. In general, it will suffice to puncture it occasionally with a small trocar, to evacuate its contents, the escape of which is often followed by the rapid contraction and ultimate obliteration of the sac. Something, too, may be done, in such cases, by graduated compression. When there is a strong tendency to reaccumulation, a large opening may be made, and a tent inserted ; or the necessary inflammation may be provoked by injections of weak solutions of iodine. It is only in old and intractable cases that excision of the bone, at the site of the disease, will be likely to be required. Dr. J. Mason Warren, in 1866, published the particulars of two cases of this affection, going to show that, even when the tumor is of considerable size, a cure may gradually be effected by puncturing the cyst within the mouth, cutting away a portion of its wall, and then pressing the opposite sides forcibly together with the fingers. The disease to which writers at one time so generally applied the vague and unmeaning terms osteosarcoma and spina ventosa, is an exaggerated form of the tumor just described, but usually due to mucoid softening and cystic degeneration of myeloid formations. It is by far the most common of the benign growths of the lower jaw. Appearing at all periods of life, it is most frequent in young adults, and is capable of acquiring an immense magnitude. Instances have fallen under my observation in which its volume was so so great as to cause the most hideous and disgusting deformity. Always slow in its devel- opment, the tumor is free from pain, never affects the constitution, and does not return after extirpation. The most common site of it is the body of the bone, but cases occur in which nearly the whole jaw is involved. The surface of the tumor is generally lobu- lated, and of unequal consistence, some parts being very hard and firm, others soft and fluctuating. The subcutaneous veins are rarely much enlarged, and there is no contamina- tion of the neighboring lymphatic glands. When the tumor is very voluminous, it may encroach seriously upon the mouth and throat, interrupting speech, mastication, and deglu- tition ; but, commonly, it enlarges mostly at the expense of the cheek, which is often frightfully distorted in consequence. The external appearances of this form of tumor are well shown in fig. 298, from a private patient, a young man of nineteen. Fig. 298. Fig. 299. Cystic Tumor of the Lower Jaw. The structure of this growth is essentially composed of cavities, filled with various kinds of fluid, as serous, glairy, sanguineous, and purulent, surrounded and traversed by osseous spicules, and fibrous, fibro-cartilaginous, and cartilaginous septa. They vary much in size and figure, and it often happens that several communicate with each other. The adjoining cut, fig. 299, exhibits an enormous cystic tumor of the lower jaw, which I removed from a man upwards of forty years of age, during the last sixteen of which it had been troubling him. The operation was completely successful. 410 DISEASES OF THE JAWS, TEETH, AND GUMS. CHAP. XI. The diagnosis of such a tumor cannot be mistaken. The tardiness of its development, its unequal consistence, its fluctuating feel, and its outward growth, together with the absence of local and general contamination, are sufficient to distinguish it from all other affections of the jaw. In cases of uncertainty, the exploring needle is employed. Some- times the tumor, especially when composed of large cavities, sounds, on percussion, like a dice-box, a noise which is never heard in sarcoma. Relief is afforded by excision of the diseased mass ; and it is here, more particularly, that modern surgery has achieved some of its proudest triumphs. Tumors of enormous volume, and involving nearly the whole of the jaw, have been removed, again and again, successfully ; and such undertakings may always be attempted the more cheerfully be- cause of our positive conviction that there will be no repullulation. What are called dentigerous cysts of the jaw, depending upon the presence of unde- veloped teeth, are uncommon, and cannot always be distinguished from ordinary cysts and solid tumors, although the presumption will be strongly in their favor if a certain tooth lias never made its ap- pearance at its proper situation, or has never been extracted. Their formation is almost invariably connected with the permanent teeth. The tumor is generally of tardy development, and seldom attains any great bulk. Legouest has reported a very singular case of den- tigerous cyst of the lower jaw, which at one point pulsated syn- chronously with the radial artery, a circumstance due to the exces- sive vascularity of its lining membrane. Formations of this kind are liable to suppurate, and to give rise to great suffering. The annexed sketch, fig. 300, from Heath, affords a good illustration of this species of tumor. j3. Aneurism So far as I know, only two cases of aneurism of the lower jaw have been observed; one by Rufz, and the other by Heyfelder. The tumor, in the latter, was situated at the extreme edge of the bone, below the incisor and canine teeth, had a rounded, fungous appearance, very similar to that of an epulis, bled on the slightest touch, and pulsated isochronously with the heart. The patient, thirty-two years of age, dying of cholera, the dissection revealed a large excavation of the dental canal of the horizontal ramus of the jaw, accompanied by the destruction of the interal- veolar septa, and the partial displacement of the corresponding teeth. The proper remedy for such an affection, if it could be recognized during life, would be to open the tumor freely, and to plug the cavity firmly with lint steeped in a strong solution of subsulphate of iron, with a view of provoking suppurative inflamma- tion. Should this fail, the only resource would be excision of a part of the bone. y. Hematoid Tumors.—There is a peculiar tumor of the lower jaw, which, from the nature of its structure, deserves to be designated by the term hematoid, as most expressive of its true character. I have seen only one case of it, a brief history of which will afford a sufficiently accurate idea of its anatomy, symptoms, and progress. The patient, a man, aged thirty-five, had first noticed the affection about three years before I saw him. It had made its appearance in the form of a hard, solid tubercle, not larger than a hazelnut, on the left side of the jaw, just behind the cuspid tooth. Its progress was very slow for a long time, but at length it began to increase with considerable rapidity, and became the seat of a constant, dull, aching pain. At the time of my examination, the tumor extended from the middle of the large grinder on the left side to the lateral incisor on the right, bulging forwards in such a manner as to cause considerable deformity of the chin. The corresponding teeth inclined backwards and inwards, and were so loose as to be unfit for mastication. The gum was abnormally red, and somewhat hypertrophied, but otherwise perfectly sound. There was no enlargement of the neighboring lymphatic glands, and the general health was good. The tumor was found, after removal, to be about the volume of a medium-sized orange, and to consist of a mere osseous shell, occupied by three red, solid coagula, the largest of which did not exceed the volume of a pigeon’s egg. The cavity was only partially filled by the clotted blood, which adhered to the inner surface of the bony wall, and ex- hibited distinct traces of organization. The man promptly recovered after the operation, and has ever since remained well. 8. Fibrous, Cartilaginous, and Osseous Tumors These growths usually arise between the angle of the bone and the canine socket, and are capable of acquiring large dimensions, Fig. 300. Dentigerous Cyst of the Lower Jaw. CHAP. XI. AFFECTIONS OF THE INFERIOR MAXILLARY BONE. 411 particularly the periosteal forms. The enormous bulk to which a chondroma may at- tain, is well illustrated by a case referred to by Paget, in a woman, thirty-nine years of age, who had a tumor of this kind that inclosed the entire jaw, with the exception of the right ramus, and measured two feet in circumference by six inches in depth. It had been growing for eight years, during the last two of which it had become ulcerated, and finally destroyed life by inducing starvation. Ried extirpated a chondroma which was as large as a child’s head, and Wagner has described one that weighed three pounds and a half. An exostosis, of which the spongy and ivory-like forms appear to be equally frequent, rarely ever exceeds the size of a small fist, and is more slow in its progress, as well as of harder consistence, than fibroma or chondroma. In 1851, Dr. Pinkney, of the Navy, showed me a piece of the inferior maxilla, which he had removed for a hard, firm, solid tumor, constituting partial hyperostosis of the bone, from a man at Lima, and which was so dense that he found it almost impossible to divide it with the saw. Beautiful examples of ivory-like hyperostosis have been delineated by Volkmann, O. Weber, Heath, and others. All of these tumors may readily be distinguished from malignant growths of the lower jaw, by their firm consistence, by their slow and painless progress, by the freedom from involvement of the submaxillary lymphatic glands and the superincumbent integument, by their non-fungating character, and by the non-impairment of the general health so long as the patient can respire and swallow without difficulty. The discrimination, however, between these individual tumors is not so easy. In general terms it may be said that fibrous tumors possess an ovoidal or globular form, with a uniformly smooth sur- face, that they are firm, hut elastic to the touch, that they are most common in young adults, and that their growth is more rapid than that of cartilaginous or bony tumors. Chondroma is distinguished by its deeply-lobed outline, its occurrence in youth, its more rapid progress, its larger size, and its more dense consistence, which, however, is not uniform. The diagnosis of exostosis is based upon its smooth or nodulated surface, its uniform and excessive hardness, its greater frequency in middle aged and elderly sub- jects, its very tardy development, and its comparatively small bulk. s. Myxomatous Tumors.—Pure myxoma of the maxillae is rare, but it has been met with, particularly in the lower jaw, where it is developed from the medulla. It presents no characteristics by which it can be distinguished from other central growths, and is usually associated with chondroma. f. Osteoid Chondromatous Tumors From the fact that osteoid chondroma is seated most frequently on the shafts of the long bones, and that it was not met with in a single instance of the 307 tumors of the superior maxilla, referred to in the preceding section, I am induced to believe that its occurrence on the lower jaw is estimated too highly in the table of Professor Weber, which indicates 18 cases in 403 neoplasms of this bone. Some pathologists, indeed, are disposed to include it among the ossifying periosteal sar- comas, from which, however, they are unable to distinguish it, either by its minute, gross, or clinical features. Osteoid chondroma does not possess a single element by which it may be diagnosticated from periosteal sarcoma. It is most frequent in young persons ; is of a firm consistence ; of an ovoidal or pyriform shape, with a smooth or only slightly uneven surface; grows rapidly, and attains a large volume. Closely connected with the body of the jaw, it receives an investment from the periosteum, which, however, may finally give way, and permit the mass to infiltrate the surrounding tissues. The huge dimensions which it may acquire are well illustrated by a case under the charge of Sir Astley Cooper, in a girl, thirteen years of age, in whom the tumor, of twelve months’ growth, measured sixteen inches in circumference. The tongue was pushed not only to one side, but backwards into the pharynx, while the epiglottis was recurvated upon the superior aperture of the larynx, through which death finally ensued from the combined effects of starvation and respiratory embarrassment. y. Sarcomatous Tumors The general features, symptoms, diagnosis, and treatment of sarcoma of the lower jaw, whether central or peripheral, are precisely similar to those of the superior maxilla. In this situation, however, they are of more frequent occurrence, and attain a larger volume, extending in all directions, and not unfrequently weighing, after removal, between four and five pounds, as in the instances recorded by Syme, Heath, and other surgeons. The central or myeloid tumor is more common about the period of the second dentition, and has been observed at a very early age, as in the case of a boy of seven and a half years, under the charge of Mr. Heath, in whom the disease was first noticed when he was eighteen months old. A remarkable, and, probably, unique, feature 412 DISEASES OF THE JAWS, TEETH, AND GUMS. CHAP. XI. of this case was the simultaneous involvement of both sides of the jaw, the central portion of the bone remaining intact. Mucoid softening and cystic degeneration of the myeloid tissue are met with in almost every central sarcoma, and they are sometimes so extensive as to produce the disease formerly known as spina ventosa. The recurring tendency of sarcomatous epulis, the earlier and more advanced stages of which are delineated in figs. 301 and 302, the former from a private patient, the latter Fig. 301. Fif the tube. When the intestine hangs out at the external wound, the nature and extent of the mischief are at once apparent. But it is very different when the bowel is retained in the belly ; for then the most important sign is an escape of feces, bile, mucus, ingesta, or [fetid air. As these substances can proceed only from the alimentary canal, the stomach, or the gall-bladder, their presence is characteristic. 610 THE ABDOMEN AND ITS CONTENTS. chap. xv. When the wounded bowel does not protrude, there is usually, at an early period after the receipt of the injury, a development of tympanites, evidently due to an escape of gas into the general peritoneal cavity, causing a hollow, drum-like sound on percussion, with tenderness on pressure, and difficulty of respiration. The distension is sometimes enor- mous, and, as it is often present when the other symptoms above mentioned are absent, it is an occurrence of great diagnostic value. Occasionally the gas escapes from the wounded intestine into the subperitoneal connective tissue, and thence travels among the muscular and subcutaneous structures of the wall of the abdomen, where, diffusing itself more or less extensively, it forms a puffy, crepitating swelling, easily distinguishable by sight and touch. A discharge of blood from the anus is occasionally observed, and is a symptom of great value. Shock and pain are always present. The countenance is deadly pale, there is nausea, either alone or accompanied with vomiting, the pulse is small and tremulous, the bi-eathing is feeble and embarrassed, the mind is bewildered, there is frequent sighing with excessive restlessness, and a constant desire for cold air and drink, griping pain is complained of, and, in the more severe cases, there is a remarkable tendency to syncope and to alvine evacuations with a sense of extreme prostration. The pain and shock are always excessive when there is fecal effusion into the peritoneal cavity. Wounds of the bowels are often complicated with hemorrhage, from lesion of the vessels of the abdomen. A considerable quantity of blood sometimes flows back into the cavity of the peritoneum from an opening in the epigastric artery, but most commonly the bleeding proceeds from injury of the omentum, the mesentery, or some other structure, accidentally divided along with the intestine. In gunshot, sabre, and dirk wounds, the hemorrhage may be dei*ived from the aorta or vena cava, and in such an event, unless the outer opening is unusually large, very little blood will appear externally. The existence of hemorrhage accompanying wounds of the bowel is denoted by excessive pallor of the countenance, a small, tremulous state of the pulse, frequent sighing, clammy sweats, coldness of the extremities, intense thirst, and constant jactitation. Diagnosis—In the diagnosis of a wounded bowel, important information may frequently be obtained, in regard to the direction, extent, and depth of the lesion, by a careful con- sideration of the size and shape of the vulnerating body, and the relative position of the parties at the time of the accident. If the opening in the wall of the abdomen is large, the best instrument for ascertaining its condition is the index-finger, or a grooved director; with either of these it is generally easy to determine whether the wound involves the mus- cles only, or the muscles and the peritoneal cavity. The pocket-probe is not well adapted to such an examination, as it is liable, from its small size, to have its point arrested among the tissues. Whatever instrument be employed, all olficious interference must be avoided, as likely to do harm instead of good. In exploring the wound, it is important that the part and body should be placed as nearly as possible in the position in which they were at the moment of the accident. When the injured bowel protrudes at the external opening, the diagnosis is at once obvious, as the nature and extent of the lesion may be determined by simple inspection. The lesion, in the absence of pathognomonic symptoms, ought to be suspected when nausea and vomiting occur after a penetrating wound of the abdomen, accompanied with griping pains, great debility and faintness, jactitation, extreme anxiety, and cold sweats. The case is plain enough when there is a discharge of the contents of the alimentary tube, or a sudden development of tympanites, gradually increasing, and attended with decided tenderness of the abdomen. Effects—It is an interesting fact that, although an instrument may pierce the peri- toneal cavity, it need not necessarily wound the bowels, or, indeed, any other important organs. Nay, further, it may not only lay open this cavity, but completely traverse it, or even emerge at the opposite side, and yet inflict no serious mischief upon the contents of the abdomen. Instances like the latter are certainly uncommon, but that they do occa- sionally occur is abundantly proved by the concurrent testimony of military and civil practitioners. That the extravasation of fecal matter is greatly influenced by the direction and extent of the wound, I ascertained long ago by numerous experiments performed upon dogs. Thus, for example, I found, that, when the opening is six lines in extent, whether trans- verse, oblique, or longitudinal, there is almost invariably an escape of fecal matter, speedily followed by fatal peritonitis. If, however, the wound, whatever may be its direction, do not exceed four lines in length, or a third of an inch, such a contingency will not only be less likely to happen, but in many cases, if not in a majority, nature, aided by appropriate therapeutic measures, will be fully competent to effect restoration. chap. xv. WOUNDS OF THE STOMACH AND INTESTINES. 611 The safety of the patient, in comparatively small wounds of the bowels, no doubt fre- quently depends upon the diminution which the opening instantly experiences after their infliction, from the contraction of the muscular fibres of the tube, and the eversion of its mucous membrane, as seen in fig. 462. The following experiments bear directly upon this point: 1. A longi- tudinal incision, two lines and a half in length, immediately con- tracted to one line and three quarters, with a sufficient degree of eversion of the lining membrane to close the resulting orifice. 2. A similar wound, four lines long, diminished in a few seconds to three lines, by one line and a half in width; it assumed an oval shape, and the mucous tunic protruded on a level with the peri- toneal surface, leaving no perceptible aperture. 3. An oblique cut, seven lines in length, contracted to five, by two and a half in width, with marked eversion of the lining membrane. 4. A trans- verse wound, two lines anda half long,was reduced almost instantane- ously to two lines in diameter; it was of a rounded form, and the two outer coats of the bowel retracted so as to expose the mucous tunic. 5. In this experiment, in which the incision, likewise transverse, was half an inch in extent, the orifice assumed a rounded, oval shape, and was reduced to four lines, by two and a half in width, the inter- nal coat exhibiting, as in the other cases, a pouting or everted arrangement. These observations are of the deepest interest, as showing the efforts which nature makes to close a breach of this kind, the very instant it is inflicted. The eversion of the mucous membrane forms a constant and striking feature in all incised wounds of the bowel, of whatever shape, extent, or direction, and may be compared, in its effects, to the contraction and retraction of the extremities of a divided artery. As the latter are in- tended to prevent the effusion of blood, so the former is intended to oppose the effusion of fecal matter. In gunshot wounds of the bowels, and in incised wounds attended with severe contu- sion, the eversion of the mucous coat is generally very slight, and sometimes even absent. Owing to this circumstance, wounds of this description, even when very small, are ex- tremely prone to give rise to fecal extravasation and fatal peritonitis. The extravasation of fecal matter is always speedily followed by inflammation of the peritoneum, generally, indeed,within a few hours, after its occurrence. The disease, once begun, progresses with great rapidity, and often extends over nearly the whole surface of the membrane. The symptoms, denotiveof its presence, are,violent burning pain in theab- domen, with exquisite tenderness on pressure, and retraction of the thighs; constipation of the bowels; a sharp, frequent, and contracted state of the pulse; intense thirst; constant wakefulness; excessive restlessness; great anxiety ; and coldness of the extremities. In the latter stages, there is generally some degree of nausea, with occasional vomiting; the pulse is weak and fluttering; the surface is bathed with a cold, clammy sweat; the fea- tures are collapsed ; the breathing is oppressed and laborious ; the belly is extremely tense and tumid; the strength rapidly declines; and, finally, the patient dies under all the symptoms of one sinking from the effects of mortification. The attack, as previously stated, rarely continues beyond two days and a half, and often terminates in a much shorter period. The appearances after death are always well marked, even when the dis- ease has not been protracted. The peritoneal surface is highly inflamed, the bowels are covered with lymph, and the abdominal cavity usually contains a small quantity of turbid serum. Occasionally a considerable amount of pure blood, or blood mixed with lymph and other substances, is present. At the seat of the wound, and frequently also at other points, fecal matter, or other evidence of intestinal effusion, is found. The edges of the opening are usually somewhat everted, and adherent to the surrounding parts, which are always extremely red and inflamed. Extensive adhesions generally exist between the bowels, as well as between the bow’els and other structures; and, on penetrating the belly, there is almost invariably a free escape of fetid gas. Prognosis.—The danger in wounds of the intestines is always very great, even when the opening is of very small extent. The most common causes of death are shock, hem- orrhage, and peritonitis; the latter being almost inevitably fatal whenever there is the slightest fecal extravasation. A mere contusion of the bowel, however slight or circum- scribed, may occasion destructive inflammation. Gunshot wounds are especially dangerous, particularly when the missile perforates the tube in a number of places. Yet, even in such a condition, a person may occasionally live for a number of days, as in one of my patients, Fig. 462. Wound of the Intestine, with Eversion of its Edges. 612 THE ABDOMEN AND ITS CONTENTS. chap. xv. a man, twenty-two years of age, who survived a pistolshot nearly one week, notwith- standing that there were eight openings, involving the ileum, jejunum, duodenum, and the arch of the colon. A wound of the large intestine is, as a rule, less dangerous than one of the small, owing, apparently, to its more fixed position and the more solid nature of its contents. During the late war, a very considerable number of cases of gunshot injuries of the large bowel recovered, whereas most of those involving the small proved fatal. Mode of Repair Wounds and punctures of the bowel, unaccompanied by effusion of fecal matter, heal, if left to themselves, either by the adhesion of their edges to the sur- rounding parts, or by a deposit of lymph upon their surface, and the gradual approxima- tion of their lips. In the majority of cases, it is probable that the repair is effected in the former manner, inasmuch as there is always a great tendency in the injured structures to attach themselves to those in their immediate vicinity. Even wounds of large size are occasionally cured in this way. In some instances, again, the breach is closed by a piece of omentum, which, projecting into it, fills it up like a tampon. AVhen this occurs, the contiguous serous surfaces become firmly adherent to each other, and that portion of the plug which lies within the bowel, and assists in maintaining its continuity, is eventually absorbed ; a circumstance which leads to the gradual approximation of the lips of the wound, and their ultimate reunion. The mucous portion of the wound always heals with difficulty, first, because it naturally furnishes lymph very sparingly, and, secondly, because it is constantly in contact with feces, bile, and other heterogenous matter, interfering with the process of repair. It is generally only after a long time that the edges are flattened down, and that the breach is finally closed. Occasionally the cure is effected by granulation, as I found in a number of my experiments upon dogs. AVhen the wound is sewed up, the mode of repair is essentially the same, whatever may be its form. The inflammation which is lighted up induces an effusion of lymph, which is speedily followed by the adhesion of the injured coil to the neighboring struc- tures, among which it is sometimes completely buried. At other times no such adhesion occurs, but the affected part throughout the entire line of the suture is coated with a layer of plastic substance, by which the continuity of the serous membrane is finally reestablished, and the threads used in sewing up the wound are concealed from view. In dogs, there is, in a great majority of cases of this injury, an attachment of the omentum to the surface and to the edges of the wound, as seen in fig. 463, which thus remarkably assists in the process of restoration ; but it is seldom, according to my expe- rience, that such an occurrence is witnessed in the human subject, owing, apparently, to the fact that the omentum is so much smaller in man than in the canine race of animals. The manner in which the ligatures used in sewing up a bowel are detached varies, according to the mode in which they are applied. Both in the interrupted and the continued sutures, with their different modifi- cations, the threads, if cut off close to the surface of the wound, always fall into the interior of the canal, along with the contents of which they are afterwards evacuated; the reverse being the case when the ends are brought out at the abdominal opening. The period at which the detachment of the ligatures occurs varies, on an aver- age, from ten days to several weeks. In dogs, I have frequently found them still firmly adherent at the end of a month. Treatment.—From what has been said, it is evident that the great danger in this class of injuries is from fecal effusion, so liable to occur even when the wound is compara- tively insignificant. The proper treatment, therefore, is, at once, to sew up the wound, to replace the bowel, and to use every possible means to watch and prevent undue perito- neal inflammation. It is folly to think of any other practice; the sheerest nonsense to talk about the irritating nature of intestinal sutures. Enterorraphy is, in itself, one of the most innocent of operations, and it is only surprising that it should ever have been regarded in any other light. What possible harm can result from depositing a little thread in the coats of an intestine, and retaining it there for ten ora dozen days? Some inflammation must, of course, arise, but this is precisely what is needed for the safety of Fig. 463, Wounded Bowel with Adherent Omentum. chap. xv. WOUNDS OF THE STOMACH AND INTESTINES. 613 the patient and the cure of the wound. Even if the wound is not more than a line and a half in length, the bowel ought not to be returned without stitching it. Fecal extrava- sation might occur, and the patient should, therefore, not be subjected to any such risk. In several of my experiments death was produced, not by sewing up the bowel, or by the manipulation employed in performing the operation, but by the escape of fecal matter, along the large interspaces between the sutures, which thus allowed the wound to gap, and to favor the occurrence in question. Indeed, it may be laid down as an axiom that, whenever the closure of the wound is incomplete, there is danger of intestinal effusion. My experience is that there are only two sutures which are at all suitable for sewing up a wound of the intestines. These are the continued and the interrupted, with the modifications of the latter proposed by Lembert and Gely. All other expedients of this kind are complicated, uncertain, and, therefore, inapplicable. The continued and inter- rupted sutures are easily executed with a long, slender cambric needle, armed with a small but strong, well waxed silk thread, or, what is preferable, a carbolized catgut ligature. The continued suture, fig. 464, is made by passing the needle from one side of the wound to the other, across all the tunics of the bowel, except the mucous in such a man- ner as to bring the serous edges in the most accurate apposition. Each stitch should not include more than half a line of substance, and the ends of the thread, after being well secured at each angle of the opening, should be cut off close to the surface of the tube. Fig. 464. Fig. 465. Continued Suture. Ligature Partially Detached. In the interrupted suture, the needle is introduced in the same manner as in the con- tinued, the ligatures being placed about two lines apart, but none being tied until all have been applied. The ends are then secured with a double knot, and cut off close. As the sutures become detached they gradually pass into the intestinal tube, into which they finally drop, to be discharged along with the fecal matter. In the adjoining sketch, fig. 465, the ligature is seen to be partially separated. In Lembert's suture, fig. 466, which I have often employed very successfully upon dogs, a short stitch, including only the peritoneal and muscular coats, is taken on one side of the wound, about two lines and a half from its edge, when the needle is carried across the gap, and a similar stitch is taken on the opposite side. In this manner one thread after another is deposited, the intervals between them not exceeding the sixth of an inch; when they are all arranged, they are drawn firmly together, and tied with a double knot, the ends being cut off as in the ordinary operation. By this procedure the wound is completely closed in every portion of its extent, its lips being inverted so as to approximate their serous surfaces, at the same time that they form within the tube a ridge, upwards of a line in length. Gely’s suture, which is merely a modification ot that of Lembert, is made with two needles inserted near the angle of the wound, about one line from its edge ; they are then carried along the interior of the bowel, parallel with the wound, for the sixth of an inch, when they are brought out precisely at the same level, so as to appear again on the pen ■ Fig. 466. Fig. 467. Lembert’s Suture. Gely’s Suture. 614 THE ABDOMEN AND ITS CONTENTS. CHAP. xv. toneal surface. The threads are then crossed, the right needle being passed through the puncture made by the left, and conversely, when the ends are firmly tied, and cut off close as in the ordinary operation. The number of sutures varies, of course, according to the extent of the cut. In this way the edges of the wound are thoroughly inverted, and, consequently, all danger of fecal effusion is prevented; the coaptation, in fact, is so accurate as to conceal the ligatures. The annexed cut, fig. 467, conveys a correct idea of the manner of inserting this suture. In small wounds, of whatever direction, a decided preference ought, in my opinion, to be given to the ordinary interrupted suture. It is easy of execution, and, if proper care be taken in placing the stitches, the most perfect closure may be effected with it, even as it respects the serous edges of the wound. Of Lembert’s modification of this method, I have also a favorable opinion, although it is more complicated, and more liable to be fol- lowed by undue contraction of the bowel at the seat of the injury. When the wound is of unusual length, the continued suture will be the most suitable, as it admits of easier application, and is attended with less risk of fecal extravasation. When the opening amounts to a mere puncture, its edges may be included in a ligature, as is occasionally done in the operation for strangulated hernia. The wound being closed, and any dirt, blood, or fecal matter that may be present thoroughly removed, the bowel is replaced upon the same principle as in the operation for strangulated hernia. If the tube be tightly girt, the external opening must be dilated with the probe-pointed bistoury, a very small incision generally sufficing for the purpose. When the bowel is so much distended with gas as to impede the l-eduction, a few little punctures may be made in it, but this must be done with unusual care. When the bowel and omentum are protruded together, the former should always,as a rule, be replaced first. When the omentum is inflamed and swollen, as it usually is when it has not been promptly restored, the best plan is to cut off the affected portion, any bleeding vessels being immediately tied with the catgut ligature. In the attempts at replacement, it is very important to know that the bowel has actually slipped into its natural situation. If the external wound is very devious, or if the peritoneum has been detached from its inner edges, a portion of the tube might be retained on the outside of the serous cavity, and be subjected to severe, if not fatal strangulation. To guard against such a contingency, the surgeon should not rest satisfied until he has assured himself that the passage is perfectly free, and that his finger has been fairly within the abdomen, in contact with the convoluted surface of the bowel. The external wound is carefully closed with the twisted suture, made with a stout pin carried through the muscular walls of the abdomen in such a manner as, if possible, to embrace the edges of the peritoneum. Unless the deep portion of the wound is properly united, the occurrence of hernia will be inevitable. A compress and a broad bandage complete the dressing. It is still a mooted question as to what should be done when the wounded bowel does not protrude at the opening in the wall of the abdomen. When we reflect upon the fact that in all lesions of this kind the great danger is from fecal effusion, and that such effu- sion is almost inevitable even when the opening of the intestine is of very small extent, the duty of the surgeon, I think, plainly, is to enlarge the abdominal orifice, to seek for the wounded tube, and to’sew up the cut in the usual manner. Such a procedure, promptly and efficiently executed, while it holds out the only possible chance of safety, would not place the patient in a worse condition than a woman who has undergone the Ctesarian section, or a person whose abdomen has been ripped open by accident; recovery from both of which, as is well-known, is by no means infrequent. The truth is, the fatality of penetrating wounds of the abdomen has been greatly exaggerated; and hence a degree of prejudice has arisen against this practice so deeply rooted as to render it almost impossible to surmount it by any course of argument, however well founded. These remarks are more especially applicable to incised wounds. In gunshot wounds little or no benefit could result from such a course of treatment, except in cases in which the lesion is of the most simple kind. When the bowel, as so often happens, is perforated at several points, the only rational procedure is to excise the injured portions, and to stitch the ends together with carbolized sutures. Any thing short of this would be folly, and even this would scarcely hold out any prospect of benefit when the openings are numerous, or situated widely apart. Thorough drainage, as has been so ably advocated in the treatment of this class of lesions by Professor Hunter McGuire, of Richmond, Professor Dugas, of Georgia, and the late Dr. Otis, of the Army, should, if possible, be promptly CHAP. xv. GUNSHOT INJURIES OF THE ABDOMEN. 615 secured in the most dependent portions of the abdomen, which should be frequently washed out with carbolized water, the most favorable point in the female being Douglas’s cul- de-sac, and in the male the bottom of the cavity in the fold between the bladder and the rectum, the fluids being turned into the latter. All effused blood .should be carefully removed before the wound in the wall of the abdomen is closed. Of 9 cases in which enterroraphy was performed during our late war on account of gunshot wounds, only one was completely successful ; 3 recovered with fistulous openings, and 5 perished. During the after-treatment the patient should be watched with the greatest possible care and assiduity. The abdominal muscles must be maintained in a constantly relaxed condition ; and, as the great danger after all accidents of this kind is from peritonitis, the bowels should be kept effectually locked up with anodynes for the better part of a fort- night, or, indeed, even longer, peristaltic motion being prevented at all hazards, as the only means of safety. After the first few days, flatus may be relieved by means of an enema of cold water, or, what is preferable, of turpentine and assafoetida. All laxatives, even of the mildest and most gentle character, are utterly inadmissible during the first few weeks. The urine should be drawn off regularly with the catheter. The diet should be entirely fluid, and as concentrated as possible. If peritonitis arise, the free ex- hibition of opium, and the abstraction of blood by the lancet, and leeches with blisters, and anodyne fomentations will be the most suitable remedies. Any fluid, serous, sero- plastic, or sero-purulent, that may be effused into the abdominal cavity must be promptly removed with the trocar or aspirator, for the twofold purpose of relieving the viscera of undue pressure, and of averting the absorption of deleterious matter. Such a procedure, provided there is not too much exhaustion, will greatly facilitate recovery. During convalescence, as well as for a long time afterwards, the greatest attention must be paid to the diet and bowels, and the abdomen must be well supported, to prevent the occur- rence of hernia at the seat of the external wound. SECT. IY. GUNSHOT INJURIES OF THE ABDOMEN. Gunshot wounds of the abdomen offer few peculiarities apart from those of ordinary injuries. When the missile penetrates the muscular walls of this cavity, it generally inflicts irreparable mischief, even when it does not enter any important viscus, simply by exciting violent inflammation of the peritoneum. Indeed, fatal disease of this membrane is not unfrequently induced by the contusion merely which it experiences from the blow of a ball or shell, without any actual wound of its substance. Gunshot lesions of the stomach, intestines, spleen, liver, gall-bladder, kidneys, and urinary bladder, are nearly always fatal, death being caused either by shock, by shock and hemorrhage, by hemor rhage alone, or by inflammation usually supervening within a few hours after the accident, and rapidly tending to destruction, despite the best directed efforts of the surgeon. A bullet occasionally traverses the abdomen completely without inflicting any serious injury upon its contents. Professor Hunter McGuire has reported the particulars of four cases of shot wounds of the peritoneum unaccompanied by visceral lesion. Guthrie relates the case of a soldier, whose abdomen was transfixed by a ramrod, entering two inches below the umbilicus, and emerging at the second lumbar vertebra, followed by recovery without any untoward occurrence. A similar example, observed by Dr. Throop, is re- corded in Professor Hamilton’s Treatise on Military Surgery. In 1871 I saw with Dr. Allaband a girl, sixteen years old, whose abdomen had been transfixed a few hours pre- viously by a ramrod, which, entering nearly midway between the pubes and umbilicus, a little to the left of the middle line, passed through the iliac bone, and emerged a short distance above the hip-joint. Great force was required to extract the ramrod. No gas or fecal matter escaped at either opening of the wound. Death occurred at the end of the sixth week from peritonitis. Gunshot wounds of the abdomen involving the viscera are always attended with excessive shock ; and, when the bowels are laid open, tympanites is sure to show itself within a very short time after the infliction of the injury. Shock, on the contrary, is seldom considerable, when the mischief is limited to the walls of the belly, and in such a condi- tion there is no meteorism. These facts, as suggested by McGuire, may be regarded as almost characteristic of these two classes of injuries. Penetrating wounds of the abdo- men with fecal effusion are, as a rule, rapidly followed by peritonitis, generally terminating fatally in from twenty-four to forty-eight hours. Gunshot wounds of the transverse colon are more fatal than those of other portions of the large bowel. In the Surgical History of the War many cases of recovery are re- 616 THE ABDOMEN AND ITS CONTENTS. chap. xv. corded after perforations of the caecum and ascending portion ot the bowel, and a still greater portion in wounds of the sigmoid flexure and of the descending portion of the colon. Not a few of the cases were complicated with lesions ot the innominate bones, and nearly all were attended with stercoraceous fistules, “ which commonly closed after a time without operative interference, reopening at intervals, and then healing permanently.” Of 1996 flesh wounds of the abdomen reported as having occurred during our late war, 29 were fatal; while of 3475 penetrating wounds, of which the results had been ascer- tained, 3031, or 87 per cent., were mortal. In many instances fecal fistules ensued, but they usually closed without operative interference. Gunshot lesions of the walls of the abdomen present the same characters as similar in- juries in other muscular regions. Erysipelas is a common effect, and they are occasion- ally followed by tedious abscesses, the matter forming in the' track of the missile and pro- ducing, if not speedily evacuated, extensive havoc among the surrounding structures. Of the symptoms, diagnosis, and treatment of these accidents nothing need be said here, as these topics are fully discussed in the preceding section. Frightful injury and even death sometimes follow shell wounds and grazes by round shot with little, if any, apparent mischief of the surface of the abdomen. A case which occurred at Sadoolapore affords an excellent illustration of the nature of such an accident. A man was struck by a round shot on the right arm and chest, with the effects merely of a bluish spot on the former, and hardly any visible mark on the latter. He expired at the end of twenty hours, without having rallied from the shock. The peritoneal cavity was filled with dark blood, and the right lobe of the liver was torn into small pieces, some of which were quite loose. The other viscera were healthy, and there was no evidence of inflammation. SECT. Y FOREIGN BODIES IN THE STOMACH AND BOWELS. Foreign bodies, varying much in their character, occasionally descend into the stomach, and, becoming arrested there, cause great distress, and sometimes even death. Jugglers in the exercise of their profession and persons intent on self-destruction are, perhaps, the most common subjects of such accidents. A few years ago a man in Iowa, in performing some tricks at legerdemain, allowed a bar of lead, ten inches long by upwards of six lines in diameter, and weighing one pound, to fall into the stomach. The usual symptoms are, violent pain in the epigastrium, extending about in different directions, a sense of weight and obstruction in the stomach, nausea, and constipation of the bowels. The pa- tient is generally able to walk about, and even to attend to business, especially during the first few days after the introduction of the extraneous body. The manner in which these substances are disposed of varies. Pieces of bone, carti- lage, pins, needles, and coins, often pass into the bowels, and are finally discharged along with the feces. When the body lodges, and is productive of pain and danger, extrusion must be effected with the knife, the place of incision being regulated by the site of the in- truder, which may often be distinctly felt through the walls of the abdomen. In the case above alluded to, Dr. Bell, of Davenport, removed the bar of lead by making an incision, four inches in length, from the umbilicus to the false ribs, some distance beyond the mid- dle line. The opening made in the stomach was just large enough to admit of the passage of the bar, and required no sutures, as it became immediately closed by the contraction of the muscular fibres of the organ. The external wound was stitched in the usual man- ner. The man recovered in less than a fortnight without an untoward symptom. Mr. Little, of London, lately succeeeded in fishing out of the stomach a gold plate surmounted by four artificial teeth, one inch and three quarters in length by one inch and a quarter in width. The chief difficulty experienced was in getting the foreign body through the upper narrow portion of the oesophagus. The astonishing faculty which the stomach possesses of accommodating itself to the presence of foreign bodies, is strikingly illustrated in the remarkable instances recorded by Borelli, Fournier, Harrison, and others, in which the most curious substances, as pieces of wood and iron, nails, forks, spoons, knives, buckles, compasses, door-hinges, and pieces of coin, were swallowed, sometimes in large numbers, and in rapid succession, with very little immediate suffering, although they all ultimately proved fatal. A case is men- tioned by Crollius of a man who lived many years in great comfort, after having swal- lowed forty-six pebbles, weighing altogether nearly three pounds, the smallest being about the size of a pigeon’s egg. Dr. Otto, of Copenhagen, met with an instance in CHAP. XV. GASTRECTOMY. 617 which a silver teaspoon, swallowed twelve months previously, was discharged through an ulcer in the precordial region, followed by recovery. Gastrotomy was originally performed by Florian Mathis, of Brandenburg, in 1602, for the removal of a knife nine inches in length, swallowed by a man, thirty-six years of age, who made a successful and perfect recovery. Schwabe, of Konigsburg, repeated the operation in 1635, the patient surviving ten years. After this gastrotomy seems to have been lost sight of until the latter part of the last century, when it was performed by Professor Frizac, of Toulouse, for the removal of a knife blade, two inches long. Since that period the operation has been practised by Hiibner, Cayroche, Garcia, Caizergues, New, Rodney, Gluck, Bell, Labbe, and a surgeon mentioned by Sedillot; and, what is remarkable, every case, with one exception, made a rapid recovery. The incision is the same as that made in gastrostomy. The operation of enterotomy is sometimes required on account of the presence of a for- eign body in the bowels, whether formed within, or introduced from without. In this country, intestinal concretions are exceedingly rare, but in certain parts of Europe, es- pecially in Scotland, they are by no means uncommon, and occasionally call for the use of the knife. In the latter country they usually consist of the fibres of the beard of the oat, cemented together by albumen and phosphate of lime, and they sometimes acquire a very large bulk, weighing many ounces, and even three or four pounds. When small, they generally move about, changing their place from time to time ; but, when the reverse is the case, they are liable to become impacted in a kind of pouch, formed by the expanded tube. In general, they are solitary, but now and then quite numerous, as many as seve- ral dozens being found in the same individual. Their increase is usually tardy. The symptoms denotive of their presence are colicky pains, a sense of weight and soreness at the site of the concretion, dyspeptic derangement, and mechanical obstruction to the evacuation of the feces, with gradual emaciation and failure of the general health. When the foreign body occupies the rectum or sigmoid flexure of the colon, the patient is tor- mented with a constant desire to go to stool, tenesmus, and distress in the sacrolumbar region. When the concretion is large, or the emaciation considerable, it may generally be felt through the walls of the abdomen, and, if several are lodged together, they may even be made to strike against each other, so as to cause a distinct noise. These concretions are sometimes ejected by vomiting or stool; when situated in the rectum they may occasionally be extracted with the finger, scoop, or forceps. When they are not disposed of in this way, and life is in danger, enterotomy must be performed, the operation, not unfrequently, proving successful. An incision of adequate length being made through the abdomen, in the direction of the muscular fibres, at the site of the for- eign body, the bowel is laid open to an extent barely sufficient to seize and extract it, when the opening is immediately closed with the continued or interrupted suture, as may be deemed most advisable. The external wound is treated in the ordinary manner. Foreign bodies, introduced from without, give rise to the same train of symptoms as those formed ivithin ; but the effects are generally more violent, and the treatment re- quires to be more prompt and decisive. When the ordinary remedies fail the knife is employed, the two wounds being managed afterwards in the same manner as in the former case. The operation is, unfortunately, not often successful, chiefly for the reason, per- haps, that it is commonly performed too late. In a case under Dr. Samuel White, ot Hudson, early in the present century, a large teaspoon, swallowed in a paroxysm of de- lirium, was extracted in this way from the ileum, and the man recovered in a few weeks. Dr. Thorndike, of East Boston, successfully removed, through an incision in the left iliac region, five inches in length, a stone, weighing nearly two pounds, that had escaped from the rectum into the peritoneal cavity, it having been introduced by the patient to promote the flow of urine. Hardly any inflammation was provoked either by the pres- ence of the stone or as a consequence of the operation. SECT. VI GASTRECTOMY. During the extirpation of a tumor of the abdominal walls, Cavazzini, of Castelfranco, about three years ago, successfully excised a portion of the anterior wall of the stomach ; but it remained for Fean, on the 5th of April, 1879, to practise gastrectomy as a formal procedure, on account of carcinoma. He removed the pylorus and a portion of the duo- denum two centimetres in length, the patient dying four days afterwards from exhaustion. The operation has been repeated for carcinoma by Billroth four times, and by Rydygier, Wrolfler, Bardenheuer, Czerny, Nicolaysen, Liicke, Kitajewsky, Southam, Lauenstein, 618 THE ABDOMEN AND ITS CONTENTS. chap. xv. Berns, and Caselli, each once. Of the sixteen cases, twelve proved fatal, of which eight expired within fifteen hours of collapse, two of inanition, respectively, on the fifth and eighth days, one in twenty-six hours, of hemorrhage, and one on the eighth day of peritonitis from gangrene of the transverse colon. Of the four recoveries, Billroth’s first case died, nearly four months after the operation, of carcinomatous peritonitis; his fourth case was alive two months subsequently. Wolfler’s patient was doing well at the end of eight months ; and Czerny’s case was alive ten months afterwards. To these operations may be added one performed by Rydygier, in 1881, for perforating ulcer with dilatation of the stomach, in which the pyloric sphincter and a portion of the posterior wall of the organ were ex- cised, The duodenum was attached to the stomach by thirty-two internal and twenty-nine external catgut ligatures. At the expiration of six weeks there was no return of the at- tacks of vomiting, the digestion was good, and the patient considered herself well. The records of the Vienna General Hospital, analyzed by Gussenbauer, show that metastatic tumors were present in 592, that the stomach was adherent to the neighbor- ing organs in 394, and that the lymphatic glands were involved in 273, of 903 examples of carcinoma of the stomach, features which were met with in several of the cases of resection, and which led to the abandonment of the operation in at least one instance. In view, therefore, of the facts that incipient carcinoma is difficult of detection, that exten- sive adhesions, glandular contamination, and secondary visceral growths, are frequent complications, that three-fourths of all patients have heretofore perished from the effects of the operation, and finally, that the procedure has materially shortened instead of pro- longing life, I am of the opinion that gastrectomy for carcinoma will soon fall into desuetude, and that its details, need, therefore, not be described. In at least three instances in which it was found impossible, on account of the extent of the disease, to remove the stomach, other procedures were resorted to with a view to prevent death from starvation. Thus, Langenbuch practised duodenostorny, or attached the first portion of duodenum to the abdominal walls, as in gastrostomy, and opened the gut one week subsequently. The patient, nevertheless, died of inanition ten days later. Wolfler made an incision into the stomach near the middle of the great curvature and a similar cut into the jejunum, and carefully united the openings by sutures. By this operation, termed gastro-enterostomy, he hoped to provide for the passage of the ingesta into the intestinal canal, without obstructing the escape of the secretions of the liver and pancreas ; and he so far succeeded in his object that at the date of the report, four weeks subsequently, the vomiting had ceased, the bowels were moved daily, and food was taken in gradually increasing quantities. In a second operation of this nature, in the hands of Billroth, the patient vomited bile until his death on the tenth day, when it was discovered that the viscera had been united in such a way as to cause the bile and pancreatic fluid to be poured into the stomach. SECT. VII INTESTINAL OBSTRUCTION. Obstruction of the intestines may arise from various causes, some of them of the most opposite character, and a knowledge of this fact suggests the propriety of arranging them under the following heads: 1. Internal strangulation from the development of a mem- branous band, from the attachment of one portion of bowel to another or to an adjoining organ, or from unnatural adhesions of the free extremity of the vermiform appendage, omentum, ovary, or Fallopian tube. 2. Rotation of the tube upon its own axis, or around an axis formed by the mesentery. 3. Compression of one portion of bowel by another, by a tumor, an enlarged ovary, or a diseased uterus. 4. The interception of the intestine by an opening in the mesentery, omentum, or mesocolon. 5. Intussusception of the tube, or the falling of one portion into another. G. Stricture, generally the result of carcinoma. 7. Concretions, foreign bodies, worms, or indurated fecal matter. 8. Paralysis. 9. Spasm. 10. Inflammation. A rare case of complete occlusion of the ileum from the pressure of a large quantity of extravasated blood, consequent upon the rupture of an aneurism of the hepatic artery, has been reported by Dr. Drummond. The patient was a man fifty-four years old. Ot the relative frequency of these different species of intestinal obstruction, some idea may be formed when it is stated that of 169 cases, analyzed, in 1848, by Mr. Benjamin Phillips, of London, the impediment in 60 depended upon strangulation by bands of false membrane, in 69 upon intussusception, and in the remainder upon torsion and other causes, apart from imperforate anus and stricture of the rectum. Of 124 consecutive fatal cases that occurred in Guy’s Hospital, 33 were due to acute obstruction, 76 to chronic CHAP. XV. INTESTINAL OBSTRUCTION. 619 obstruction, and 15 to intussusception. The obstruction, liowever induced, presents itself under two distinct varieties of form, the acute and the chronic, each being characterized by a peculiar train of phenomena. Acute obstruction is generally occasioned by internal strangulation by membranous bands, morbid adhesions, or some diverticulum ; by a sudden twist of the bowel or by a rotation of the bowel upon its axis; by the passage of a coil ot intestine into an abnormal aperture in the mesen- tery, omentum, or mesocolon ; or by the occurx-ence of intussusception, or the falling of one portion of bowel into another, as in fig. 468, from a preparation in my collection. It may also arise from inflammation or spasm, although this is uncommon. The symptoms which characterize this form of obstruc- tion are generally of a most severe nature ; they are more or less sudden in their appearance, and they bear the closest resemblance to those which denote the existence of strangulation in hernia. The individual may be in the most perfect health at the moment of their occur- rence, or he may have been more or less unwell, although still able to attend to his accustomed business. The disease is usually ushered in by pain in a particular portion of the abdomen, of a sickening, griping, or colicky character, and soon followed by decided nausea, and a sense of constriction in the situation of the stran- gulation. Prostration is an early symptom. The vital powers are depressed, as if the system had received a violent shock. Excessive restlessness exists. The patient is in great agony ; he tosses about in bed, his thirst is intense, and he is overwhelmed with despondency. The vomiting increases in frequency, and the ejected matter, consisting at first simply of ingesta, or of bile and mucus, at length becomes stercoraceous ; the belly is exquisitely sensitive, so much so that the slightest pressure of the finger is almost intolerable; the bowels are tympanitic and obstinately constipated; the lower limbs are retracted to take off the weight of the abdominal muscles; the pulse is small, frequent, and wiry ; the features are pinched ; the extremities are cold ; the mind wanders ; in a word, the suffering is intense. By and by, muttering delirium sets in, the countenance exhibits the Hippocratic expression, the tongue is dry and black, the surface is covered with clammy perspiration, there is hiccup with twitching of the tendons, and, unless relief is speedily procured, the patient dies either from exhaustion or mortification of the bowel. The period at which this event occurs varies, on an average, from six to eight days. Sometimes it takes place as early as forty-eight hours from the commencement of the attack. Dissection generally reveals all the evidences of a high state of peritonitis. In chronic obstruction, the obstacle to the onward passage of the feces usually depends upon organic disease of the bowel, as stricture of the rectum, sigmoid flexure of the colon, or ileo-cxecal valve ; the presence of indurated feces, foreign matter, morbid growths, worms, or intestinal concretions ; or, finally, upon the pressure produced by some tumor, as an enlarged ovary, uterus, or Fallopian tube. The symptoms are much less violent than those which mark the acute attack. Tbeir development is gradual, not sudden and overwhelming. The individual is unwell; his disease is slowly but steadily gravescent, worse at one time, and better at another. The chief trouble, at first, is constipation of the bowels, with rumbling noises and frequent eructations, disordered appetite, more or less torpor of the liver, and progressive failure of the strength. Colicky pains are occasionally experienced, and defecation is performed with great difficulty, being always accompanied with straining and tenesmus, and, at times, with prolapse of the rectum. Not unfrequently obstinate constipation exists. Sometimes the bowels are not relieved for days or even weeks, although the desire to do so may be most urgent. This is especially liable to be the case when the obstacle is seated in the rectum, from the pressure of the fecal matter upon the pelvic nerves. After the case has proceeded in this manner for a variable period, it gradually or suddenly assumes a more serious character, evidently dependent upon the occurrence of inflammation, which never fails to mark the close of the affection, whatever may be the nature of the exciting Fig. 468. Intussusception of the Bowel. 620 THE ABDOMEN AND ITS CONTENTS. CHAP. xv. cause. The peritoneum is now the chief seat of the disease, and the danger is always in proportion to the extent and violence of the attack. In many cases the morbid action involves the entire membrane, visceral and parietal; in some it is more limited, being confined to the parts around the seat of the obstruction. The features are pinched and shrunk, the pulse small, frequent, and wiry, the abdomen tender and tympanitic, the stomach nauseated and unable to retain even the blandest fluid, and the surface covered with clammy perspiration. The strength rapidly fails, the mind wanders, hiccup and muscular twitchings ensue, and the patient sinks very much as one dying of mortification from strangulation of the intestines. In the worst cases stercoraceous vomiting is some- times present. Diagnosis.—The diagnosis of intestinal obstruction is often determined with diffi- culty. It is generally sufficiently easy when it depends upon disease of the rectum situated within reach of the finger or probe, or when it is occasioned by the presence of indurated fecal matter, an intestinal concretion, or some foreign body known to have been swallowed, but not passed by the anus. In almost all other cases it must necessarily be obscure. The affection with which it is most liable to be confounded is hernia; for, whenever the case is one of sudden occurrence, the symptoms of the two diseases are absolutely identical. Error here is not always avoidable, even when the attendant is thoroughly upon his guard in respect to the probable nature of the case. The symptoms of hernia are sometimes extremely obscure. In the incomplete variety of the affection, there is often an entire absence of everything like a tumor, and the consequence is that the surgeon is left wholly to conjecture as to the precise character of the complaint. A very minute portion only of the wall of the bowel may be intercepted, and yet the transmission of fecal matter may be as effectually arrested as if the entire caliber of the tube were constricted. The symptoms of strangulation exist in full vigor, but no practitioner, however intelligent, can possibly affirm whether they are produced by a hernia, properly so called, or by mere internal obstruction. I have witnessed a number of such cases, and it need hardly be added that every one proved fatal. In intussusception of the bowel, the access of the symptoms is generally sudden, and without any assignable cause. The individual is seized with violent pain in the abdomen, attended with nausea and vomiting, without any tension, tenderness, or appreciable tumor. The countenance is pallid, and he feels weak and depressed. Obstinate constipation exists, and the case effectually resists all attempts at relief, both by the mouth and the rectum. The suffering steadily progresses. The pain increases in violence ; the abdomen is tym- panitic and exquisitely sensitive; the pulse is small, hard, and frequent; the eyes are sunk ; the anxiety is intense ; and the vomiting is stercoraceous. In obstruction dependent upon the presence of a membranous band, a twist of the bowel upon its axis, or the passage of a coil of intestine through a hole in the mesentery, omen- tum, or mesocolon, the symptoms so closely resemble those of invagination and ordinary hernia as to defy all attempts at accuracy of discrimination. 'The most prominent phe- nomena are violent pain and tension of the abdomen, with great tenderness on pressure, excessive restlessness, fecal vomiting, pinched features, and a small, quick, thready pulse. Obstruction caused by colic occasionally produces confusion in regard to the diagnosis of the case. In general, such attacks are dependent upon disorder of the digestive organs, or the presence of ingesta, bile, or acid in the alimentary canal. The pain is spasmodic, relaxing and increasing in severity with temporary intermissions; there are frequent eructations and rumbling noises in the bowels; the patient rolls about and seeks relief by compressing the abdomen; there is no fecal vomiting; and alvine evacuations occur either spontaneously or through the agency of medicine. The passage of a gall-stone sometimes closely simulates the symptoms of intestinal obstruction, especially those dependent upon strangulation. The attack usually comes on within a few hours after a hearty meal, with severe pain, like that of colic, referred to the hypochondriac region, and paroxysmal in its recurrence, with intervals of comparative ease. The pain is generally extremely agonizing, but is always relieved by pressure. There is distressing nausea, with frequent vomiting of acid matter; the patient is exces- sively restless, rolling and tossing about in bed ; the countenance is pale ; the pulse is slow and weak ; the tongue is foul; and the surface is covered with a cold sweat. If re- lief is not speedily afforded, the skin assumes a jaundiced aspect, the urine is tinged with bile, the abdomen is tender on pressure, especially in the epigastric region, and there are often well-marked rigors. When the concretion is very large, it may, upon escaping from CHAP. X V. INTESTINAL OBSTRUCTION. 621 the gall-bladder, obstruct the bowel, and thus occasion obstinate constipation, with all the symptoms of internal strangulation. The most important phenomena, diagnostically considered, are, the spasmodic character of the pain, the icterode condition of the skin, the presence of bile in the urine, the soft and open state of the pulse, the absence of constipation and fecal vomiting, and the sud- den cessation of suffering the moment the calculus escapes into the bowel. Obstruction dependent upon mechanical causes, as morbid growths, concretions, foreign bodies, or indurated feces, may occasion much suffering, but in most cases the symptoms are for a long time comparatively mild, the bowel gradually accommodating itself to its new' relations. Eventually, however, the case assumes a more serious character, and, if relief is not obtained, the patient perishes from peritonitis, preceded by excessive disten- sion and tenderness of the abdomen, and great prostration of the vital powders. The diagnosis of this kind of intestinal obstruction must often necessarily be very obscure. A stricture, carcinoma, hardened feces, or an intestinal concretion, occupying the lower part of the rectum, may generally be detected with the finger, probe, or bougie ; but when the source of the difficulty is higher up, there can be no certainty as to its pre- cise nature. When the impediment is very great, it may sometimes be detected through the 'walls of the abdomen, but such an occurrence must be very uncommon. Occasion- ally the obstacle is external to the tube, as when it is caused by an ovarian, uterine, or mesenteric tumor, and then the diagnosis is generally sufficiently evident. Obstruction from mere torpor of the bowels is most common in nervous, hysterical females, and is usually readily recognized by the history of the case, the frequent eructa- tions, and the rumbling noises in the abdomen. Obstinate constipation sometimes arises from injury of the spine. The diagnosis of intestinal obstruction, the result of peritonitis, is marked by great un- certainty. The most reliable circumstances are, the tympanitic and tender state of the abdomen, the small, thready pulse, the coldness of the extremities, the frequent eructa- tions, with occasional vomiting, or regurgitation of the contents of the stomach, .dorsal decubitus, retraction of the limbs, absence of severe pain, shrunken features, general prostration, and obstinate constipation. Much light is sometimes thrown upon the diagnosis of these affections by the history of the case, as the nature of the exciting cause, the peculiarity of the attack, and the char- acter of the symptoms. When the attack is sudden and violent, and speedily followed by peritoneal inflammation, the presumption is that it is dependent upon internal strangula- tion ; while, if it is slow' in its progress, or decidedly chronic, the probability is that it has been occasioned by mere torpor of the bowel, attended with fecal impaction, or by the presence of some morbid grow'th, carcinoma, stricture, intestinal concretions, worms, or foreign matter. The pain in internal strangulation generally comes on suddenly, and, although it is liable to remit, it is nearly always continued. It usually begins at some particular spot, from which it is more or less rapidly diffused over the rest of the abdomen. In the more severe cases, it may be so intense as to cause death in less than forty-eight hours, the patient sinking as if he were laboring under violent shock. In the chronic form of the disease, on the contrary, there may be almost an entire absence of pain for days and even weeks together. Along with pain, there is generally, in the more severe forms of the affection, consid- erable tenderness of the abdomen, either circumscribed or diffused. When the obstruc- tion is rapid, it usually appears early in the attack, and is often so great as to render the slightest pressure of the finger intolerable. Tympanites is a constant symptom, but of itself of little diagnostic value, as it is a con- comitant of many other affections. It generally arises gradually, and often proceeds to a most distressing extent. When it exists in a very high degree, the abdomen is as tight as a drum, and the distended coils of intestine may readily be perceived through its stretched parietes. The constipation is commonly complete. Sometimes, however, a small evacuation takes place, or a little fecal matter may be brought away by an enema. In the chronic form of the disease, the patient often labors under distressing tenesmus, with a frequent desire to relieve himself. A discharge of blood, or of offensive mucus, is a frequent attendant upon intussusception, especially if the disease has made considerable progress, and may be re- garded as almost characteristic. A tumor or enlargement is also occasionally perceptible through the walls of the abdomen, although its outline is not always distinctly defined. Vomiting is seldom absent. In acute obstruction, it commonly appears within a few 622 THE ABDOMEN AND ITS CONTENTS. CHAP. xv. hours after the attack, and continues, as a prominent and distressing symptom, until the case terminates. When the obstruction is chronic, it may not come on until late in the attack, or until there is serious peritoneal involvement. It is usually most harassing when the obstacle is seated in the small bowel, and when the patient is subjected to the the use of irritating cathartics. It generally continues until the ejected matter acquires a fecal character. Distressing hiccup often attends, especially when the impediment exists in the upper portion of the small bowel. It is, however, a symptom of no diagnostic significance. The precise seat of the obstruction can only, as a rule, be determined when the dis- ease upon which it depends is situated in the rectum or lower part of the colon, within reach of the finger, probe, or tube. In most other cases, only an approximative opinion can be formed. When the constriction is in the small bowel, or at the ileo-caical valve, the swelling is usually central, and less considerable than when the large intestine is dis- tended. When the inflation exists mainly in the colon, the tube not unfrequently forms a kind of belt around the boundaries of the abdomen, the outline of which may be dis- tinctly traced through the stretched and attenuated parietes with the finger, if not also with the eye. An enormously distended caecum is occasionally thrust over into the left hypochrondriac region, where it presents itself as a large prominence, emitting a clear sound on percussion. In intussusception, a distinct tumor, more or less hard, and of an elongated, cylindrical form, may generally be traced ; a circumstance which, coupled with the existence of bloody mucous discharge, is almost characteristic of the nature of the affection. Finally, in distention of the large bowel, there is always unusual fullness of the loins with remarkable resonance on percussion. The symptoms are generally most urgent when the small bowel is involved; the pain and vomiting come on at a very early period, often, indeed, within the first few hours, and the attack is characterized by uncommon severity; the abdominal tenderness is greater, the pulse smaller, and the prostration more rapid and profound. The impossibility of inserting a long tube into the bowel may generally be taken as an evidence that the obstruction is seated in the upper part of the rectum or in the sigmoid flexure of the colon; but it must not be forgotten, in the use of this instrument, that it may bend upon itself, and so convey erroneous information. When the impediment is situated low down in the rectum, its character may always be readily ascertained with the finger, probe, or bougie. Finally, it should be borne in mind that carcinomatous obstruction is most common in the sigmoid flexure of the colon, and in intussusception in the left portion of the large intestine, the displaced tube often lying in the rectum, and sometimes even protruding at the anus. Moreover, whenever the case is of an acute character, simulating strangulation, a most thorough examination should be made of the abdomen, especially in the situation of the inguinal, femoral, and pelvic apertures, for some of the more obscure forms of hernia; for it has often happened that the obstacle, instead of being internal, has been found after death to be external, a small portion of the bowel having been intercepted by the edges of one of the rings. Great uncertainty in regard to the diagnosis often arises when intestinal obstruction occurs in a person laboring under chronic hernia. The obscurity, in such an event, can only be cleared up by a most careful exploration of the parts concerned in the protru- sion. If the hernia is reducible, the finger should be carried into the abdominal ring, and if, after this, doubt still exists as to the real nature of the case, the proper plan is to operate. Treatment—In the absence of correct diagnostic intelligence, the treatment of intes- tinal obstruction must often be conducted in a purely empirical manner. One important fact, however, in regard to the subject is now fully settled, the avoidance of everything in the form of irritating medicine, until recently so much employed even by the best prac- titioners. If a drastic cathartic, as colocynth, scammony, jalap, or croton oil, has occa- sionally afforded relief, it is very certain that the tendency of such an agent generally is to do harm, by increasing the gastric distress and promoting abortive peristaltic action of the bowels. The same objection is applicable to the exhibition of crude mercury, which, instead of unlocking the intestine, only, in most cases, augments the mechanical impedi- ment. Numerous instances have been published in which enormous quantities of this metal were found, after death, in the bowel without, apparently, having made the slightest impression upon the obstruction. In the milder cases success will often attend our treatment, and even in the more severe ones the surgeon need not always despair of being able to surmount the difficulty. In CHAP. XV. INTESTINAL OBSTRUCTION. 623 intussusception, nature occasionally affords relief by the occurrence of mortification, even- tuating in the separation and discharge of the invaginated portion of the tube. The late Professor John Dawson, of Columbus, Ohio, presented to me a portion of colon twenty- nine inches in length, passed by a child six years of age, who, notwithstanding, made an excellent recovery. Dr. Van Buren and Dr. Peaslee have each reported favorable in- stances of five feet. In 35 cases, analyzed by Dr. William Thomson, the invaginated pieces varied in length from six inches to three feet, nearly all including the entire cylin- der of the tube along with a portion of the mesentery. The small bowel was concerned in 22 cases, and the large, or large and small, in 13. The average duration of the disease was from four to five weeks. To insure so favorable a result, it is evident that everything should be done to sustain the system, and that all perturbating measures should be care- fully refrained from, especially during the elimination of the slough, otherwise they may break up the adhesions. The great remedy in nearly all cases, whether dependent upon strangulation, or con- stipation, is opium, administered in liberal and sustained doses. The object is not merely to allay pain and gastric irritability, but, for a time at least, to prevent the peristaltic action of the bowels. In this way, especially in intussusception, an opportunity is afforded to the affected intestine either to unroll itself or to throw off the invaginated portion, whereas, if the tube has been twisted upon its axis, or strangulated by bands of lymph, a diverticulum, morbid adhesions, or a hole in the mesentery, the patient will be made comparatively comfortable, and thus placed in a better condition to bear up under sur- gical interference, should this eventually become necessary. When the difficulty depends solely upon torpor of the bowels, experience has shown that the steady, persistent use of opium will, in time, more effectually relax them than any other remedy; and the same treatment is strictly applicable when the obstacle is occasioned by spasm. The quantity of opium should not be less than two grains, given every six or eight hours, according to the urgency of the case. When there is marked disorder of the secretions, a minute quantity of calomel, as one-half a grain to a grain, may often be advantageously com- bined with the anodyne, but anything like a large dose of the article would be decidedly prejudicial, from its tendency to excite nausea, to provoke peristaltic action, and to de- press the system. When great torpor of the bowel exists, strychnia may be serviceable. Gastric distress may generally be relieved by effervescing draughts, the neutral mixture, champagne, or lime-water in milk. Within the last five or six years favorable reports have been published of the employ- ment of extract of belladonna, as a means of overcoming obstinate obstruction from con- stipation. The dose should vary from half a grain to a grain every two, three, or four hours, until, if necessary, as much as one-fourth of a drachm has been given, the effect of the remedy being carefully watched. Abdominal tenderness should be assuaged with leeches, and fomentations, medicated with laudanum. A light emollient cataplasm, similarly prepared, sometimes answers a good purpose. When the distress is very great, the best plan is to cover the abdomen with a large blister, well sprinkled with morphia. Great relief has sometimes followed exposure of the abdomen to cold air ; and it is highly probable that intussusception may occasionally be cured in this manner, the bowel releasing itself by reversed peristaltic action. Iced water, or pounded ice applied to the abdomen, might be useful. The strength is maintained with nutritious food, given in as concentrated a form as possible. Milk punch is generally required at an early period of the attack. To remove the flatus, which is always a source of so much distress, nothing answers so well as frequent injections of turpentine largely diluted with tepid water, and introduced with a long tube, inserted high up into the colon. In obstinate cases trial should always be made with injections of cold water. In intussusception great relief has occasionally followed the inflation of the intestines with air introduced by means of a tube attached to a pair of bellows. When the displaced bowel projects through the anus, or is low down in the rectum, reduction may be attempted with the fingers, a bougie, or even, it the patient is an adult, with the hand. Tenesmus is relieved with anodyne enemas, or enemas of olive oil, mucilage of gum arabic, or infusion of flaxseed. Dr. Robert Battey, of Georgia, was, I believe, the first to establish satisfactorily by experiments upon the dead subject, and observations upon the living, the fact that fluids thrown into the rectum can be made to traverse the entire alimentary track from the anus to the stomach ; and he has published the particulars of a number of cases in which he successfully applied this mode of treatment for the relief of various kinds of obstruc- 624 THE ABDOMEN AND ITS CONTENTS. chap. xv. tion. The operation, to secure the best advantage, should be performed with simple tepid water injected slowly with a common rubber-bulb syringe, with short intervals of rest to afford the liquid an opportunity of gradually forcing its way upwards. The anus should be firmly compressed with a towel wrapped round the tube to prevent regurgita- tion ; and the object of the procedure will be greatly facilitated if the patient be kept steadily under the influence of an anaesthetic. A treatment so simple as this confessedly is should always, in ordinary cases, precede the employment of harsher measures. There can be no danger of rupturing the bowel if proper care be taken. My opinion has long been that great, if not permanent, relief might be afforded in some of these cases of excessive gaseous distension by puncture of the bowel, as the escape of the fluid might not only enable the tube to regain its contractility, but facilitate respira- tion by taking the pressure off the diaphragm and abdominal muscles. No opportunity, however, was presented to me of putting this idea into practice until 18G4. The patient was a man, fifty-one years of age, under the charge of Dr. Andrew Nebinger. He had already had one attack of obstinate constipation, attended with great pain in the bowel, of a paroxysmal character, rumbling noises, and excessive distension. After continuing in this condition, alternately better and worse, for twenty-one days, copious alvine evacuations occurred, and the health improved so much that he was able to walk about his room. At the end of three weeks, however, the symptoms returned in all their previous intensity. The pain and meteorism steadily increased, the stomach was oppressed with nausea, and all efforts to move the bowels Avitli purgatives, enemas, and a long rubber-tube proved fruitless. When I saw the patient, the tympanites was so excessive that he was hardly able to breathe or swallow. As a dernier resort, I introduced a very delicate trocar at the middle line, first about, two inches below, and then about the same distance above, the umbilicus. A large quantity of gas, of a fecal order, escaped at each orifice, followed by great relief of the suffering and the most marked reduction of the size of the abdomen. The improvement continued for nearly a fortnight, when the man become gradually worse, and died exhausted in less than a week, no alvine evacuation having occurred during the entire period of thirty-five days. The cause of the obstruction was found to be a tight ring of epithelial carcinoma at the lower part of the sigmoid flexure of the colon, completely occluding the tube. The whole of the large bowrel was enormously distended with gas and fecal matter, especially the latter, more or less displaced, and upw'ards of twTelve inches in circumference. A gan- grenous perforation existed in the descending colon, and the mucous membrane was ulcer- ated at two points. The peritoneum of the lower portion of the abdomen was highly inflamed, and there was some effusion of serum and lymph. Although this case necessarily terminated fatally, it is evident that the operation afforded great relief, and I can see no reason why it should not be frequently practised, on the principle, if nothing more, that anything calculated to ameliorate suffering is proper under such desperate circumstances. In Bolivia, where gastro-intestinal pneu- matosis is very common, especially among the natives w'ho live almost exclusively upon vegetables, puncture of the stomach has been repeatedly performed with very gratifying results. Of 20 cases operated upon by Dr. Olivieri 8 were perfectly successful. In a discussion of this subject in the Academy of Medicine of Paris, in July, 1871, the im- portant fact was elicited that this operation had been successfully performed by many of the French surgeons, as Bouley, Depaul, Nelaton, Guerin, Piorry, Barth, Blot, Giraldes, and Fonssagrieves. It has also been successfully performed by Stein, Oppolzer, Iloch- stetter, and other German surgeons. Ordinarily one or twTo punctures suffice, but when the bowel is loaded with fecal matter, and divided, as it were, into different compart- ments, a greater number may be required. The most suitable instrument for performing the operation is a very delicate trocar or aspirator. Excessive distension of the abdominal cavity may arise from the extrication of gas in peritonitis. In such an event the boAvels will be pushed back by the accumulated fluid, beyond the reach of the finger, and a hollow, drum-like sound emitted on percussion. The respiration is generally embarrassed, and, in some instances, the dyspnoea is so ex- cessive as to threaten asphyxia. As to the propriety of laparotomy, or abdominal section, in such cases, the question presents great difficulties. Of these the most important is the uncertainty of the nature of the disease, and the fact that the division of the peritoneum is always attended with great risk when it is inflamed or even only highly congested. Under such circumstances, indeed, the danger must necessarily be imminent, and even in the most favorable condi- tion, and with the best possible precautionary measures in performing the operation, the CHAP. XV. ARTIFICIAL ANUS — LUMBAR COLOTOMY. 625 patient will often slip through one’s hands. One of the great misfortunes attending the operation is that it is very generally undertaken at a period of the disease when it is too late to do any good, owing either to neglect, the hope of relief from the employment of ordinary remedies, or errors of diagnosis. In two instances in which, after mature deli- beration in consultation with eminent physicians, interference was deemed advisable, I signally failed in conferring the slightest benefit from the abdominal section, one patient dying at the end of four hours, the other in less than thirty-six. In internal strangula- tion, depending upon intussusception, a twist of the bowel, or the interception of the bowel in an aperture of the mesentery or omentum, the diagnosis is necessarily so uncertain that the proper time for relief is usually allowed to pass before an operation is agreed upon, and when, at length, it is performed, the case must, almost of necessity, speedily terminate fatally. In a very interesting paper on laparotomy in the American Journal of the Medical Sciences for July, 1874, Professor Ashhurst has furnished a table of 13 cases in which the operation was performed as a remedy for intussusception, and one of 57 cases in which it was undertaken for the relief of acute intestinal affections dependent upon other causes. Most of the cases in the first table ended fatally. In some of them, indeed, the patient was moribund at the time of the operation. Of the 57 cases in the second table only 18 were successful, showing a mortality after laparotomy of over 68 per cent. Experience, as Ashhurst justly remarks, holds out no encouragement to surgical interference in intussusception occurring in infants under one year of age ; and we may well add from all the knowledge we have upon the subject, that what is true of infants is, with very rare exceptions, true of adults. If the operation could always be performed under antiseptic precautions at an early period of the disease, before there is any serious peritoneal or in- testinal involvement, the results would no doubt be much more flattering to our feelings and more creditable to surgery. If, after opening the belly, a stricture of the intestine be discovered, the bowel may be opened above the seat of the obstruction, and the edges of the wound united to the lips of the external incision, with a view to the. formation of a fecal fistule. Or enterectomy may be resorted to, as was done by Koeberle, who successfully excised, on account of four fibrous strictures, six feet and a half of the small bowel, and sutured the ends of the gut. Enterotomy, first performed by Nelaton, and recommended by Maunder, Wagstaffe, and Bryant, may be practised when the obstruction is situated low down in the small intestine or high up in the large bowel, the object being the establishment of a fecal fistule in the right iliac region by attaching the opening in the intestine to the sides of the ab- dominal incision, begun a little above the crest of the ilium and carried for three or four inches parallel with Poupart’s ligament. The operation is far less fatal than laparotomy; but it subjects the patient to all the annoyances of an artificial anus. When the obstruction depends upon the existence of carcinoma of the colon, colectomy, or the excision of the morbid growth, along with uninvolved adjoining portions of the intestine, may be resorted to, as was first done by Reybard, of Lyons, in 1833, and has since been repeated by Gussenbauer, Baum, Martini, Czerny, Bryant, Marshall, and Fischer. Of the 8 cases, 3 proved fatal, repectively in fifteen hours, on the third day, and on the ninth day; and 5 recovered, of which those of Martini, Bryant, and Fischer were alive at the expiration, respectively, of two, five, and seven months, while the cases of Czerny and Reybard died of recurrent disease at the end of seven and ten months. Five of the operations were completed by uniting the ends of the colon by suture, and three by the formation of an artificial anus. In all of the cases excepting that of Bryant the tumor was reached by an incision carried through the walls of the abdomen. Three attempts at colectomy by Gussenbauer, Thiersch, and Schede had to be abandoned in con- sequence of the extent of the disease. SECT. VIII. ARTIFICIAL ANUS LUMBAR COLOTOMY. The establishment of an artificial anus is indicated when life is in imminent jeopardy on account of the existence of some insurmountable mechanical obstacle to the evacua- tion of the feces. Hence, in cases of obstruction from carcinomatous stricture of the rec- tum, the sigmoid flexure, or the transverse colon, and of obstruction from non-malig- nant stricture, adhesions, or the pressure of morbid growths, as, for example, an enlarged uterus or pelvic tumor, the operation is generally considered not only as justifiable, but as imperatively called for as a means of prolonging life. As a choice of evils, lumbar eolotomy may also be employed for the relief of vesico-intestinal fistules, and to mitigate 626 THE ABDOMEN AND ITS CONTENTS. chap, xv. the exquisite suffering produced by the passage of the feces in cases of ulcerated rectum, without there being actual obstruction. But, although this may be so, I cannot, I must confess, appreciate the benevolence which prompts a surgeon to form an artificial outlet for the discharge of the feces in a case of imperforate anus in a child, in whom the rectum is either completely absent, or terminates blindly several inches above its normal situa- tion. Let the surgeon, if he be a parent, ask himself the question, whether he would not rather see his child die without an attempt at relief than to place it in a condition which must inevitably render it an object of disgust to itself and of loathing to every one around. Littre, as early as 1710, proposed, in a case of imperforate anus, to open, by an incis- ion through the left lumbar region, the sigmoid flexure of the colon, and to secure the orifice in the tube to the wound in the wall of the abdomen by means of a thread passed through the mesentery. The first attempt, however, to carry out this suggestion, or, more correctly speaking, the principle upon which it was founded, was made by Pillore, of Rouen, in 1776, in the case of a man affected with a carcinomatous tumor of the rec- tum, completely obstructing the evacuation of the feces. The artificial anus was made in the cajcum, and the patient survived twenty-eight days, the immediate cause of death being violent inflammation of the jejunum, occasioned by the accumulation of an immense quantity of metallic mercury, taken previously to the operation. The first operation of this kind that was ever performed for the relief of an imperforate anus was executed by Dubois, in 1783; but it was unsuccessful, the child dying on the tenth day. Duret, of Brest, in 1793, was more fortunate. He opened the sigmoid flexure of the colon of a child two days old, who not only survived the immediate effects of the operation, but, when last heard from, had attained the age of forty-two years. Four years after this, Fine, of Geneva, made an artificial anus in the arch of the colon, by cutting through the umbilical region of a woman, aged sixty-three, in a case of constipation from epithelioma of the upper part of the rectum. She lived upwards of three months and a half, when she perished from the effects of the disease. Two distinct processes have been employed for establishing an artificial anus; in one, usually known as that of Littre, the bowel is entered through the peritoneum, both parie- tal and visceral; and in the other on the outside of that membrane, in the space left uncovered by the fold of the mesocolon. The latter was originally described by Cal- lisen, of Copenhagen, in 1796, in his System of Surgery, but whether the suggestion was his own or not is not known. However this may be, the operation was almost univer- sally condemned by the profession, on ac- count of its supposed difficulties, until 1835, when it was revived and improved by Amus- sat, of Paris. The operation of Amussat, fig. 469, the only one which I shall formally describe, consists in perforating the bowel through the iliac fossa, midway between the last rib and the crest of the ilium, the incision com- mencing at the edge of the sacrolumbar and long dorsal muscles, and extending horizon- tally forward for about four inches. The skin and subcutaneous connective tissue having been divided, the muscles and apon- euroses are successively penetrated to the full extent of the external wound, constant use being made of the grooved director, es- pecially as the knife approaches the more deep-seated structures. In very corpulent subjects it is sometimes necessary, in order to obtain a sufficiency of room, to incise the different muscular layers perpendicularly, so as to give the wound somewhat of a crucial shape, but, in general, this may be obviated by drawing the parts forcibly asunder with stout retractors. The muscles involved in the operation are the broad dorsal, external oblique, internal oblique, and transverse abdominal, together with a small portion of the square lumbar, although this occasionally entirely escapes. The bottom of the wound is Fig. 469. Amussat’s Operation for the Formation of an Artificial Anus in the Lumbar Begion. CHAP. XV. ARTIFICIAL ANUS—LUMBAR COLOTOMY. 627 formed by a large quantity of cellulo-adipose substance, especially conspicuous in fat sub- jects; this must next be carefully divided with the finger, or handle of the scalpel, and the colon sought for as it lies in the iliac fossa, at a point almost midway between the anterior and posterior spinous processes of the ilium, but a little nearer to the latter than the former. The colon is generally easily recognized by its greenish hue, by its fixed- ness, and by its distended condition, by which the small intestine is pushed out of the way. If any unusual trouble be experienced in finding it, it may be made to bulge into the wound by forcing air up the rectum. As soon as the cellular connections at the bot- tom of the wound have been severed, the bowel projects freely forward, and is then pierced with a tenaculum, in order to prevent it from slipping back after it has been in- cised. A transverse opening, or, what will answer equally well, a vertical one, is now made into the most prominent portion of the gut, about two inches in length, and its edges tacked to those in the external wound by at least six sutures, two corresponding with each side, and one with each angle. The whole procedure of incising and stitching the bowel should be conducted with the greatest possible care, lest fecal extravasation occur, and so produce severe inflammation. Despite this precaution, however, some of the contents of the tube generally escape as soon as penetration has been effected. Thorough clearance having been established, the patient is replaced in bed, and the parts are covered with tepid water-dressing, confined with a suitable bandage. Very little bleeding usually attends the operation, as, owing to the horizontal direction of the incision, only a few vessels are divided. In the operation of Callisen, in which the incision is perpendicular, the hemorrhage, on the contrary, is frequently considerable. The operation of Amussat may be performed upon either side; in carcinoma of the rectum, or recto-anal region, however, it is always best to select the descending colon. The procedure is usually difficult of execution, especially in infants and children, and, unless conducted with great care and judgment, is very liable to be followed by injury of the peritoneum. Any tendency to undue contraction of the artificial anus should be counteracted by means of tents ; and as soon as the parts have sufficiently recovered from the effects of the operation, the patient should be furnished with a suitable apparatus for preventing the escape of fecal matter. In some cases, there is a strong disposition to protrusion and eversion of the mucous membrane of the bowel, but this generally soon disappears of its own accord. The greatest attention must be paid to cleanliness. Dr. F. Von Erckelens, of Aachen, has carefully analyzed 1B4 cases in which an artifi- cial anus was established by Amussat’s operation. Of these 101, or 63 per cent, survived the operation, and 63, or 38 per cent., died, 83 being examples of carcinoma, of which 52, or 63 per cent., recovered. Only four patients survived more than twelve months, one being still alive at the end of two years, and three having died, respectively, in fourteen months, two years and a half, and four years and a half. The operation was practised for fistules 13 times, with 10 recoveries and 3 deaths; for atresia 11 times, with 4 recov- eries and 7 deaths ; for stricture 38 times, with 25 recoveries and 13 deaths ; and for other obstructions 19 times, with 10 recoveries and 9 deaths. Of 83 operations performed in accordance with the method of Littre, 44, or 53 per cent., survived, and 39, or 47 per cent., perished. Of 23 examples of carcinoma, 14 re- covered and 9 died; but of the former life was prolonged lor more than a in only 2, one being still alive at the end of fifteen months, and the other having died in twenty-five months. Of 32 operations for atresia, 16 were successful and 16 died. Seven of the patients were living, respectively, for fourteen months, eighteen months, two years, twenty- eight months, thirteen years, forty-three years, and forty-six years ; while one died at the end of forty-three years of an intercurrent malady. Of 9 cases operated, upon tor stricture, 3 recovered and 6 died. Of 18 cases operated upon for other obstructions, 10 survived and 8 perished : the one subjected to the knife for fistule recovered. From the facts furnished by Dr. Yon Erckelens, it is obvious that lumbar colotomy is decidedly preferable to the direct abdominal incision, since the recoveries are in favor of the former by 10 per cent. In only 29 per cent, of the fatal cases was there any evidence of recent peritonitis, while this affection was present in 43 per cent, of the fatal cases by Littre’s method. Professor Verneuil has published an account of a number of cases in which, as a sub- stitute for Amussat’s operation, he successfully established an artificial anus by removing, either in whole or in part, the coccyx, the opening thus made being at a position above and somewhat behind the natural outlet. The advantages claimed for this procedure are, the harmless character of the excision, the larger field for the manipulations ot the sur- 628 THE ABDOMEN AND ITS CONTENTS. chap. xv. geon, and the increased facility of finding, bringing down, and attaching the bowel to the margins of the wound in the skin. This ingenious operation is still on trial. SECT. IX AFFECTIONS OF THE OMENTUM AND MESENTERY. The only affections of the omentum and mesentery of any surgical interest, are wounds, hypertrophy, hydatids, serous cysts, neoplasms, and tubercle. Wounds of the omentum are treated upon the same principles as similar injuries of the other contents of the abdomen. If the parts protrude at the external opening, they may, if seriously lacerated, require to be retrenched, care being taken to ligate any vessels that may, if left to themselves, be likely to bleed. A laceration of the omentum, unaccom- panied by any outward marks of injury, sometimes causes death, as in a case reported by Dr. Derner, of a hussar, who, in a violent leap of his horse, received a rent in this mem- brane, one inch and a half in length, from the effects of which he died the next morning. The dissection revealed the existence of five ounces of blood in the peritoneal cavity. Hypertrophy is most common in old, capacious hernias attended with protrusion and long retention of the omentum, which is then entirely changed in its character, deprived of its serous structure, and composed of a hard, dense mass, rough and tuberculated on the surface, as if it were inlaid with fibro-cartilaginous matter. Similar alterations occa- sionally arise from chronic disease when the omentum retains its intraabdominal relations, the membrane being rolled up into a firm, solid mass, having more or less of the shape and consistence of a fibrous tumor, perhaps the size of a fist or even of a foetal head. * Such formations not unffequently contain serous cysts, colloid material, or fibro-cartilaginous concretions, either alone or variously combined; and, consequently, may, especially if they are of considerable bulk, literally fill the abdominal cavity, thus simulating an enlarged ovary, a fibroid tumor of the uterus, a hypertrophied spleen, or a malignant growth. A good illustra- tion of such a mass is represented in the annexed sketch, fig. 470. Hydatids of the omentum, or of the omentum and mesentery, seldom occur except as secondary formations in connection with hydatids of the liver and spleen. Varying in size between a mar- ble and an apple, they are of a spherical shape, solitary or multi- ple, and inclosed each in a distinct sac, in which the acephalocyst with its echinococci securely resides. When the hydatids are very numerous or fully developed, a large tumor may thus be formed, very much as in the case of a hypertrophied omentum, and liable, like it, to lead to errors of diagnosis. Serous cysts of the Omentum and mesentery are uncommon. Such formations are more liable to arise beneath the peritoneum in the wall of the abdomen, where they sometimes acquire a very large bulk. Fatty tumors are the most common of the neoplasms of the mesentery and omentum, and may attain an enormous volume, Waldeyer having described one which weighed sixty-three pounds, and Spencer Wells having unsuccessfully extirpated one weighing twenty pounds. A myxomatous tumor not unfrequently forms in the omentum, and may eventually acquire an enormous size, as in several cases that have been under my personal observa- tion. The disease is usually tardy in its development, and, in its progress, nearly always involves the abdominal and pelvic viscera, the morbid growth sending processes about in different directions, so as to encroach more or less upon the functions of the contained organs. The sarcomatous tumor of the omentum is uncommon. Its growth is generally rapid, and it sometimes attains an extraordinary volume. Thus, in a specimen in my private collection, kindly sent to me by Dr. George E. Conant, of Ohio, the mass weighed upwards of eleven pounds, and occupied the whole abdominal cavity, covering in the urinary blad- der, uterus, bowels, spleen, and liver, and reaching as high up as the ensiform cartilage. The patient, a child, five years of age, suffered from the most frightful dyspnoea, and died in a state of great emaciation. Fig. 470. Hypertrophied Omentum. CHAP. XV. AFFECTIONS OF THE PANCREAS. 629 Great enlargement of the mesenteric glands sometimes arises, generally in young chil- dren, the subjects of strumous disease in various parts of the body. When a considerable number of these structures are affected, a tumor the size of a big fist, or even of a foetal head, may thus be formed, of a globular shape, of a dense, firm consistence, and more or less movable, although eventually it becomes firmly fixed in its position. The diagnosis of these different formations must be based, in great degree, upon the rapidity of their development, the shape, volume, and mobility of the particular growth, and the condition of the general health. A roughened and enlarged omentum may often be distinguished by its superficial situation, its hard feel, and its tuberculated outline. When it is converted into a sarcomatous mass, it usually presents itself as a firm, circum- scribed tumor, rolling about under the fingers, and changing its position with the move- ments of the patient. The existence of hydatids of the omentum and mesentery may be suspected when, along with marked disease of the liver, or liver and spleen, there is enlargement of these parts, with a faint sense of fluctuation and crepitation. When the tumor is adherent or immovably fixed, an exploring needle may be used, the fluid, if any follow its withdrawal, being subjected to microscopic inspection with a view to the detection of echinococci. Serous cysts may generally be detected by their soft, semielastic, fluctuating feel, the history of the case, and the aid of the exploring needle. Hydatid tumors present no peculiarities apart from serous cysts. Solid tumors of these structures cannot always be readily distinguished from each other. The myxomatous is characterized by its great hardness, the uniformity of its surface, its superficial situation, and its tardy development. The symptoms of the sarcomatous growth are, in most respects, diametrically opposite to those of myxoma. Rapid development, in- equality of surface and consistence, and rapid impairment of the general health are its most important features. Sarcoma occurs at all periods of life; myxoma chiefly in middle- aged and elderly persons. Mesenteric tumors are distinguished by their excessive hardness, the irregularity of their surface, and their deep and median situation. They generally occur at an early period of life, and nearly always coexist with evidence of strumous disease in other parts of the body. The examination of these various formations will be greatly facilitated by an empty state of the bowels and bladder, thorough relaxation of the abdominal muscles, and change of posture, the patient being turned from side to side, upon his back, and even upon his face. The distinction between these growths and an aneurism of the abdominal aorta or of its larger branches is always readily determined by the absence of pulsation in the former and its presence in the latter. The surgery of omental and mesenteric tumors is still in its infancy. Nevertheless, experience has clearly shown that interference with the abdominal cavity is, under proper antiseptic precautions, not nearly so dangerous as was formerly supposed. Mr. Lawson Tait, of Birmingham, England, has reported two cases in which he successfully removed hydatids from the peritoneal cavity by the abdominal section, both patients making a rapid recovery. Madelung, of Bonn, was equally fortunate in a case of myxomatous lipoma of the mesentery, including a portion of the small intestine; and Tillaux recently excised a cystic and fatty tumor in this structure, the patient making a perfect recovery. Dr. Buckner, of Cincinnati, in 1852, successfully extirpated a tumor of the mesentery, as large as a man’s head, the true nature of which was, however, not ascertained. Omental tumors may, no doubt, occasionally be extirpated with safety, especially when they are of a fatty, sarcomatous, cystic, or hydatid character. In 1877 I removed a cylindrical-celled epithelioma which was connected by a pedicle, one-third of an inch i>n diameter and half an inch long, with the omentum, of a man fifty years of age. The main mass was subcutaneous, and had made its exit from the belly through an opening in the linea alba. The growth was, of course, of a secondary nature; but as I was refused an inspection of the body, on death two months after the operation, I was unable to determine the origin of the primary tumor. SECT. X AFFECTIONS OF THE PANCREAS. The lesions of the pancreas possess little of surgical interest. The deep situation of the organ places it beyond the reach of the ordinary causes of disease and accident, and renders it extremely difficult to discriminate between its own maladies and those which effect the neighboring viscera. The most common forms of tumors to which it is liable are the cystic and sarcomatous. Carcinoma, as a primary affection, is of rare occurrence, THE ABDOMEN AND ITS CONTENTS. chap. xv. but this disease not unfrequently extends to it during the progress of carcinoma of the liver and of the stomach. I am not aware that any surgeon has yet been so daring as to extirpate the pancreas when involved in this manner, or when it had become the seat of sarcoma. Such an operation would be attended with many difficulties, and would, in almost any event, be fatal, either from shock, hemorrhage, or peritonitis, or all combined. Of cysts of this organ numerous examples are upon record, but none of such deep interest, surgically considered, as that observed by Dr. Bozeman, in 1881, in a woman, forty-one years of age, whose case had been confidently diagnosticated by a number of medical men as ovarian dropsy. Having made the usual incision for the cure of this com- plaint, Dr. Bozeman, much to his surprise, found the cyst connected with the tail of the pancreas, from which it was separated with the knife. The tumor, with its contents, weighed twenty pounds and one-half. The fluid was of a light, brownish color, of acid reaction, and of the specific gravity of 1020. The pedicle was very vascular, and about three-fourths of an inch in length. The artery which supplied the cyst, and which was, apparently, a branch of the splenic, was remarkably large. The disease was first noticed four years before the operation, which was entirely successful, recovery having occurred without one untoward circumstance. In another case, which antedated that of Bozeman, by nine months, and which had also been mistaken for an ovarian tumor, Rokitansky, of Vienna, was unable to remove the en- tire cyst on account of extensive adhesions to the omentum, stomach, and transverse colon. The patient nearly succumbed on the table, and died ten days subsequently of suppurative peritonitis. Other practitioners have met with cysts of the pancreas. Tlius, Becourt and Doupon- chel each refer to a case in which there was a tumor of this kind, the volume of a child’s head; Thiersch evacuated three pounds of a chocolate-colored fluid from a cyst connected with the tail of the organ, and a fistule remained; while Kulenhampff, of Bremen,in 1881, opened the belly, united the peritoneum to the incision, and, four dayrs subsequently,when the sac was adherent to the walls of the abdomen, laid open the cyst, evacuated a pound of fluid, and inserted a tent, the cure being complete in six weeks. Pancreatitis has been known to terminate in abscess, the matter sometimes amounting to many ounces. As the case progresses adhesions form with the neighboring structures, and the contents eventually find their way either into the peritoneal cavity or into some coil of intestine. It is easy to conceive that, when the abscess is very large, it might overlap the aorta, and thus receive an impulse from it, causing one to suspect the exist- ence of an aneurism. SECT. XI INJURIES AND DISEASES OF THE LIVER. Wounds Wounds of the liver are infrequent in civil practice, but common enough in military. Varying in their nature, site, and extent, they are generally attended with con- siderable hemorrhage, and are always to be regarded as serious accidents. The symptoms are often extremely obscure. The most reliable, perhaps, in a diagnostic sense, are, a fixed pain and a feeling of weight in the region of the affected organ, and a discharge from the wound of bilious matter, of a yellowish or greenish color, very thin, and of a viscid consist- ence. Along with these symptoms there is generally gastric irritability, with frequent vomiting, great thirst, constant jactitation, and excessive prostration, occasionally amount- ing to complete collapse. If the patient survive a short time, the eyes, skin, and urine become jaundiced, and there is violent headache, with indescribable languor. Sometimes the nature of the accident is revealed by an escape of hepatic tissue at the wound. In most cases important information may be obtained, in regard to the probable character of the injury, by observing the situation and direction of the external opening, or the course pursued by the vulnerating body. When two orifices exist in the hepatic region, at opposite points of the body, and there is at the same time a discharge of bilious matter, there can hardly be any doubt respecting the diagnosis. In wounds of the gall-bladder there is commonly a flow of pure bile. It is easy to understand why wounds of the liver are so frequently attended with severe hemorrhage. The organ is extremely vascular, having three distinct sets of vessels ; and hence it is impossible for any weapon, however small, to penetrate the parenchymatous substance without dividing some of their branches. If the wound involve a large vascular trunk, the hemorrhage may prove fatal, either speedily or soon after its infliction, as in the case of a man, twenty-eight years of age, who, in an affray, received a transverse cut in the epigastric region, three inches in length, penetrating the peritoneal cavity, along with CHAP. XV. INJURIES AND DISEASES OF THE LIVER. 631 the left lobe of the liver, which projected at the external opening. He lived thirty-six hours, looking very pallid, and having a small, feeble pulse. He bled considerably at the wound. On dissection, performed by Dr. Gilpin, the medical attendant, the cut in the liver was found to be an inch and a half in length by three-quarters of an inch in depth; the parts around were incrusted with coagula, and nearly thi*ee quarts of fluid blood were contained in the abdominal cavity. There was hardly any trace of peritonitis. A little wound, not three lines in length, existed in the omentum. The man had evidently died from loss of blood, chiefly of the liver. Wounds of the liver, especially gunshot, are among the most fatal of accidents, death, if not instantaneous, generally coming on within the first forty-eight hours after the i*eceipt of the injury, in consequence of the joint agency of shock, hemorrhage, and peritonitis. Of 173 cases of gunshot wounds of the liver imported in the Medical and Surgical History of the Rebellion, 62 recovered, notwithstanding that 37 of them were complicated with lesions of other organs. Hennen has recorded 2, and Guthrie 5, examples of x-ecovery from gunshot wounds of the liver. The subjoined case, one of my own, affords an addi- tional proof that such lesions are not always fatal. A boy, eight years of age, was accidentally shot with a pistol, the ball entering on the right side, between the eleventh and twelfth ribs, nearly midway between the linea alba and the spine, and emerging on the opposite side of the spine, not quite half an inch from the median groove, both openings being situated on the same horizontal plane. Consider- able hemoi-rhage followed, which, together with the shock of the injury, px-oduced an alarming degree of prostration, amounting to absolute collapse, and lasting upwards of two days. Under the influence, however, of injections of brandy and hai’tshorne, with sinap- isms to the extremities, chest, and spine, the boy soon began to revive, and at the end of twenty-four hours reaction seemed to be complete. Free supuration gradually arose, attended by the discharge of a slightly greenish, viscid fluid, having every appearance of bilious matter. This continued for about ten days, when it progressively diminished, both wounds closing in less than a month. The treatment, after the establishment of reaction, consisted simply of an occasional laxative, and of light, but nutritous, food, with a liberal use of brandy. The recovery was complete. Six years after the accident, I found the anterior scar four inches below the axilla, as the arm hung by the side, and six inches from the posterior one. Wounds of this organ, inflicted with the sword, sabre, or bayonet, occasionally get well. Dr. N. R. Smith has recorded an instance of recovery from a stab in the liver with a table-knife; a similar case, only much more severe, occurred to Dr. Roux, of St. Peters- burg ; and in one reported to me by Dr. T. A. Andrews, of this city, although the wound in the liver was fully two inches in depth, and of nearly that length, the patient, a man, twenty-two years of age, was perfectly well at the end of four weeks. A remarkable case of incised wound of the liver, four inches in length by one inch in depth at the deepest part, inflicted by a circular saw, attended with the complete division of the eighth, ninth, tenth, and eleventh ribs, the costal pleui’a, and the diaphragm, and followed by rapid recovery, in a lad, fifteen years of age, was reported, in 1869, by Mr. Hamnet Hill, of Ottawa City. The large external wound, closed with fourteen sutures, united, in great degree, by the first intention. The internal treatment consisted mainly of supporting measures, with the fi’ee use of opium. The diagnosis of wounds of the liver must generally be attended with more or less un- certainty. The most reliable sign, unquestionably, is a discharge of biliary matter. When this is absent we can only guess that such a lesion exists by its situation and direction, by the copious hemorrhage, by the severe pain in the right hypochondriac region, and by the existence of great shock. A gunshot wound would be more likely to be attended with an escape of bile than one made with a knife, or a sharp-pointed instrument. The liver is sometimes severely lacerated by falls, blows, or kicks upon the side, or by the forcible compression of the body, as when it is jammed in between two hard, resisting objects, as a post and the wheel of a carriage. Such accidents are not always attended by external marks, not even by any contusion of the skin. The number, extent, situation, and direction of the fissures vary much in different instances. More or less hemorivhage necessarily attends these lesions, especially if complicated with extensive rupture of the peritoneal coat of the liver. Occasionally this membrane retains its integrity even in severe laceration of the hepatic substance, and then the effusion of blood is generally pro- portionally slight. The following case, one under my pei’sonal observation, will serve as an example of such an accident:—A stout, athletic boatman, twenty-three years of age, in a fit of deli- 632 THE ABDOMEN AND ITS CONTENTS. chap. xv. rium, jumped off the portico of a house upon the pavement below, a distance of fifteen feet, bruising and otherwise injuring several parts of his body. Death occurred in an hour after the accident. The liver, somewhat enlarged, softened, and of a dark bluish color, was lacerated in thirteen places. The rents ran in different directions, and, with the ex- ception of two, were perfectly distinct from each other. They varied in length from a few lines to four inches, and in depth from two and a half to six lines, none extending com- pletely through the substance of the organ. The spleen was ruptured on its convex sur- face, the right kidney ecchymosed, and the small intestine extensively contused. The abdominal cavity contained upwards of eight pounds of fluid blood. None of the large vessels were injured. Laceration of the liver, as of any other abdominal organ, is characterized by severe shock; the persistence of which, along with shallow and quick respiration, and a rapid and thready pulse, is indicative of hemorrhage. In the treatment of these wounds of this organ, the great object is to limit inflammation, by the most perfect quietude, gentle enemas, and a careful restriction of the diet. If the patient be young and robust, the use of the lancet may be required; otherwise it will be better to be contented with leeches, fomentations, and blisters. When suppuration is threatened, mercury, to the extent of slight ptyalism, is administered, to modify the in- flammatory action and favor resolution. Pain is relieved by the liberal use of anodynes. When a portion of the liver protrudes at the wound, it should be promptly restored to its natural position, the opening, if necessary, being dilated for the purpose. If some time have elapsed since the accident, it might be proper to let it remain, inasmuch as its reduction might, in such an event, occasion fatal peritonitis. Instances have been related by Blankaard, Schmucker, Dieffenbach, Macpherson, and others, in which the projecting piece was either cut off or removed by ligature, and yet a good recovery ensued. Such treatment is always proper when the parts are seriously injured, as the only means of safety. Hydatid Tumors Hydatids, forming tumors of variable size and shape, and almost uniformly inhabited by echinococci, are occasionally met with in the liver, most generally upon its convex surface and at its inferior border, either alone or in union with similar products in other parts of the body. Usually arising without any assignable cause, their development is sometimes traceable to external injury, as a blow or fall upon the side ; and, although they may occur at any period of life, they are most common from the age of thirty to that of fifty. In their shape, they are generally globular, but, when several are clustered together, they are more or less compressed and flattened ; they are occupied, while young and healthy, by a thin, saline, non-albuminous, colorless fluid, and are con- tained each in a dense, fibrous cyst, of a white, opaque appearance. In old cases, however, or when suppuration has taken place, the fluid is generally turbid, and tinged more or less with bile. Occasionally the tumor is filled with a substance resembling putty, plaster, or cheese, intermixed with fragments of dead hydatids. Ordinarily of tardy growth, the hydatids manifest, in time, a disposition to perish, either from inflammation set up in their own structure, or as an effect of disease in the neighboring hepatic tissues, followed either by the death of the patient, or by a process of elimination by which they find their way into the bowel, gall-bladder, lung, or peritoneal cavity. In rare cases, they escape through the walls of the abdomen. A liver, affected with hydatids, may be of the normal size and shape, although generally it is variously altered in these respects. The diagnosis of hydatids of the liver must necessarily be very difficult, if not impos- sible, in the earlier stages of their existence. As soon, however, as they have attained a considerable bulk, they are commonly sufficiently easy of detection. A sense of weight and of uneasiness is generally felt, but severe pain exists only when the tumors are of rapid formation, inflamed, or so large as to interfere seriously with the functions of the organ. Up to this time also there is ordinarily no disturbance of the general health. The most important signs, diagnostically speaking, are the tardy but steady development of the growth, its globular shape, its comparative indolence, and its fluctuating character. As it increases, it gradually encroaches upon the wall of the abdomen, lifting it up, and thus causing a distinct projection, readily perceptible by sight and touch. During inspi- ration, the hydatic fremitus, as it is termed, is sometimes noticed. When the tumor is of great bulk, there is generally extraordinary enlargement of the superficial veins of the abdomen. The affections with which it is most liable to be confounded are, abscess of the liver, carcinoma, enlargement of the gall-bladder, and aneurism of the aorta. Abscess of the liver is comparatively rapid in its formation, and is invariably accom- CHAP. XV. INJURIES AND DISEASES OF THE LIVER. panied by well-marked symptoms of hepatitis, followed by rigors and severe pulsatile pain. Hydatids, on the contrary, are of tardy development, indolent, and unattended by inflam- mation, except when they are very old, or in a state of decay. In carcinoma, the tumors are multiple, forming small, hard, circumscribed projections on the surface of the organ. They are always accompanied by severe pain, of a sharp, lancinating character, and by more or less jaundice, followed, as the disease progresses, by unmistakable signs of the cancerous cachexia. Encephaloid has sometimes a soft, elastic feel, and may even afford obscure fluctuation. In dilatation of the gall-bladder, there is invariably deep jaundice, which is rarely, if ever, present in hydatids, except in their more advanced stages. The affection, generally caused by mechanical obstruction, is marked by the existence of a smooth, globular tumor, free from pain and tenderness, characterized by a distinct sense of fluctuation, and situated at the lower border of the liver, the movements of which it readily obeys. The alvine evacuations always show an absence of bile. From aneuristn of the aorta, hydatids of the liver are distinguished by the absence of pain, pulsation, and bellows-murmur ; by the more gradual development of the tumor; and by the freedom from sympathetic disturbance, always so prominent in aneurism. When the tumor is not arterial, but derives its pulsation from its proximity with the aorta, the nature of the case may, in general, be easily determined by placing the patient upon his knees and elbows, to favor gravitation. When the wall of the abdomen is very thin, valuable information may be derived from the use of the exploring needle. If the fluid is clear and colorless, perfectly unco- agulable, strongly saline to the taste, and of the specific gravity of 1010, the probability is that it is from an acephalocyst, as no other fluid of the body possesses such properties. When the tumor discharges itself externally, into the bowel, or through the lung, the fluid may contain characteristic booklets, discoverable by the microscope. When a hydatid tumor of the liver, after having been long indolent, inflames and sup- purates, the occurrence will be denoted by severe pain and tenderness in the right hy- pochondriac region, followed by rigors, and excessive constitutional disturbance. The matter thus formed may discharge itself in different directions, as in an ordinary hepatic abscess, as the peritoneal or thoracic cavity, stomach, bowel, bile-duct, or wall of the abdomen. A hydatid tumor, especially if very large, may cause serious mischief by its pressure upon adjacent structures. A not uncommon effect is ascites. The duration of the disease varies, on an average, from two to four years. In certain cases, the tumor occasionally retains its vitality for fifteen, twenty, and even thirty years, as in some of the cases analyzed by Barrier. In the treatment of hydatid tumors of the liver nothing whatever is to be excepted from internal medication. Indeed, the only reliance is tapping of the sac with an aspira- tor or a very delicate trocar, introduced in such a manner as to prevent, if possible, the ingress of air. Care must be taken, also, not to permit any of the fluid to escape into the peritoneal cavity, for fear of provoking fatal inflammation. Unless the cyst is adherent to the wall of the abdomen, as it may be, if old and large, the best plan will be to estab- lish, as a preliminary measure, a caustic issue over the most prominent part of the swell- ing, as in the treatment of hepatic abscess. When any doubt remains, as to the strength of the adhesions, the abdomen should be well bandaged after the contents of the cyst are withdrawn, in order to confine the liver, and thus oppose an effectual barrier to peritoneal mischief. If the operation is followed by suppuration of the hydatid, the patient will be almost certain to perish from the resulting irritation. Of 20 cases of this disease, treated by tapping, collected by Dr. Murchison, of London, 17 recovered, and 3 died; one from the development of secondary tumors, one from a miscarriage, and one from suppuration of the sac, the patient being moribund at the time of the operation. Dr. Harley maintains that the ingress of air into the sac is not attended with danger. Hence, he advocates the establishment of a permanent opening made by retaining a large canula until it has been loosened by suppuration, when it is replaced by a large elastic catheter, through which the sac is frequently washed out with a weak solution of iodine. Of 31 cases treated in this way, 18 were cured, 9 died, the result was not determined in 2, and in 2 the cyst discharged its contents through the lungs. Although the mortality after this procedure is greater than after ordinary paracentesis, the views of Dr. Harley are confirmed by the experience of Lawson Tait, who successfully opened the abdomen, incised the cyst, attached its edges to those of the external wound, and inserted a drain- age-tube in five cases, as well as in one of cystic abscess of the liver. THE ABDOMEN AND ITS CONTENTS. chap. xv. Eight cases of successful treatment of hydatid tumors of the liver by electrolysis have been reported by Dr. Fagge and Mr. Durham. Two needles connected with the negative pole of a modified Daniell’s battery of ten cells were passed into the cyst, the positive pole, terminating in a moistened sponge, being placed upon the surface of the abdomen. The current was maintained for a period varying from ten to twenty minutes in the dif- ferent cases. The operation was generally followed by a rapid diminution of the tumor, together with slight febrile disturbance, and more or less pain, which, however, usually vanished in a few days. The duration of the treatment varied from two weeks to up- wards of a month. Serous Cysts Serous cysts may occur either in the substance of the liver, or upon its surface, immediately beneath the peritoneum, and are capable of attaining a large bulk, encroaching thus greatly upon the diaphragm and abdominal viscera, as well as upon the right hypochondriac and iliac regions. Like hydatids, they are generally of slow growth, and they may be either solitary or multiple, simple or multilocular. They are dull on percussion, fluctuate distinctly under the finger, and are generally unattended with pain and constitutional disturbance. Their contents are of a limpid, saline character, coagu- lable by heat, alcohol, and acids, thus differing essentially from those of hydatids. A serous cyst of the liver sometimes attains an enormous size. A few years ago I drew from a tumor of this kind, in a delicate female, aged twenty-three, nearly a gallon and a half of fluid, as clear as spring water. No accident ensued, and she has remained well ever since. A cyst of this kind might easily be confounded with a hydatid of the liver ; in fact, the only mode of distinguishing between them is the use of the exploring needle. In a serous cyst the contents are always coagulable, whereas in a hydatid there is an absence of albumen. In both affections the fluid is saline, but less so in the former than in the latter. A serous cyst may, like a hydatid, empty itself into a neighboring organ, or it may point externally, and ultimately open upon the abdomen, although such an occurrence must necessarily be very uncommon. When the fluid is poured into the peritoneal cavity, fatal inflammation speedily follows. The proper treatment, of course, is tapping, but not until there is reason to believe that the tumor is firmly adherent to the wall of the abdomen. SECT. XII INJURIES AND DISEASES OF TIIE GALL-BLADDER. Wounds of the gall-bladder are almost invariably fatal. In fact, the only authentic instance, so far as I know, of recovery, is one mentioned by Parroisse, in which a man received a gunshot injury in the right hypochondriac region. He died at the end of two years of thoracic disease, when the ball was discovered in this reservoir. The period at which death occurs varies, on an average, from thirty-six to forty-eight hours. In a case recorded by Dr. Stewart, in which the gall-bladder was traversed by a sword, the patient lived seven days. On the other hand, Mr. Edlin met with an instance of bayonet wound of this sac, in which death was caused in thirteen hours. Rupture of the gall-bladder is generally produced by falls, kicks, or blows, and may occur without any appreciable injury of the external surface of the body. A remarkable case, in which the gall-bladder was found separated from the liver, has been related by Dr. Kilgour. The injury, caused by a jump upon the abdomen, proved fatal in thirty- six hours. Wounds and lacerations of the cystic, hepatic, and choledoch ducts are followed by the same disastrous consequences as similar lesions of the gall-bladder. Extraordinary distension of the gall-bladder, from an accumulation of bile, concretions, or hydatids, is occasionally met with, and may present points of the deepest surgical in- terest. The affection is, for the most part, due to mechanical obstruction, either tempo- rary or permanent, of the cystic or choledoch duct. The tumor thus formed varies in size from a fist to that of an adult’s head. In a case related by Gibson, it contained eight pounds of inspissated bile, and ivas so large as to reach over into the left hypochondriac region, forcing out the ribs on both sides, and causing great embarrassment in breathing. Parallel examples have been recorded by other observers. The swelling is generally of a globular shape, with a smooth outline, and a distinct sense of fluctuation, especially when it is of unusual bulk, or, indeed, even when it is comparatively small, provided the ab- dominal walls are abnorminally thin. Its most common situation is the hypochondrium, where it often projects below the cartilaginous margins of the right ribs; cases, however, CHAP. XV. INJURIES AND DISEASES OF THE GALL-BLADDER. 635 occur in which it is most prominent in the epigastrium, towards the umbilicus, or in the iliac region. The contents ot the distended gall-bladder do not always consist of bile. When its coats are inflamed, the fluid may be purulent, or pus may find its way into it from an abscess ot the liver. In most instances there are biliary concretions ; and exam- ples have been recorded in which the fluid contained hydatids. The tumor formed by a distended gall-bladder is free from pain and constitutional dis- turbance, and is generally very tardy in its development. When the obstruction upon which it depends is permanent, dyspeptic symptoms at length ensue, and the whole sur- face becomes deeply jaundiced. When the gall-bladder is very large, it may occasion great difficulty of breathing and other symptoms of mechanical embarrassment. The principal affections with which it is liable to be confounded are abscess, hydatids, and en- cysted tumors of the liver. The importance of an accurate diagnosis in this disease is illustrated by the fact that a distended gall-bladder has occasionally been punctured under the supposition that the case was one of abscess of the liver. Such a mistake, which the acute and sagacious Petit once came very near committing, would almost certainly be fatal. A temporarily distended gall-bladder may relieve itself either spontaneously or under the influence of cholagogue remedies. When the obstruction, however, upon which the accumulation depends is permanent, the case will generally terminate in one of four ways : by rupture of the organ, and the effusion of its contents into the peritoneal cavity, by its adhesion to the intestine and the escape of the fluid in that direction, by the discharge of its contents through the wall of the abdomen, or, finally, by the induction of constitu- tional irritation. The surgical treatment of this affection is limited to the puncture of the distended or- gan with a small trocar or an aspirator, the latter being, perhaps, the safer instrument. Firm adhesions existing between the gall-bladder and the wall of the abdomen undoubt- edly diminish the risks of the operation, but it is well to know that such a condition of things is not indispensably necessary to safety. If the case admits of delay, plastic effu- sions may be provoked in the same manner as in abscess of the liver. The puncture should be made as near to the border of this organ as possible, and should immediately be closed with adhesive plaster. The operation may be repeated as often as may be deemed proper, its safety having now been tested in quite a number of cases. Large gall-stones, escaping from the gall-bladder, and passing into the bowel, may be- come so thoroughly impacted in it as to impede the passage of fecal matter, and require special interference. Such an event may reasonably be inferred when, several days or weeks after the occurrence of violent pain, of a spasmodic character, in the hypogastric region, attended with excessive gastric disturbance, and a jaundiced condition of the skin and eyes, obstinate obstruction of the intestine supervenes, resisting the ordinary means of relief. When the concretion is of unusual bulk, and there is no distension of the ab- domen, it may sometimes be felt in its new situation, as a hard, immovable body. Three methods of treatment present themselves under such circumstances. The first, and most natural, is to promote the peristaltic action of the bowel, by means of active cathartics, as calomel, colocynth, and croton oil, aided by stimulating enemas. Sulphate of magnesia, senna, and castor oil are sometimes sufficiently active for the purpose. Secondly, when the concretion is within reach of the hand, extrusion may be effected in that way, great care being taken not to inflict any injury upon the bowel. Thirdly, when both these methods fail, the only thing to be done with any reasonable hope of success is to perform the abdominal section, and to extract the concretion through the bowel. The operation should be done under antiseptic precautions, and the wounds closed in the usual manner; the one in the intestine with the catgut ligature, and the ex- ternal one with silver wire. If the bowel at the seat of the impaction is much inflamed, it will be well to push the concretion gently into a sound portion of the tube before open- ing it, as less likely to be followed by injurious effects. The treatment of such an opera- tion involves the same principles as that of wounds of the gut from other causes. Cholecystotomy is a device of recent date, the first operation of the kind having been performed by Dr. Marion Sims in 1878, since which it has been repeated with varying success, by other practitioners, prominent among whom, as early pioneers, may be men- tioned C. Kocher, G. Brown, W. W. Keen, Thomas Bryant, Lawson Tait, A. Camp- bell, and J. Ransohoff. The procedure would seem to be justifiable when, all other means having failed, the gall-bladder forms a large, tense tumor crowding the surrounding struc- tures, and pressing upon them in such a manner as to render life either intolerable, or undesirable. It is very certain that, when the organ is in this condition, nothing else 636 THE ABDOMEN AND ITS CONTENTS. chap. xv. holds out any possible chance of relief, and it need hardly be added that death is seldom far off. To reach the enlarged organ a free incision, either straight or more or less oblique, should be made over the most prominent part of the tumor, fii’st through the skin, then through the abdominal muscles, and lastly, through the peritoneum, as closely as possible to the bor- der of the liver. The wound must be ample, otherwise it will be difficult to perform the necessary manipulations. The organ must now be opened, its contents removed, and its edges stitched by the continued suture to the lips of the abdominal wound. If the viscus should be found to be the seat of a morbid growth the operation must be converted into a cholecystectomy, by dissecting the organ from the liver with great care, and the gall- duct must be cut between two ligatures, one of which is placed within an inch of the hepatic duct, and the other a little farther back, to prevent the escape of bile into the abdominal cavity, an occurrence which could hardly fail to prove fatal. The after treat- ment must be conducted with strict reference to the condition of the system and the pre- vention of peritonitis. SECT. XIII INJURIES AND DISEASES OF THE SPLEEN. Wounds of the spleen are still more rare than wounds of the liver, which they strictly resemble in their character, and in the mode of their production. The prognosis is usu- ally unfavorable, rather on account, however, of the consequent hemorrhage than the severity of the resulting inflammation. All the cases of gunshot wounds that occurred during the late war were fatal, excepting one in which the protruding organ, lacerated by a shell, was successfully extirpated by Dr. Alston, of Texas. When there is a large opening in the side or abdomen, a portion of the spleen may protrude, thus affording an op- portunity of ascertaining the true nature of the lesion by direct inspection; but, in gen- eral, the only phenomena which the practitioner has to guide him in the formation of his opinion of the case are, the situation of the external Avound, the fixed nature of the pain, and the extreme pallor of the countenance, indicative of the great hemorrhage which is so liable to follow such accidents. The absence of symptoms of intestinal, gastric, and other lesions affords important negative evidence. The treatment should be conducted upon general antiphlogistic principles, of which rest and light diet are among the most important. If copious hemorrhage exist, acetate of lead, ergot, and opium should be administered in large and sustained doses, aided by the internal and local use of ice. Stimulants are employed warily, lest the reaction be great and sudden, reinviting hemorrhage, or hastening inflammatory development. If the wounded organ protrude, or lie within the edges of the outer opening, prompt replacement is effected, provided the wound is small, and not disposed to bleed much, otherwise it will be much better to let it remain in its impacted situation than to restore it to the abdomi- nal ca\Tity, as such a step would only serve to favor profuse effusion from the divided and now unsupported vessels. I am inclined to believe that the most of the recoveries after lesions of this kind are due to the partial escape of the organ from the abdomen, and the compression of the wounded structures by the edges of the external orifice. Hence, the circumstance is to be regarded, at least sometimes, rather as a propitious than as an unto- ward occurrence. If the splenic artery is pierced or severed, the ligature must be em- ployed, even at the risk of greatly enlarging the external wound. Instances occur in which the spleen protrudes some distance beyond the external wound, in a state of severe inflammation, several days, having, perhaps, elapsed since the inflic- tion of the injury. The proper treatment, in such an event, is not to restore the projecting portion, lest it should mortify, or lead to dangerous hemorrhage, but to remove it, either with the knife or ligature, on a level with the surrounding surface. The propriety of this practice is sanctioned by the report of numerous cases in which it was successfully adopted ; among others, by those of Alston, and Dr. W. B. Powell, of Kentucky. Of 26 splenec- tomies for injuries collected by Nussbaum, 16 recovered. Rupture of the spleen is sometimes produced by the most trifling accidents, especially if there be considerable softening of its substance, as so frequently happens during the progress of intermittent fever. Under such circumstances, indeed, the organ has been known to give way spontaneously, or under the slightest violence, as a blow upon the ab- domen, a sudden twist of the body, or straining at stool. The accident is usually fatal in a few hours from the loss of blood, which is often effused in immense quantities, and which no remedies can control. An instance of death from laceration of the splenic vein, CHAP. XV. ABSCESSES WITHIN THE CAVITY OF THE ABDOMEN. 637 caused by severe bodily exertion, in a man, twenty-six years of age, has been recorded by Dr. Miling. The spleen is sometimes fatally ruptured by external violence without any apparent marks of injury of the abdomen. In 1867, a boy, seven years of age, died in less than half an hour after he had been struck by a piece of brick thrown at him by a man some distance off. An examination made by Dr. Shapleigh, of this city, showed that the spleen, enlarged in consequence of a former attack of intermittent fever, had been exten- sively lacerated, and that the peritoneal cavity contained nearly a quart of blood, the result of the injury. Splenectomy—Excision of the spleen, on account of chronic enlargement, is said to have been performed by Zaccarelli, of Naples, in 1549, upon a married female, twenty- four years of age. The incision was simple, and the wound healed in less than a month. The operation has now been practised in 85 cases, and the mortality is greatly influenced by the morbid condition for which it is required. Thus, of 18 examples of extirpation for leucocythaemic hypertrophy all, with one exception, died at periods varying from fifteen minutes to three days, the cause of death having been hemorrhage in twelve, shock in four, and peritonitis in one. The operators were Bryant, Wells, and Billroth, each in two cases, and Koeberle, Watson, Langley Browne, Fuchs, Simmons, Czerny, Arnison, Geiswell, Miner, Haward, Franzolini, and Baker Brown, each in one instance. Of 17 cases, on the other hand, in which the procedure was adopted for simple hypertrophy in ten, wandering spleen in four, cystic hypertrophy, hydatid tumor, and a spleen seques- trated in a peritoneal abscess, 8 recovered, the causes of the nine fatal issues having been shock in four, hemorrhage in three, and thrombosis and peritonitis, each in one. The operators were Pean and Urbinati, each in two cases, and Zaccarelli, Ferrerius, Quittenbaum, Dorsey, Kiiehler, Wells, Koeberle. Martin, Czerny, Aonzo, Franzolini, Chiarleoni, and Bonora, each in one. It will thus be seen that splenectomy is a perfectly justifiable procedure when the organ is a source of great discomfort and pain in all diseased conditions except hypertrophy connected with leucocythannia in which it is positively contraindicated. The enlargement constitutes only an insignificant portion of a general disease, and the tendency to hemorrhage is an inseparable obstacle to surgical interference. SECT. XIV ABSCESSES WITHIN THE WALE AND CAVITY OF THE ABDOMEN. Parietal Abscess It is not often that abscesses form in the wall of the abdomen. The occurrence is chiefly witnessed as a result of external injury, as a blow or kick, but it is also occasionally noticed as a consequence of inflammation of the bowel from the presence of impacted feces, or of a foreign body. However induced, the symptoms are usually well marked, being such as attend acute inflammation in other parts of the body, only that there are generally more pain and constitutional disturbance. The matter may collect, first, immediately beneath the skin, in the cellulo-adipose substance; secondly, between the layers of the different muscles; and, thirdly, between the muscles and the peritoneum. In the latter case, it is usually of a decidedly stercoraceous odor, owing to the imbibition of sulphuretted hydrogen from the intestinal tube, which is very apt, as the disease advances, to become adherent to the posterior wall of the abscess. This event often happens even when the bowel retains its integrity, as, indeed, it generally does, however extensive may be the accumulation, its tendency being always to the external surface. Owing, however, to the manner in which the pus is bound down by the muscles and aponeuroses, it is a long time in coming to a head. The diagnosis of these deep-seated abscesses is sometimes extremely obscure, especially in their earlier stages. The most reliable phenomena are, the occurrence of rigors, alter- nating with flushes of heat, the indurated and circumscribed nature of the swelling, the excessive pain and throbbing, and the existence of an erysipelatous blush of the surface, with marked oedema of the subcutaneous connective tissue. The fluctuation is always very faint, even when the matter is approaching the surface. If the abscess is situated towards the middle line, it may receive an impulse from the aorta, and thus induce a suspicion of the existence of aneurism. Whenever there is any doubt about the diagnosis, recourse is had to the exploring needle. The treatment is, of course, rigidly antiphlogistic; by venesection, leeching, and medicated poultices, along with the frequent application of iodine, and the use of pur- gatives, nauseants, and anodynes. As soon as fluctuation is perceived, or even before, provided there is no doubt respecting the diagnosis, a free incision is made, patency THE ABDOMEN AND ITS CONTENTS. CHAP. XV. being afterwards maintained with the tent. If the matter is permitted to remain long pent up, it must necessarily lead to serious structural changes, rendering the cure very tedious. Hepatic Abscess within the abdomen are usually situated in the liver, their occurrence being very frequent in warm climates, especially in the East and West Indies. They are also sufficiently common among the boatmen of our southern rivers. During my residence at Louisville nearly a dozen cases of hepatic abscess, all from Louisiana, were admitted into the Marine Hospital of that city within less than two months. The causes are various. The most common are, malarial influences, ulceration of the large bowel, chronic dysentery, and injury inflicted upon the hemorrhoidal veins, as in opera- tions upon the anus and rectum. Abscesses of the liver as a result of pyemia are not un- common after injury of, and surgical operations upon, the scalp, skull, and brain. Malarial inflammation of the liver is a very frequent cause of the disease in tropical climates. Mechanical violence rarely gives rise to it. Thus, of 308 cases reported by Morehead only 4 were traceable to this circumstance. The matter may discharge itself in different directions; most generally, perhaps, into the peritoneal cavity, where, of course, it promptly excites fatal inflammation, or into a neighboring coil of intestine, into the lungs, or externally through the wall of the abdomen. It is only in the latter event that the disease ever calls for surgical interference, and it is evident that an early and correct diagnosis here is a matter of paramount importance. If the case be neglected, or misunderstood, the abscess, giving way, may suddenly burst into the peritoneal sac, and thus destroy a patient, who, under other and more favorable auspices, might be saved. Besides, if the fluid is long retained, it may cause irreparable injury to the hepatic tissues, so that, although it may ultimately find an external outlet, recovery will be impossible. The most valuable diagnostic characters of hepatic abscess are, a severe, gnawing, aching, or throbbing pain in the hypochondriac and scapular regions, marked enlargement of the liver, great embarrassment of breathing, and inability to lie on the left side, accompanied by violent rigors, alternating with flushes of heat, excessive gastric irritability, and a muddy, jaundiced state of the eye and skin. As the matter accumulates and nears the surface of the organ, it excites inflammation in its peritoneal covering, causing adhesions between it and the wall of the abdomen. The morbid action steadily advancing, ulcera- tion is set up in the superincumbent structures, leading, eventually, after weeks of suffer- ing, to an escape of the fluid, its approach being always preceded by an erysipelatous blush, and by a doughy, cedematous state of the surface. There are four circumstances in connection with abscess of the liver worthy of special attention. 1st. The swelling must not be punctured until there is a well-marked red, purple, or livid spot, with an cedematous state of the skin and connective tissue, over its most prominent part. If these phenomena are wanting, it maybe assumed, as a rule, that there is no adhesion between the liver and the wall of the abdomen, and, consequently, that, if an opening be made, the matter will inevitably flow into the peritoneal cavity, causing fatal inflammation. 2d. When the pus is slow in reaching the surface, and the symptoms are urgent, a free incision should be made over the more protuberant part of the swelling, through the abdominal muscles, but no farther, the object being to excite prompt and efficient adhesion between the contiguous surfaces, by means of a, tent carried deeply into the bottom of the wound. As soon as this event has been brought about, the abscess may be opened with entire impunity. 3d. Care should be taken not to confound the disease with chronic distension of the gall-bladder, an accident which has, more than once, been followed by fatal results. The signs of distinction are generally sufficiently clear. In enlargement of the gall-bladder, the tumor is globular, uniformly hard, and situated lower down than in hepatic abscess, in which the swelling is more diffused, more painful, and also more soft, generally fluctua- ting at its summit, while at the base it is firm and resisting. 4th. The puncture in hepatic abscess should not be direct, but valvular, so as to exclude the ingress of the air, the presence of which is always a source of severe irritation by causing rapid decomposition of the pus. To obviate this effect, the operation should be performed in the same cautious manner as in paracentesis of the chest, with a trocar having a canula furnished with a stopcock and a bladder; or, instead of this, what is decidedly preferable, an aspirator may be employed, the instrument in either case being inserted into the most prominent part of the swelling which will generally be found to be between the eighth and ninth or the ninth and tenth ribs. The only exception to CHAP. XV. ABSCESSES WITHIN THE CAVITY OF THE ABDOMEN. 639 this rule is where the matter lies immediately below the skin, ready at any moment to discharge itself, when the knife should take the place of the trocar or aspirator. The recent observations of some of the East India practitioners go to show that punc- ture ol hepatic abscesses is a much more fatal operation than had generally been supposed. Of 81 cases, collected by Dr. Waring, of the Madras Army, 6G died, and only 15 re- covered. Of 24 cases recorded by Dr. Morehead, two-thirds died. The cause of death in most of the cases was gangrene of the tissues around the puncture and of the subjacent structures. In a majority of the successful cases the abscess pointed either at the epigas- trium or at the border of the right ribs above the level of the ninth. In a case recently recorded by Ransohoff, of Cincinnati, after the failure of aspira- tion, the abdomen was opened, the wall of the abscess stitched to the edge of the wound, and the sac evacuated by a free incision. A constant stream of water was passed through the cavity for six or eight hours at a time, and several large sloughs removed by the aid of a laryngoscopic mirror. The result was all that could be desired. Another successful case of the same nature has been reported by Lawson Tait. Biliary Abscess.—Abscesses of the gall-bladder opening outwardly are uncommon. Their exciting cause is usually external injury, or some mechanical obstruction to the evacuation of the bile, which thus, in consequence of its irritating properties, sets up in- flammation, terminating in suppuration. As the case progresses, adhesions form between the affected organ and the walls of the abdomen, and these, in turn, are succeeded by ul- cerative action, and the discharge of the matter. The manner in which such an abscess is developed is usually very insidious; and, as to its diagnostics, they are altogether unreliable. The affections which it is most liable to simulate are abscess, hydatids, and serous cysts of the liver, and from these it is sel- dom in the power of the surgeon to distinguish it until he meets with the characteristic discharge; that is, bile mixed with pus, or pus and gall-stones. Deep jaundice, gastric irritability, clayey stools, and high-colored urine, along with chilly sensations, or occa- sional rigors, are prominent symptoms in the latter stages of the complaint. The abscess generally points in the lower part of the hypochondrium, but a long time commonly elapses before it reaches the surface. In some cases, the matter pursues a very long and devious route before it finds an outlet. Its approach is always preceded by great pain and tenderness, and by an erysipelatous blush of the skin. Gall-stones sometimes pass off by these abscesses, occasionally in large numbers, fol- lowed by a good recovery, as in a case which I saw, along witli a former colleague, Pro- fessor Henry Miller, of Louisville. The patient, a lady, aged forty-one, had suffered for several years from severe pain in the right hypochondrium, with inability to lie on either side, but especially the left. After some time a hard, circumscribed swelling, about the size of an egg, appeared at the most tender part, and, at length, terminated in an abscess, which, breaking externally, gave exit, at various intervals, altogether to thirty-six biliary concretions, of a tetrahedral figure, perfectly smooth, of a dark cinnamon color, and about the volume of an ordinary cherry. The mouth of the abscess was situated on a level with the umbilicus, five inches from the middle line. In a case more recently under my observation, nine calculi, the largest upwards of half an inch in diameter, were discharged from an abscess in the right side, the patient, a woman, thirty-eight years of age, making an excellent recovery. The treatment of biliary abscess must, in the first place, be rigidly antiphlogistic, as in abscess of the liver. Surgical interference should be refrained from until the matter fairly points, or until there is reason to believe, from the character of the local symp- toms, that firm adhesions have formed between the gall-bladder and the wall of the abdo- men. If this precaution is neglected, the fluid may pass into the peritoneal cavity, and thus provoke fatal inflammation. Stercoraceous or Perityphilitic Abscess This variety of abscess, which, as the name implies, is connected with the intestinal tube, may occur in any portion of the abdomen, but is most common in the right iliac region, from disease of the colon, caacum, or ver- miform appendix, brought on by the abuse of purgatives, the impaction of foreign bod- ies, external injury, or perforative ulceration of the bowel, as a result of typhoid fever. The most common cause, however, of all is the lodgment of some extraneous substance in the caeca! appendix, as a fruit-stone, piece of bone or cartilage, shot, bristle, worm, inspissated mucus, or calculous concretion. Sometimes the obstruction is occasioned by indurated feces, dry, brittle, and, perhaps, incrusted with carbonate and phosphate of lime. Whatever the substance may be, it is sure, if long retained, to excite irritation and ulceration in the coats of the appendix, followed by adhesions, and ultimately, it the 640 THE ABDOMEN AND ITS CONTENTS. chap. xv. morbid action is not checked, by the development of a stercoraceous abscess, opening externally, into the peritoneum, into some neighboring coil of intestine, or even into the urinary bladder. The pus attending the formation of an abscess of this kind is generally of an ill- elaborated character, and excessively fetid, owing either to the absorption ot sulphuretted hydrogen from the alimentary canal, or the actual admixture of fecal matter, which some- times escapes in large quantities. The disease, although most common between the ages of ten and thirty-five, occurs at all periods of life, sometimes even in very young subjects. Males are much more liable to it than females. The symptoms of stercoraceous abscess are always well marked, being invariably such as characterize the development of phlegmonous abscess in other parts of the body. The local distress, however, is generally more than ordinarily severe, owing to the resistance which the accumulating pus encounters from the surrounding structures. The swelling is deep-seated, very painful, and extremely tender on motion and pressure, and there is nearly always marked oedema of the right thigh and leg from obstruction to the return of the blood in the iliac vein. Great constitutional disturbance is present; the rigors are violent and protracted, and the patient is harassed with gastric irritability, insomnia, a sense of excessive prostration, tympanites, and constipation occasionally alternating with diarrhoea. Sometimes the vomiting is stercoraceous, indicating intestinal obstruction from pressure of the overlapping tumor. As the matter advances, the integument is ele- vated into a distinct tumor, exquisitely tender to the touch, and characterized by an ery- sipelatous blush, with an appearance of oedema, both so characteristic of deep-seated abscess. Owing to the manner in which the fluid is bound down, it is seldom possible to detect fluctuation until after the disease has committed severe, if not irreparable, mischief. In some cases air passes from the bowel into the abscess, where its presence may readily be detected both by the ear and the finger, the part, on percussion, emitting a peculiar tympanitic sound. Valuable information is generally afforded by the use of the exploring needle. The treatment of this affection is by an early and free incision ; for, unless the case be met in this way, the matter will be sure to burrow more or less extensively, and may even find vent by the bowel, thus eventually causing a stercoraceous fistule, since, not- withstanding this occurrence, the abscess will ultimately also discharge itself externally. Before the operation is performed, the nature of the disease should always be carefully ex- plained to the patient and his friends, lest, gas and pus escaping, the surgeon be accused of having wounded the bowel, when the opening has been made by the pressure of the pus, or the ulceration which preceded and caused the abscess. When the matter is deep- seated and small in quantity, the safest plan is to make a free incision first through the skin, and then, with the aid of the grooved director, through each muscular layer; other- wise the intestine will be endangered. The cavity of the abscess should always be thor- oughly explored with the finger to ascertain that it does not contain any foreign body; and during the after-treatment it should be washed out well several times a day with car- bolized water. To Professor Willard Parker is due the credit of having first prominently brought be- fore the notice of the profession of this country the treatment of this form of abscess, as he did in 1867, in a paper in the New York Medical Record. The subject, however, had already engaged the attention of Mr. Hancock, of London, as early as 1848. Of 46 cases, tabulated by Dr. J. H. Pooley in 1878, in most of which the abscess was opened by incision, all recovered save 5, death having been caused in 3 by peritonitis, in 1 by abscess of the lung, and in 1 by exhaustion. Splenic Abscess—Abscess of the spleen should be treated upon the same principles as that of the liver. Of this rare disease I have seen only one case, the patient being a young, robust farmer, who suffered immensely for a fortnight. The spleen gradually augmented in volume, and, at the expiration of this period, it projected over towards the umbilicus, forming a large, rounded tumor, between the linea alba and the margin of the ribs. In a short time fluctuation was perceived, and, on introducing a trocar, about three pints of fetid, dark-colored matter issued from the incision. The wound was kept open for several days by means of a tent; but it soon closed, and thence on the patient’s health began gradually to improve. The disease had supervened upon repeated attacks of inter- mittent fever, and was characterized by excessive irritabitity of the stomach, great pain and tenderness, and an impending sense of suffocation, caused, no doubt, by the pressure of the enlarged organ upon the diaphragm. In a similar case Mr. Tait opened the abdo- CHAP. XV. TUMORS IN THE WALL OF THE ABDOMEN. 641 men, evacuated two pints and a half of pus, stitched the sac to the outer incision, and in- serted a drainage tube. At the expiration of six months there was every prospect of a satisfactory recovery. The abscess most generally bursts into the peritoneal cavity, the stomach, colon, or small bowel. Occasionally the spleen becomes adherent to the diaphragm, and then the matter may find an outlet through the lungs, as in the interesting cases observed by Nasse, Man tell, and other practitioners. The metastatic abscess of the spleen is much less common than that of the lung, liver, or brain. It is usually multiple, small, and imperfectly elaborated, being made up, in great degree, of bloody matter interspersed with pus globules. llio-Pelvic Abscess Finally, there is a form of abscess which occasionally supervenes upon parturition, coming on within the first fortnight after delivery, in consequence of in- flammation of the uterus. It differs from the more ordi- nary abscess in the iliac region in that the matter is situ- ated lower down towards the antei’ior superior spinous process of the ilium, or even in the ilio-inguinal region, the fluid extending, perhaps, slightly beneath Poupart’s ligament. Very frequently, indeed, the matter is strictly lodged in the pelvis, its starting point being, probably, the broad ligament of the uterus, the ovary, or the retro- peritoneal connective tissue. However this may be, the dis- ease is much more common on the left than on the right side. Although such attacks are most frequently met with in lying-in females, they occasionally occur as the result of external injury, the use of pessaries, or suppres- sion of the cutaneous perspiration. An abscess in this locality is generally fraught with danger, the patient being worn out by the intensity of her suffering. Occasionally, however, a recovery takes place, the matter eventually finding an outlet at the upper and external part of the groin, near Poupart’s ligament, the opening usually remaining fistulous for a long time. Now and then the abscess empties itself into the rectum, vagina, uterus, bladder, or abdo- minal cavity. In chronic peritonitis, as well as in pelvic cellulitis, the pus has been knoAvn to extend along the spermatic cord, and finally to point at the external ring. The most conspicuous symptoms are excessive pain in the lower part of the pelvis, in- creased by pressure and motion, difficulty in defecation and urination, a feeling of aching, weight, and suffering at the seat of the disease, and high constitutional disturbance. A careful exploration with the finger in the vagina or rectum will generally readily serve to disclose the true nature of the case. When the abscess points in the posterior cul-de-sac of the roof of the vagina, as de- noted by the soft and yielding character of the part, it may be punctured with the bis- toury, guided by the forefinger, or, what is usually preferable, a long, curved trocar. Great care must, of course, be taken not to wound any important structures. The man- ner of performing the operation is shown in the annexed sketch, fig. 471, from Simpson. SECT. XV TUMORS IN THE WALL OF THE ABDOMEN. Various morbid growths, benign and malignant, form within the wall of the abdomen, and, although they do not differ from those in other regions, they deserve particular atten- tion, from the peculiarity of their situation, and their liability to be mistaken for tumors developed in the cavity of the abdomen. The principal growths of this situation, demand- ing brief notice, are the fatty, sarcomatous, and cystic. The fatty tumor is not often found in this situation ; it may lie immediately beneath the skin, among the muscles, or in the inguinal canal. When it occupies the site of the natu- ral outlets of the abdomen, or the linea alba, it may be confounded with hernia, as in the interesting case of Scarpa, in which that illustrious surgeon was induced to perform an operation, under the supposition that his patient was laboring under strangulation of the bowel, when he had merely some colicky pains and abdominal tenderness. Ilad due in- quiry been made into the history of the case, such a mistake might easily have been avoided. The diagnostic characters of the fatty tumor are, the tardiness of its growth, its pei ect Fig. 471. Mode of Puncturing Pelvic Abscess. 642 THE ABDOMEN AND ITS CONTENTS. CHAP. xv. indolence, or freedom from pain, its doughy, inelastic feel, the absence of discoloration of the skin, and the integrity of the general health. A sarcomatous tumor is occasionally met with in the wall of the abdomen. An inte- resting case of this kind was brought under my notice in 1858, at the College Clinic, in a youth of eighteen. When first perceived, thirteen months previously, it was hard and firm, but perfectly movable, and about the size of a pullet’s egg, its situation being on the left side, some distance from the umbilicus. Its progress, for several months, was very gradual, but during the last six or eight weeks it had increased rather rapidly, and, when the case fell into my hands, the growth was about nine inches in length, solid, inelastic, almost immovable, free from pain, and without any enlargement of the subcutaneous veins, or derangement of the general health. A curvilinear incision being carried down over the long axis of the tumor, it was found to be placed under cover of the abdominal muscles, which were very much stretched and attenuated, its posterior boundary being formed by the transverse fascia, from which it was obliged to be separated with great care. Its chief supply of blood was derived from a branch of the superficial epigastric artery, which was enlarged and required a ligature. Under the microscope, the tumor exhibited all the characteristics of spindle-celled sarcoma. The recovery from the operation was rapid, and, thus far, there has been no tendency to relapse. The cystic tumor of the wall of the abdomen is very uncommon. In most of the cases that have hitherto been observed, it was deep-seated, lying immediately exterior to the peritoneum, in which situation it is developed out of the remains of the foetal urachus. It fluctuates, although usually rather faintly, under pressure, and is capable of attaining so large a bulk as to simulate ascites, or ovarian dropsy. Its contents are of a serous nature. Its progress is very slow and painless, and the patient’s health is commonly excellent. These circumstances will generally serve to distinguish this morbid growth from others of a more solid character, but, if any doubt exist upon the subject, it will promptly be dis- pelled by the use of the exploring needle. An instance in which three immense cystic tumors existed simultaneously in the wall of the abdomen, has been related by Dr. Scott in the eleventh volume of the London Medical Gazette. In the diagnosis of tumors of the wall of the abdomen, much valuable information may be derived from a careful consideration of the history of the case, and a thorough exami- nation of the parts, the bowels having been freely evacuated a short time previously. The patient, should lie upon his back, with his limbs well retracted, and the shoulders elevated, so as to cause complete relaxation of the abdominal muscles. The tumor being now grasped with one hand, the fingers of the other may generally be readily insinuated be- neath it, if it be situated in the abdominal wall, at the same time that it will convey an idea of fixedness, which does not belong to intraperitoneal growths. If the patient turns upon his side, the tumor will steadily maintain its position ; generally, too, there will be a degree of tension in the parts which is altogether foreign to internal formations and enlargements. In the intraperitoneal tumor, no matter what may be its character, the growth is originally loose, usually moving or floating about when the patient changes his position in bed ; in the parietal, on the contrary, it is fixed. A growth situated in front of the muscles of the abdomen becomes more prominent when these muscles actively contract; no change is produced by this cause when the tumor is developed in the sub- stance of the muscles ; when the morbid mass lies behind the muscles, it is forced back- wards at each effort, and therefore rendered less distinct. When a tumor follows all the motions of the wall of the abdomen, whether dependent upon respiration, pressure, or traction, the presumption is that it was developed there; but when it does not obey them, the probability is that it is situated behind it, or, what is the same thing, that it has no connection with it. The diagnosis between a tumor and an abscess is readily deter- mined by the history of the case, and the absence or presence of inflammatory symptoms. It any doubt exist in regard to the precise position of the morbid growth, and an opera- tion be urgently demanded, an exploratory incision will be the only thing likely to clear up the difficulty. In the extirpation of tumors in this situation, the incision should always be made as much as possible in the direction of the muscular fibres of the abdomen ; free use should be made of the grooved director; all bleeding vessels should be tied as soon as they are divided; and unusual pains should be taken to tack together, first, the muscular edges of the wound, and afterwards the integumental, lest, when the parts are healed, hernia should take place. The abdomen should be well protected with long, broad, adhesive strips, aided by a compress and broad bandage, which, when the patient is about to rise, should be replaced by an elastic supporter, to obviate all danger of visceral protrusion. CHAP. XV. ASCITES OR DROPSY OF THE ABDOMEN. 643 When the tumor is cystic, the best plan is to evacuate its contents by a free incision, and then mop its inner surface thoroughly with dilute Monad's solution. Professor Nelaton, in 1862, described with great accuracy what he calls the fibrous tumor of the iliac fossa, a growth which I have myself never met with in this situation. It usually occurs in young married women, closely resembles in its structure the fibrous tumor of the uterus, and is situated just above Poupart’s ligament, near the anterior supe- rior spinous process, where it is generally, if not invariably, connected by a fibrous band to the iliac bone. It is solitary, hard, elastic, tardy in its progress, and easily pushed a little upwards and backwards, but not downwards or inwards. In volume it varies from a fist to that of a foetal head. The accompanying pain is of a lancinating character, and extends about in different directions, especially down the thigh and leg. The skin retains its natural color and consistence. The tumor is developed in the connective tissue between the peritoneum and the iliac fascia. In examining such a tumor care should be taken not to confound it with a chon- droma of the iliac bone, a fibrous tumor of the uterus, a collection of feces, a glandular enlargement of the groin, or a tertiary syphilitic tumor in the wall of the abdomen. Its most important characteristics are its remarkable firmness, the fact that it is always solitary, its great depth and fixedness in the iliac region, the lancinating nature of the pain, its slow growth and small size, and, finally, the absence of oedema and discoloration of the skin. The general health commonly remains sound. If the tumor is small, free from pain, and slow of growth, it should be let alone; otherwise it may be removed, care being taken, in laying it bare, not to wound the peritoneum and the iliac vessels. The incisions should be made in the direction of Poupart’s ligament. SECT. XVI ASCITES OR DROPSY OF THE ABDOMEN. Ascites is a collection of watery fluid in the cavity of the abdomen, generally the result of mechanical obstruction to the return of venous blood. The immediate causes of this obstruction are usually valvular disease of the heart, enlargement of the liver, spleen, ovaries, uterus, omentum, and mesenteric glands, organic affections of the kidneys, closure of the vena cava by fibroid concretions, cirrhosis, carcinoma, and hydatids of the liver, and chronic inflammation of the peritoneum. Suppression of the cutaneous perspiration from the effects of cold may also give rise to it. An impoverished state of the system, however induced, whether the direct result of the loss of blood, inadequate supply of food, or protracted and exhausting disease, as scarlatina, measles, and typhoid fever, may be enumerated as so many predisposing causes of ascites. The malady occurs in two varieties of form, the acute and chronic. The fluid of ascites is generally of a pale amber color, slightly viscid, saline, and strongly albuminous. When the peritoneum is actively inflamed, it may be reddish, and intermixed with pus and lymph. In organic disease of the kidneys it occasionally ex- hibits traces of urea, and crystals of cholesterine are also sometimes seen in it. In quantity it ranges from a few ounces to many quarts, from two to three gallons being the average when surgical interference is demanded. The symptoms of this complaint are usually well marked. Among the earliest and most prominent is a gradual failure of the general health; the flesh and strength decline; the countenance is pale and wan; the abdomen progressively enlarges; the renal secretion diminishes; and the lower extremities swell and pit on pressure. As the accumulation increases, the fluid encroaches more and more upon the bowels and other viscera, which, in their turn, press upon the diaphragm, pushing it up against the lungs and heart, and thus causing mechanical obstruction to respiration and circulation. The breathing is often exceedingly embarrassed, so much so, indeed, that the patient is unable to lie down; the action of the heart is irregular; the pulse is abnormally feeble and frequent; the appetite is .impaired ; the bowels are constipated; the urine is scanty, and not unfrequently loaded with albumen and renal casts; the distension of the abdomen steadily augments; the skin is harsh and dry; the emaciation becomes excessive; the scrotum, penis, walls of the abdomen, thighs, and legs are infiltrated with serum ; and the patient at length, after the lapse of several months, dies in a state of complete exhaustion. The blood, in chronic ascites, is always remarkably thin and watery. In the acute form of the malady, the symptoms are more severe, the accumulation advances more rapidly, and there is usually active febrile disturbance, with marked tenderness of the abdomen. Fluctuation is always present, even when the quantity of fluid is comparatively small. I he tumor is dillused and soft to the touch. 644 THE ABDOMEN AND ITS CONTENTS. chap. xv. The situation of the cause of the disease may often be satisfactorily inferred from'the manner in which the dropsy commences. When it depends upon organic lesion of the heart, lungs, or pleura, the first evidence usually is swelling of the head, face, trunk, and upper extremities; when the obstruction exists in the abdominal viscera, the swelling begins in the belly, and thence gradually extends to the legs and feet; and when it is caused by mere debility, as a sequel of exhausting disease, it always manifests itself originally in the lower extremities, or the most dependent portions of the body. The diagnosis of ascites is generally sufficiently easy. A thorough examination of the abdomen and pelvis, and a careful consideration of the history of the case, will rarely mislead the practitioner. The affections with which the complaint is most liable to be confounded are, pregnancy, ovarian dropsy, chronic tympanites, and distension of the urinary bladder. From pregnancy, ascites may generally be easily distinguished by the history of the case; by the absence of the ordinary signs of utero-gestation; by the fluctuating nature of the swelling; by the subsidence of the fluid to the more dependent portions of the body, on varying the posture of the patient; and, lastly, by the effects of hydragogue medicines. In pregnancy, the tumor is median in situation, hard and firm, not soft and yielding as in ascites; and, as it advances, it is easy to detect the pulsations of the foetal heart and of the placenta. In pregnancy, the general health is usually good; in ascites, more or less impaired. In ovarian dropsy, the tumor generally begins at one side, and becomes median only after it has acquired considerable bulk. In ascites, on the contrary, it is median from its commencement. In the former, the swelling is circumscribed, hard, tense, and pro- tuberant; in the latter, diffused, soft, and fluctuating. In ovarian dropsy, the tumor, if unadherent, may be pushed about, but its contents always follow the sac; in abdominal dropsy, on the contrary, the situation of the fluid varies with the posture of the patient; in the one, the tumor lies in front of the bowels; in the other, the bowels are behind and above the fluid. In ovarian dropsy, the disease progresses slowly, and there is, for a long time, little or no disorder of the general health; in ascites, it proceeds more or less rapidly, and the system always deeply sympathizes with the local affection. When the cyst is multilocular, the surface of the tumor is commonly irregular, and, on being per- cussed, yields a sensation as if it contained liquids of different degrees of consistence. Finally, in ovarian dropsy, the uterus is often drawn up, or to one side, almost beyond the reach of the finger; in ascites, on the other hand, it generally retains its normal position. The discrimination between ascites and chronic tympanites is not difficult. The torpid state of the bowels, the rumbling noises, the peculiar resonance of the entire abdomen under percussion, and the unvarying form of the tumor when the patient changes his posture, are too distinctive to be mistaken. The history of the case will, of course, afford additional light. It seems difficult, at first sight, to suppose that any one could mistake a hugely dis- tended bladder for ascites, and yet such an error has, doubtless, occasionally been com- mitted. It is reported of John Hunter that he punctured a distended bladder under the belief that the patient was laboring under ascites. The signs of distinction are, the his- tory of the case, the median situation of the tumor, the absence of distinct fluctuation, the immovable position of the swelling, the constant dribbling of fluid from the urethra, especially if the retention has existed for some time, the peculiar character of the pelvic pains, the bulging of the bladder into the rectum, and the urinous odor of the body. If any doubt obtains, it will be promptly dispelled by the insertion of the catheter. Other causes of embarrassment may exist, as hypertrophy of the liver and spleen, disease of the omentum, dropsy of the uterus, hydatids of the liver, excessive enlargement of the stomach, cystic growths of the Fallopian tubes, dropsy of the kidney, and cystic tumors in the walls of the abdomen. The merest allusion to these sources of deception should be sufficient to induce the surgeon to exercise the utmost vigilance in all cases of a doubtful .character. Allusion has already been made to the manner in which the fluid in ascites changes its situation with the posture of the patient. This is a most important fact in relation to the diagnosis of the disease. When the patient lies down the fluid sinks back and presses out the flanks; when he is erect, it gravitates towards the pelvis and lower parts of the abdomen ; when he lies on one side, it becomes less conspicuous on the other. Fluc- tuation is always readily detected by alternate pressure made with the hands or fingers applied at opposite points of the abdomen. The situation of the intestines is determined by the peculiar resonance elicited on percussion. Wherever there is fluid, there must necessarily be dulness. CHAP. XV. PARACENTESIS OR TAPPING OF THE ABDOMEN. 645 There are two circumstances in reference to the situation of the intestines worthy of special notice in relation to ascites. The first is that they cannot float upon the liquid when they are loaded with solid matter, or are entirely free from gas; and the second, that they may be so firmly bound down by ancient adhesions as to prevent them from rising to the surface. Under such circumstances, the diagnosis between ascites and ovarian dropsy might not only be difficult, but impossible. When the accumulation of water is excessive, it may exert so great a degree of pressure upon the recto-vaginal portion of the peritoneal sac as to cause the perineum to bulge out in the form of a tumor, from the volume of an orange to that of a fcetal head. It is of an irregularly oval figure, like the urinary bladder, fluctuates distinctly under the finger, dis- appears temporarily on pressure, is more or less translucent, and projects forward in such a manner as to occlude the orifice of the vagina. The prognosis of ascites is, for the most part, unfavorable, especially when the affection depends, as is so frequently the case, upon organic disease of an important organ, as the heart, lung, liver, spleen, or kidney. The milder forms occasionally recover spontaneously, or under the influence of very simple remedies. In the treatment of ascites, the first object should be to ascertain, and, if possible, to remove, the exciting cause of the complaint, whatever this may be. The fact should be prominently kept in view that the collection of water is merely a symptom of disease, and not the disease itself. Unfortunately the prognosis is, for the most part, for this very reason, unfavorable. If the water be removed, whether by medicine or puncture, it will be sure, sooner or later, to reaccumulate, unless the cause under the influence of which it has been effused is effectually eradicated. In the earlier stages of the affection, a great deal may frequently be accomplished in the way of relief, by attention to the diet and secretions, and by the exhibition of what are called sorbefacient remedies, as some of the preparations of mercury, hydragogue cathartics, acetate and nitrate of potassium, squills, cream of tartar, diuretic drinks, and, above all, elaterium. Of course, much judgment is required in the selection and use of these remedies. Mercury, in particular, although often exceedingly valuable, should be employed with the greatest possible care, as the slightest ptyalisin could hardly fail to be injurious. The dose of elaterium should not, on an average, exceed the one-twentieth of a grain, repeated once or twice in the twenty-four hours. Tonics are generally necessary, and are sometimes productive of much benefit. When the accumulation of fluid is very considerable, as when it amounts to several gallons, no medication, however judiciously directed, will be likely to be of any avail, owing to the inability of the absorbent vessels to exert their specific influence ; and then the only thing that can be done, with any prospect of success, is to draw off the fluid by an operation. SECT. XVII PARACENTESIS OR TAPPING OF THE ABDOMEN. Tapping of the abdomen is required for the removal of dropsical accumulations of the peritoneum and of the ovary. As it is generally intended merely as a palliative measure, it is never resorted to until the quantity of fluid is so considerable as to occasion great local inconvenience and serious embarrassment of respiration. It may be performed at various points, but the most eligible one is the linea alba, midway between the pubes and the navel. The only objection to puncturing the abdomen here is the danger of per- forating the urinary bladder, which, when distended, often rises some distance above the pelvis. Any mischief, however, that might be thus induced will be effectually obviated by previous evacuation of the organ. In encysted dropsy, it may be necessary to make the opening at the side of the abdomen; but in doing this there is danger of wounding the epigastric artery, an accident occasionally followed by fatal results. In ordinary dropsy, the intestines are pushed back by the weight of the fluid, beyond the reacli of the trocar. It is only when they have contracted adhesions to the anterior wall of the abdomen, as might happen when the operation has been repeatedly performed at the same place, that they would be at all likely to suffer. The fluid of ascites may sometimes be safely and expeditiously evacuated by puncturing the navel, or the sac of an old umbilical hernia. The only instrument required for this operation is a medium-sized, cylindrical trocar, which I greatly prefer to the flat. Some surgeons use a thumb-lancet or a bistoury and a catheter, but the operation thus performed, while it really possesses no advantage what- ever over the other, is always more painful and tedious. There should be at hand, in addition to the trocar, a broad flannel, muslin, or linen bandage, split at the ends, for swathing the belly, and several basins for receiving the water. The trocar of Dr. Morton, 646 THE ABDOMEN AND ITS CONTENTS. chap. xv. fig. 472, possesses great advantages ovrer the ordinary instrument, as the canula is pro- vided with a stopper and a lateral projection near the top for the attachment of a gum- elastic tube for conducting the fluid as it flows from the abdomen into a tub or basin. Fig. 472. Morton’s Trocar. The patient sits semierect in bed with his feet on a chair, or, what is generally preferable, especially if he is weak, he lies on his side near the edge of the bed, and the abdomen is surrounded with the bandage, the ends of which are crossed behind, and given in charge of two assistants. Holding the trocar, well w'armed and oiled, firmly in the Fig. 473. Operation of Tapping the Abdomen. right hand, with the thumb and index finger resting upon the canula, the surgeon plunges it into the linea alba, about three inches above the pubes, and, by a steady, forcible pressure, pushes it through the abdominal wall. A sudden sensation of resistance and the escape of a few drops of fluid announce the arrival of the instrument in the peritoneal cavity, and serve as a signal for the withdrawal of the trocar. The water issues in a full stream, and the discharge is usually soon completed. To prevent syncope, sometimes fol- lowing the rapid removal of the pressure of the accumulated fluid, the ends of the bandage are gradually tightened by the assistants, which compensates, in some degree, for the loss of support experienced by the diaphragm, the large vessels, and the abdominal viscera. Occasionally the passage of water is interrupted by the intrusion of a piece of omentum, a hydatid, or a mass of lymph within the canula. When this happens, the obstacle should be removed by a director, a large probe, or a female catheter, the latter of which may sometimes be advantageously retained in the abdomen until the discharge is completed. When the operation is over, the canula is carefully withdrawn, and the puncture is closed with adhesive strips, the ends of the bandage being firmly pinned over a thick compress to afford due support to the parts, and to prevent rapid reaccumulation. Union usually occurs in a few days. The only accidents at all likely to happen in this operation are syncope and hemorrhage. Of these, the first is to be prevented by a proper tightening of the bandage, in proportion as the water is evacuated; and the second, by making the puncture at the linea alba, where there is no important vessel. It is possible that a copious hemorrhage may occa- sionally proceed from injury of one of the arteries of the omentum ; but such an occurrence must be very rare, and does not, of course, admit of any remedy, since the true nature of the case will seldom be revealed until after death. Should the epigastric artery be wounded, and the blood issue externally, the opening made with the trocar should be treated with acupressure, or, this failing, the artery should be exposed and ligated. Peritonitis after this operation is a remote contingency, which hardly deserves to be taken into account as one of its dangers. chap. xv. FISTULES OF THE ABDOMEN. 647 A few examples have been recorded in which the trocar in this operation was acci- dentally thrust into the bowel. Such an occurrence is best avoided by carefully ascer- taining beforehand the precise situation of the tube by the resonant sound emitted on percussion of the abdomen. A case has been published by Mr. Gay, of London, in which the patient made a good recovery after such an accident. When the surgeon is called upon to tap a female, especially a young unmarried one, or one whose husband has long been absent, he should not be too eager to enter upon the undertaking, but assure himself well beforehand that the patient is not laboring under pregnancy instead of ascites. For want of this precaution accidents have often occurred, as ludicrous as they were disreputable. The best way to avoid this “dry tapping,” is to institute a careful examination into the condition of the mouth and neck of the uterus, if not also of the nipple, and to auscultate the abdomen, with a view to the detection of the foetal and placental sounds; or, what is still better, to employ the vaginoscope of Dr. Routh, an instrument which, brought directly in contact with the womb, reveals the placental souffle at a much earlier period, as from the eighth to the thirteenth week of gestation. This precaution will be more particularly necessary, if the patient is in excellent health, and has, withal, a ruddy complexion, phenomena which, as before stated, are never present in well-established ascites. If pregnancy exist, the hand, plunged into cold water, and suddenly applied to the tumor, will generally cause instantaneous motion of the child, thus at once revealing the true nature of the case. “ I will give you,” says Gooch, speaking of the doubtful signs of pregnancy, “a little advice as to the unmarried class. Never give an opinion until six months have elapsed since the last menstruation. Do not believe one word they say.” Great prejudice used to be entertained against tapping during pregnancy, and there is no doubt that the operation is occasionally followed by the premature expulsion of the child. A number of cases, nevertheless, are upon record in which it was performed with perfect safety even as late as the seventh or eighth month. Perhaps the most judicious plan is always to wait, if possible, until after delivery. SECT. XVIII FISTULES OF THE ABDOMEN. The abdomen is liable to different kinds of fistules, of which the principal are the gas- tric, intestinal, and biliary. Generally caused by wounds, ulceration, or gangrene, they give rise to various accidents, and always heal with great difficulty; indeed, in many cases, they effectually resist every method of treatment that has yet been devised for their relief. 1. Gastric Fistule A gastric fistule generally occupies the epigastric region, and is, consequently, always very short. Although various kinds of injury may produce it, the more severe and unmanageable forms are usually the result of gunshot wounds, attended with more or less loss of substance of the muscular structure of the abdomen. In the case of Alexis St. Martin, the fistule was occasioned by a charge of buckshot, which, tearing away the integument at the inferior part of the left side of the chest, opened the pleural cavity, and entered the great cul-de-sac of the stomach through the diaphragm. The immense gap thus made gradually cicatrized, but left a permanent opening, about four- fifths of an inch in diameter, which was usually closed by a circular fold of protruding mucous membrane. Upon pushing back this valve-like fold, the contents of the stomach could readily be extracted for examination. A fistule of the stomach is generally easily distinguished by its situation, and by the nature of its discharges, consisting of mucus, gastric juice, and various kinds of ingesta. Flatulence and dyspepsia are usually present in greater or less degree. A gastric fistule, caused by organic disease of the stomach, is, of course, incurable; and a similar remark is applicable to all lesions of this kind, accompanied with great loss of substance. Closure, on the contrary, may reasonably be hoped for when the sinus is very small; for then restoration is sometimes effected spontaneously, or under very simple treatment. The most appropriate local remedies, apart from cleanliness, are stimulating injections, and occasional cauterization with nitrate of silver. Little, if, indeed, any, benefit is to be expected from refreshing the edges of the breach, and approximating them by suture. Special attention should be paid to the patient’s diet and the condition of his system. When, in consequence of extraordinary loss of substance, the case is irreme- diable, the parts should be made as comfortable as possible by means of a suitable obtu- rator. St. Martin, whom I saw upwards of twenty-five years after his accident, had all 648 THE ABDOMEN AND ITS CONTENTS. chap. xv. along enjoyed excellent health, and really did not seem, at the time referred to, to expe- rience any material inconvenience. 2. Biliary Fistule Biliary fistule is usually caused by ulceration of the gall-bladder, leading to adhesion between this reservoir and the wall of the abdomen, the primary disease itself being produced either by ordinary inflammation, or by obstruction of the cystic duct by inspissated bile, a biliary concretion, or the pressure of some tumor. A similar effect may be occasioned by an abscess of the liver opening externally, or by gunshot and other wounds of this organ. The most common situation of the fistule is the right hypochondriac region, but cases occur, although they are rare, in which it is found lower down or farther in towards the middle line. Its course is generally somewhat devious, and its diameter so small as hardly to admit a common sized quill, especially if some time have elapsed since its for- mation. The discharge from a biliary fistule consists either of pure bile, or of bile mixed with pus and mucus, the quantity in the twenty-four hours varying from a few drops to several drachms, according to the size of the sinus. Sometimes a probe may readily be passed along the abnormal passage into the gall-bladder or into a hepatic abscess. The general health is usually a good deal disordered, the patient being sallow, flatulent, dyspeptic, constipated, and colicky. In a case which I attended with Dr. S. C. Sharp, of Kensington, the patient, a woman of forty-eight, had labored under a biliary fistule for nearly five years. It had been caused by a large hepatic abscess, followed by the discharge of seventeen calculi, varying in size from a pea to that of a horse-chestnut, with a smooth surface, and of an irregular, triangular shape. Their composition was chiefly cholesterine. Mucus and pus, mixed with bile, continued to flow from the side for upwards of four years, when the discharge materially diminished, but the pain and distress greatly increased. A probe inserted into the sinus readily detected two concretions, which I removed by enlarging the pas- sage with a blunt-pointed bistoury. They were each about the size of a small nutmeg, and were situated in a pouch two inches and a half below the surface. No untoward symptoms followed. In a case reported by the late Professor March, of Albany, a biliary calculus, the size of a hickory-nut, was lodged in the posterior part of the right iliac fossa, from which it was removed by an operation. In the treatment of this affection little benefit is to be expected from topical means. Now and then a spontaneous cure takes place, but the great majority of instances remain unrelieved, and the patient is either worn out by the concomitant irritation, or dies of some intercurrent disease, perhaps years after the appearance of the fistule. All cases depending upon permanent obstruction of the cystic duct must necessarily be of this nature. Any plastic operation would, of course, be utterly futile; for independently of the impossibility of reaching the bottom of the abnormal passage, the constant exit of bile would inevitably be fatal to the adhesive process. Any gall-stones that may appear in the fistulous track must be promptly extracted. 3. Intestinal Fistule—Intestinal fistule, generally, but improperly, termed artificial or abnormal anus, is usually the result of gangrene of the bowel from the pressure exerted upon it by the stricture in strangulated hernia. It may also follow upon a wound of the bowel, and upon stercoraceous abscess. However produced, it is most frequently met with in the inguinal, scrotal, and femoral regions, in connection with the small bowel. A form of fistule occasionally arises from ulceration of the cascum or vermiform appendix. In the fistule caused by mortification, consequent upon strangulated hernia, the two ends of the bowel lie in immediate contact with each other, in the bottom of the sac, like the tubes of a double-barrel gun, their junction being formed by their contiguous walls, each, of course, consisting of four layers. During the inflammation which precedes the sloughing process, the outer or serous surfaces become firmly adherent, not only to each other, but also to the edges of the opening in the abdomen : hence, when the bowel gives way, there is no danger of fecal extravasation into the peritoneal cavity. The junction of the two cylinders here referred to forms a kind of angular, spur-like process, ridge, or buttress, which opposes an effectual obstacle to the passage of the contents of the upper portion of the bowel into the lower, which, in consequence, soon becomes empty and col- lapsed. As the patient has no control over his feces, they have an incessant tendency to escape, thus not only irritating and annoying him, but, what is worse, rendering him an object of disgust alike to himself and to all around. Morever, he ordinarily suffers from prolapse of the mucous membrane of the gut, more especially of the superior extremity, and, if the opening happens to be situated high up in the canal, there is danger that his CHAP. XV. FISTULES OF THE ABDOMEN. 649 general health may become seriously affected from the want of proper nourishment, in con- sequence of the premature escape of ingesta. Flatulence, pain, and indigestion are also common attendants upon intestinal fistule. It is proper to add that the ridge between the two cylinders is usually much less distinct when the accident supervenes upon a wound of the bowel, or a stercoraceous abscess, than when it is caused by mortification. The opening in the wall of the abdomen, in which the ends of the bowel lie, is of vari- able diameter, shape, and depth, and is encircled by thick, irregular edges, generally more or less everted, or everted at one point and inverted at another. The surface immediately around, from the constant contact of fecal matter, bile, and mucus, is usually red, inflamed, chapped, or ulcerated, and so tender as to cause considerable suffering. At the bottom of the opening the two extremities of the bowel are closely embraced by a kind of membranous pouch, known as the infundibulum or funnel, of a firm, dense structure, from one to two lines in thickness, and formed by a prolongation of the proper hernial sac. The treatment of intestinal fistule, occasioned by strangulated hernia, naturally divides itself into palliative and radical. The first consists in promoting the comfort of the pa- tient, by strict attention to cleanliness, preventing the too early escape of the ingesta, and combating such accidents or complications as are liable to arise during the progress of the disease. The use of a well-adjusted truss, fur- nished with a broad pad t'o maintain equable pressure upon the parts, will not only afford great comfort, but may occasionally, especially if the spur-like process between the two cylinders is not too large or prominent, even effect a radical cure. When the case is irremediable, or unusually trou- blesome, a receptacle, made of hard rubber lined with silver, must be worn, the vessel being fre- quently emptied and cleansed. The radical cure may be attempted in one of two ways; either by means of the seton, as originally suggested hy Physick and Schmalkal- ken, or with the enterotome, as practised by Dupuytren. The object of both is to destroy the spur-like process between the two intestinal cylin- ders, so as to reestablish the natural route of the feces, and, when this is accomplished, the closure and cicatrization of the abnormal opening soon follow. The seton, which is best adapted to the milder forms of the affection, may consist of a piece of narrow braid ora stout gum-elastic thread, introduced with a short, curved needle, mounted upon a handle. It should be carried to a consider- able height, in through one tube and out at the other, and be retained for several weeks, or until there is reason to believe that there is firm union between the two cylinders, when all that portion of the septum lying below the foreign body is cut away. The enterotome consists of two serrated blades, a male and a female, about six inches in length, united by a movable pivot, and brought together by a screw passed through the ends of the handles. Fig. 474 exhibits the application of the instrument to the spur-like process formed by the junction of the two cylinders, one blade being inserted into the upper, and the other into the lower. Great care must be taken that the pressure in the first instance is not too firm, otherwise very serious suffering, if not death, may result. The proper plan is to tighten it gradually from day to day, until it has cut its way effectu- ally through the septum. If, notwithstanding this, the patient experience much pain, free use should be made of anodynes, strict watch being kept all the while upon the perito- neum. Moreover, it will always be well, before commencing such an operation, to sub- ject the patient to a certain degree of preparatory treatment, in order that he may be the better able to bear up under its effects. The instrument may usually be taken off in from six to eight days. The adjoining cut, fig. 475, exhibits an enterotome which I devised many years ago, while treating a case of artificial anus consequent upon a wound of the small bowel. It fulfilled the indication most admirably. It is much lighter and smaller than that of Du- puytren, while the pressure which it is capable of exerting is very great. It consists of Fig. 474. Dupuytren’s Enterotome Applied. 650 THE ABDOMEN AND ITS CONTENTS. ch ap. x v. two blades, brought together by a strong slide, and terminating each in a ring deeply ser- rated or notched on the inner surface. Of 41 cases of this operation, in the hands of Dupuytren and other surgeons, 38 survived, and 3 died, one from peritonitis, one from indigestion, and one from fecal effusion. Of the former 29 were radically cured in from two to six months, but the rest retained, in spite of all that could be done, fistulous openings, which compelled them constantly to wear a compress and bandage, to prevent the escape of air, mucus, bile, and even feces. Three-fourths of the cases had been caused by gangrene from strangulated hernia, and the remainder by penetrating wounds, attended with more or less loss of substance of the tube. An intestinal fistule, caused by a wound of the bowel, is always extremely difficult to cure, owing to the small size, or entire absence, of the intervening spur not admitting of the ready application of the seton or enterotome. In an intractable case of this kind under my charge, thirty-five years ago, I was strongly tempted to liberate the bowel from its attachments, and either to sew up the opening, or to excise a small portion, prior to its restoration to the abdomen. The patient’s indisposition to submit to the operation was the only thing that prevented me from carrying out my design. Recently Dittel, Nicoladoni, Dumreicher, Bardenheuer, and Schede, each resorted to this procedure, the steps of the operation consisting in opening the belly in the immediate vicinity of the fistule, dissecting off the adherent bowel, excising the diseased portion, uniting the divided extremities, returning it partly into the abdomen, and closing the inci- sion as well as the abnormal opening. Future observation must determine the value of this treatment. The great danger of course is from erysipelas and peritonitis. When the fistule has been occasioned by ulceration of the bowel, or by a stercoraceous abscess, especially if it is connected with the caecum or colon, great benefit, often followed by a permanent cure, will be derived from a rigid and protracted observance of the prone position, as originally suggested by Sir B. C. Brodie ; as the opening in many, if not in most, of these cases exists at the posterior surface of the tube, the fecal matter will gradu- ally, under the influence of this treatment, cease to escape, and an opportunity will thus be afforded the fistule to close. Finally, when, after the feces have resumed their natural route, the external opening refuses to heal, an attempt may be made to effect its closure by a dermoplastic operation, the flap being borrowed from the neighboring parts. In general, however, the effort will prove abortive, owing to the difficulty of preserving the flap from the contact of intestinal matter. Instances of cure, in these obstinate cases, by the repeated and careful applica- tion of the actual cautery, have been reported by Dieffenbacli and others. SECT. XIX. AFFECTIONS OF THE UMBILICUS. The only surgical affections of the umbilicus are ulceration, hemorrhage, tumors, serous cysts, carcinoma, fistules, and hernia, the latter of which has already been described. 1. Ulceration of the navel is almost peculiar to early infancy, and is usually occasioned by neglect of cleanliness, or rude traction of the cord with a view of expediting its separa- tion. Varying in degree from the merest excoriation to a deep spreading sore, it is always attended with inflammation of the adjacent parts, pain, tenderness, discoloration, and a thin, ichorous, acrid, and offensive discharge. The disease, although in general readily amenable to treatment, is sometimes exceedingly obstinate and rebellious, lasting for many years, now receding and almost entirely disappearing, and then again breaking out afresh, and proceeding with all its former energy. Occasionally an ulcer of this kind is the seat of a periodical hemorrhage, vicarious of the menses ; and cases occur in which it is evidently of an eczematous nature, influenced in its origin and march by a strumous condition of the system. The treatment of this disease will be greatly promoted, in most cases, by an occasional laxative, in union with an antacid. When the patient is pale and debilitated, the use of tonics will be necessary. The best topical remedies are mild astringent lotions, such as solutions of zinc, lead, or copper, either alone or combined with tannic acid, Turner’s Fig. 475. Enterotome. CHAP. XV. AFFECTIONS OF THE UMBILICUS. 651 cerate, or the dilute ointment of the nitrate of mercury. Dusting the surface of the ulcer with calomel, or covering it with dry lint, sometimes answers better than anything else. In all cases the greatest attention should be paid to cleanliness. When the sore is pre- vented from healing from overhanging integument, hardly anything short of the removal of the redundant structure will suffice, inasmuch as it serves to retain the secretions, and tends to rub and irritate the raw surface. When the affection extends into adult life, a mild mercurial course may be required. 2. Hemorrhage of the navel is sometimes met •with either as a mere oozing or as an actual flow, generally about the time of the detachment of the cord, in delicate, sickly infants. If not speedily arrested, it may terminate fatally. The most effectual local remedy is the twisted suture. In the milder cases the object may sometimes be attained by the use of subsulphate of iron, aided by the compress and bandage. Caustic and ordi- nary styptic applications are generally hurtful. Iron, quinine, and brandy are the most suitable internal means. Dr. Francis Minot, of Boston, has published an analysis of 46 cases of idiopathic hem- orrhage of the umbilicus in new-born children, of which 39, or more than 84 per cent., were fatal, at periods varying from six hours to six weeks from the commencement of the attack. A majority of the infants were males, and nearly one-half of them had jaun- dice. The history of the cases would seem to show that some of the children had been affected with the hemorrhagic diathesis. Of the 79 cases of this diathesis collected by Dr. Smith, of New York, other children of the same parents had perished in a similar manner in 26. Of 4 cases of fatal umbilical hemorrhage in my own practice three were preceded by jaundice and followed by petechias in different parts of the body. Three of the cases showed unmistakable evidences of inherited syphilis. 3. The 'papillary tumor of the umbilicus, which includes ordinary granulation tumors, and adenoma, developed at the expense of the persistent remains of the omphalo-mesenterie canal, which contains epithelial elements, is either congenital or comes on soon after birth, and is easily recognized by its florid, violaceous, or purple color, by its soft con- sistence, and by its rounded or conical shape. Its volume ranges from a cherry to that of a small fig, its base being at one time narrow, at another broad or expanded. It gen- erally protrudes from the centre of the navel, although occasionally it is deeply buried at its bottom, with very little or no discharge, and without any appearance of ulceration or of inflammation in the surrounding parts. When rudely touched or irritated, it is liable to bleed. Occasionally there is an aperture at it3 summit, admitting of the passage of a fine probe, but of no escape of fluid. I recently saw a lady, forty-seven years old, who has had a tumor of this kind from birth. It first became sore during one of her pregnan- cies, and has continued to trouble her more or less ever since. It is about the volume of a strawberry, of a florid color, tuberculated on the surface, and the constant seat of a thin, fetid discharge, occasionally attended with a good deal of pure blood. It is sometimes quite painful, and now and then it is covered with a scab. Removal is effected with chromic acid, applied once every other day; aided, if neces- sary, by the ligature, especially when the morbid growth is adherent by a narrow pedicle. When the reverse is the case, the tumor may be shaved off with the knife, repullulation being prevented by chromic acid, astringent lotions, and other suitable remedies. 4. Ncevoid, myxomatous, and sarcomatous tumors are occasionally observed at the umbilicus. Of these the first two are almost peculiar to early life, while sarcoma is gen- erally a disease of middle-aged and elderly persons. Their proper treatment is by early and free excision. 5. A cyst containing water is occasionally met with at the umbilicus, and may acquire a considerable bulk. The tumor is soft, elastic, and fluctuating, free from pain, and slightly translucent. Its seat is apparently in the subperitoneal connective tissue. The only disease with which it is liable to be confounded is umbilical hernia, but from this it may always be readily distinguished by its history, by its consistence, and by its fixed- ness, or our inability to push it into the abdominal cavity. In cases of doubt the explor- ing needle is employed. The proper remedy is evacuation of the contents of the cyst, and the injection of tincture of iodine, as in the operation for the cure of hydrocele. 6. A tumor, probably the result of an irreducible omental hernia, occasionally forms at the umbilicus. In a case, apparently, of this kind which I recently saw in a young woman, a patient of Professor W. H. Pancoast, a rounded tumor, the size of a small orange, occupied the umbilicus, forming a hard, firm, inelastic mass, extending deeply into the abdominal wall, and connected, if one might judge by its feel, with a well- marked pedicle. The tumor had been originally observed about a year before, and had 652 THE ABDOMEN AND ITS CONTENTS. CHAP. xv. latterly become somewhat red and tender on the surface, probably from the friction of the clothes. 7. The existence of carcinoma of the navel is extremely uncommon. The principal form in which it is observed is epithelioma, commencing as a small, indurated growth in the cicatricial tissue, from which it gradually extends, on the one hand, to the subcutaneous connective tissue, and, on the other, by means of the fibrous structures of the umbilicus, to the peritoneum. The tumor, which is nearly always very tardy in its progress, and which is met with chiefly in old subjects, is of great hardness, and the seat of sharp, lan- cinating pains; circumstances by which it may always be readily distinguished from other diseases. The skin is of a purple or violaceous color, and finally yields to ulcera- tion, followed by a thin, ichorous, fetid discharge. The growth would seem, at first sight, to be superficial, but a more thorough exploration soon shows that it extends towards the abdominal cavity, one portion occupying the subcutaneous connective tissue, and the other the subperitoneal, the shape of the mass resembling that of a shirt-stud, the constricted part corresponding with the navel. The treatment is limited to excision. 8. Stercoraceous, urinary, and other fistules are sometimes met with at the umbilicus, but their occurrence, besides presenting nothing peculiar, is so uncommon as not to require any special notice. In a case of congenital intestinal fistule in a child seven days old, reported by Dr. A. S. Mayo, the cord had separated as usual, except that it had left an ulcerated surface, permitting the escape of flatus and fecal matter, more or less of which was also discharged by the anus. Nitrate of silver was freely applied, but the opening was not effectually closed until after the ligation of the stump of the cord. An umbilical fistule, leading down to the peritoneum, perhaps several inches in length, and the seat of a clear, glairy fluid, small in quantity but more or less persistent, is occa- sionally met with. The defect is congenital, and is always difficult of cure. Laying the sinus freely open, and preventing readhesion by the use of a tent, are the only trust- worthy remedies. In the vesico-urachal fistule, the urachus, which connects the summit of the bladder to the anterior wall of the abdomen, remains pervious, and thus allows the urine to escape at the umbilicus. The affection is nearly always congenital. The orifice of the fistule is indicated by a soft, reddish papilla, and, in general, readily admits of the introduction of a probe into the bladder. Several cases have been reported—one recently by Vosburgh— in which such a passage was the seat of a urinary calculus, and one in which a ring- shaped concretion of this kind had formed around a hair. When the fistule proves troublesome a cure may usually be easily effected by paring the edges of its orifice, and approximating them with the harelip suture. Irritating the track with a probe dipped into a strong solution of nitrate of silver, acid nitrate of mercury, or chloride of zinc is sometimes followed by obliterative inflammation. Urinary concretions can generally be readily detected by a careful examination with the probe and finger. Relief is effected with the knife and forceps. SECT. XX GENERAL DIAGNOSIS OF ABDOMINAL AFFECTIONS. There are few surgeons, however skilful or experienced, who are not at times sadly perplexed in regard to the diagnosis of abdominal affections. These affections are not only of frequent occurrence, but greatly diversified in their character, and it is, therefore, of paramount importance that they should be accurately distinguished from each other. Several of them, indeed, sometimes coexist, thus not a little augmenting the embarrass- ment. Moreover, serious difficulty occasionally arises in determining whether the disease is seated in the wall or in the cavity of the abdomen. The surgical affections of the abdomen may, diagnostically viewed, be divided into two distinct classes: 1. The acute; and 2, the chronic. The former consist principally of abscesses, hernia, peritonitis, and retention of urine ; the latter, of different morbid growths, enlargements, and effusions, together with certain pulsations closely simulating those occasioned by aneurism. In all explorations of this kind the bowels should be thoroughly evacuated as a pre- liminary measure, and the surgeon should rapidly recall to mind the different regions of the abdomen with their respective contents. The patient should lie upon his back, or alternately upon his back and side, the muscles of the abdomen should be fully relaxed by elevating the shoulders and thighs, and all the manipulations, especially palpation and percussion, should be performed with the utmost gentleness, otherwise they will be sure to occasion suffering, and so mar the result. The patient’s mind should be diverted as CHAP. XV. GENERAL DIAGNOSIS OF ABDOMINAL AFFECTIONS. 653 much as possible, and no mistaken notions of delicacy should be permitted to interfere with the object of the exploration. If one examination do not suffice, another should be instituted, and thus the investigation should be continued until the diagnosis of the case has been satisfactorily determined. Sometimes an anaesthetic may advantageously be exhibited, especially when there is extraordinary rigidity of the abdominal muscles. Abscesses of the abdomen are for the most part of a phlegmonous nature, and are attended by the ordinary signs of such affections. They may be developed just beneath the surface, among the muscles, or immediately exterior to the peritoneum. Sometimes they are stercoraceous, hepatic, splenic, ovarian, or pelvic. Rigors always occur when the matter is deep-seated, or slow in finding an outlet, followed by hectic irritation and rapid emaciation. An abscess in the epigastrium and in the left side of the liver may receive a direct impulse from the aorta, and thus simulate aneurism. The stercoraceous abscess is most common in the groin and in the right iliac region ; in the former as a consequence of strangulated hernia, in the latter, of disease of the cajcum and vermiform appendix. A psoas abscess, if unusually large, may project forward into the abdomen, in such a manner as to be easily felt through its wall, and thus occasion doubt as to whether the disease is an accumulation of pus, a mass of lymphatic glands, or a sarcomatous tumor. The best guides to a correct decision are the history of the case, and a careful examina- tion of the parts. Hernia is most frequent in the groin, at the upper and inner part of the thigh, and at the umbilicus. If reducible, it will be found to be soft and gaseous, or partly soft and partly hard, as when it contains omentum, to receive an impulse on coughing, and to return with a gurgling noise. When strangulated, the tumor is tender and painful, or soon becomes so, the bowels are constipated, colicky pains are experienced, and at length stercoraceous vomiting ensues. Reduction is attended with more or less difficulty. Inguinal hernia is sometimes closely simulated by an undescended testicle, suddenly taking on inflammation, and a similar effect may be produced here, as well as in the thigh, by a diseased lymphatic gland. Occasionally these affections coexist. Whenever symptoms of strangulation occur, the judicious surgeon will not fail to seek for hernia, intussusception of the bowel, or visceral disease. Finally, hernia is sometimes simulated by psoas abscess, pointing either above or below Poupart’s ligament. Acute peritonitis, whether the result of external injury, strangulated hernia, fecal ex- travasation, cold, or tuberculosis, is characterized by excessive tenderness on pressure of the abdomen, retraction of the thighs, collapse of the features, tympanites, gastric irrita- bility, and a small, hard, wiry, frequent pulse. A distended bladder, from retained urine, might be mistaken for ascites or ovarian dropsy, but such errors can only happen in the hands of the most ignorant and careless observer. In general, the history alone of the case is quite sufficient to establish its true character. Distension of the abdomen may be produced by fluid in the peritoneal cavity, gas in the intestinal tube, and urine in the bladder. In the first case, the collection generally occurs slowly, and is nearly always dependent upon organic disease of the heart, liver, spleen, peritoneum, or large vessels. Its presence is indicated by dulness on percussion, by fluctuation, and by the gravitation of the fluid to the lower part of the abdomen during the erect, and to the posterior and lateral aspects of the cavity during the recumbent, posture. The existence of gas, meteorism, or tympanites, is declared by a hollow, drum- like sound on percussion, generally perceptible over the entire abdomen, and by the unalterable condition of the tumor during change of posture. The tympanites is sometimes partial. A rapid accumulation of gas in the peritoneal cavity after injury of the abdomen may usually be regarded as a sign of a wound of the intestine. Great and rapid disten- sion occasionally occurs from retention of urine. The history of the case, the median position of the tumor, with its gradual development from below upwards, and the inability to pass water, followed at length by incontinence, will, in general, suffice to point out the true nature of the affection. Of the tumors which are liable to occur in the abdomen, some are fixed, others movable or floating. They may, moreover, be of new growth, or they may consist simply of enlargements of some of the viscera, as the spleen, liver, omentum, or ovary. Hence, to refer them to their proper category is not always by any means an easy matter. The most common of the fixed tumors of the abdomen are the myxomatous and the colloid, which sometimes completely fill its cavity, running in among the viscera, and pro- ducing one confused mass of disease, with enormous distension. The liver, mesenteric 654 THE ABDOMEN ANI) ITS CONTENTS. chap. xv. glands, uterus, and ovary are also capable of prodigious enlargement, especially the latter, the weight of which sometimes nearly equals that of the body. Floating tumors of the abdomen are, for the most part, connected writh the omen- tum, the spleen or the ovary; more rarely with the liver. As the name implies, they shift their locality with the position of the patient, rolling about from side to side, being here at one time, and there at another. This is especially true of omental tumors, which often slip about in the most perplexing manner. Ovarian tumors are almost always movable in their earlier stages; their situation is, at first, lateral and pelvic, but bv degrees they ascend into the abdomen, and assume a median position, so as to render it difficult, if not impossible, to determine on which side they originated. A hydatid, attached to the liver, an enlarged spleen, and a dislocated kidney may float about very much as an omental or ovarian tumor. In the Museum of the University of Nashville is a dermoid cyst the size of a cocoa-nut, which, as I am informed by Professor W. T. Briggs, was attached by a long, narrow pedicle to the lower part of the descending colon of a negress, and the interior of w'hich was occupied by a mass of adipocere, intermixed with a bunch of hair a yard in length. Aneurism, of the abdomen is liable to be simulated by numerous affections, often exist- ing under very dissimilar conditions. Of these affections the principal are tumors of the stomach, liver, pancreas, mesentery, and omentum, impacted fecal matter, masses of worms, and gaseous accumulations, overlying the ventral arteries, especially the aorta, and thus receiving their pulsations. Aneurism of the abdominal aorta is much more frequent in men than in women, and seldom occurs before the age of fifty. The tumor is fixed, and easily recognized in the flaccid state of the bowels. The murmur, thrill, and impulse are steady and persistent, not changeable and occasional, as in mere nervous or inflammatory affections of the aorta. In aneurism of the superior mesenteric artery the tumor is generally more or less movable. Tumors connected with the stomach and omentum are commonly of a floating character, and readily pushed from side to side; those of the pancreas and mesentery, on the con- trary, are nearly always fixed, and remarkably hard, firm, and unyielding, especially when they are of a malignant nature. In the latter case, the enlargement is gradual, and usually attended with great gastric irritability. Fecal and gaseous accumulations generally promptly disappear under the use of a brisk purgative. An enlarged liver sometimes receives the pulsations of the aorta, and a similar phenomenon has been witnessed in a distended bladder. Extraordinary fulness in the lumbar region is denotive of hypertro- phy, dropsy, or malignant disease of the kidney, or of carcinoma of the suprarenal cap- sule. If the affection is associated with excessive pain and rigors, the existence of abscess may be suspected. In chronic enlargement of the spleen, the tumor is seated in the left side, from which it may extend across the umbilicus, and even dowm into the hypogastrium ; it is very hard and firm, almost immovable, and more or less sharp along its dextral margin. A distended gall-bladder may form a large swelling, projecting over towards the umbilicus, pyriform, elastic, fluctuating, and varying with the position of the body. Jaundice is generally a prominent attendant upon the disease. The stomach is occasionally displaced by a mass of solid substance in its interior, as in the remarkable case recorded by Mr. Marshall, in which the pyloric extremity of the organ wras dragged down into the left inguinal region by a collection of pins, swallowed from time to time by the patient. The tumor thus formed was of the size and shape of the placenta; it weighed nine ounces, and w'as distinctly traceable during life. The phantom tumor of the abdomen, as it has been called, on account of its deceptive character, has sometimes led to most serious errors of diagnosis. Thus, Dr. Bright men- tions a case in which the surgeon was so thoroughly convinced of the existence of a cyst that he was induced to perform ovariotomy, when, as w'as afterwards proved, the falla- cious appearance was solely dependent upon a tympanitic condition of the abdomen. A similar mistake w’as committed by Lizars, of Edinburgh. Gooch refers to a case in which, the abdomen being laid open, the enlargement was found to be entirely due to flatulence and fat. Dieffenbach, in 1828, was induced, at the instance of Heim, to per- form the Caesarean operation under the belief that the patient wras affected with extra- uterine pregnancy; but there was no foetus, no tumor, or even any visceral enlargement. The phantom tumor is most common on the right side, in young, nervous, hysterical females. The causes which give rise to it are, principally, solid fecal accumulations, irregular contractions of the bowel at two points, with intervening distension with flatus or fluid matter, and spasmodic rigidity of the muscles of the abdomen, especially the straight. CHAP. XVI. AFFECTIONS OF THE KIDNEYS AND URETERS. 655 The best mode of detecting the true nature of this singular affection is to make firm pressure with the hand upon the abdomen as the patient lies upon her back with the knees drawn up and the head and shoulders thoroughly elevated. Success will be more likely to follow if the attention be diverted by keeping up a conversation unconnected with the character of the complaint. If these expedients fail, recourse should be had to an anaesthetic, under the influence of which the tension and enlargement almost completely disappear, recurring, how'ever, as soon as the effects of the anaesthetic have passed off. Perplexity may be experienced in determining whether a tumor is situated in the wall or in the cavity of the abdomen. The former is occasionally the seat of sarcoma- tous, cystic, and fatty formations, and such is the obscurity attending their development as to render it often extremely difficult to establish their true site and character. A gravid uterus has sometimes been mistaken for ascites, or ovarian dropsy ; an opera- tion has been performed, no fluid has escaped, and the true nature of the case was only determined by the delivery of the child. On the other hand, numerous examples have occurred in which pregnant females were tapped under the supposition that they labored under ascites. Symptoms of a very perplexing character may be induced by abnormal pulsations of the aorta. The occurrence, although most common in nervous, anemic, or hysterical females, is also occasionally witnessed in men, and is usually associated with inordinate action of the carotid arteries. Its exciting cause is either an impoverished condition of the blood, or neuralgia of the ventral aorta, or of this vessel and of the solar plexus. It may likewise depend upon inflammation of the aorta. The pulsations are frequently so violent as to admit of being both seen and felt. The best way to escape error is to ex- amine the abdomen after thorough evacuation of the bowels, when it will generally be easy to trace the outline of the affected vessel, and thus remove all doubt respecting the real character of the complaint. Finally, grave error has sometimes arisen from the existence of a movable kidney. An instance is recorded in the London Lancet for March, 1865, in which an organ of this kind, affected with malignant disease, was supposed to be an ovarian tumor, a mistake which was not discovered until after an operation had been commenced for its extirpation. When a kidney is in this displaced condition, it may generally be readily pushed about from one point to another, and form a tumor of a dense, firm consistence, and of unvarying size ; circumstances which, added to the fact that the corresponding loin is always unnatu- rally flat, and that it affords a distinct tympanitic sound on percussion, are sufficiently de- notive of the true character of the case. CHAPTER XVI. DISEASES AND INJURIES OF THE URINARY ORGANS. SECT. I AFFECTIONS OF THE KIDNEYS AND URETERS. The kidneys are liable to wounds, lacerations, contusions, fistules, inflammation, ab- scesses, calculi, dropsy, hydatids, worms, morbid growths, displacement or mobility, and hemorrhage ; affections all of more or less surgical interest. 1. Wounds Wounds of the kidneys, whether incised, lacerated, or gunshot, generally speedily terminate fatally, either from shock, or shock and hemorrhage, from inflamma- tion of their proper substance, or from peritonitis, the latter event being sure to happen whenever there is the slightest escape of urine into the abdominal cavity. Death occa- sionally occurs at a somewhat remote period, as a few weeks or months after the infliction of the injury, from pyemia, secondary hemorrhage, hectic irritation, or purulent infiltra- tion of the perinephritic connective and adipose tissues. Wounds ot the pelvis and great vessels of the kidneys are particularly dangerous, inasmuch as the former is almost Fnvariably followed by fatal extravasation of urine, and the latter by exhausting hemor- rhage. The prognosis in wounds of the cortical substance is more favorable than in wounds of the tubular, and in wounds of the posterior surface of the kidney than of the anterior, or where it is covered by peritoneum. The Surgical History of the War of the Rebellion refers to twenty-six cases of recovery, in the same volume, from gunshot 656 DISEASES OF THE URINARY ORGANS. CHAP. XVI. wounds of the kidney, although in six of them the lesions were complicated with injury of the liver; and twenty-one additional cases, collected from various sources, are mentioned in which the result was equally fortunate. In two of these cases, the pieces of cloth which were carried into the kidneys with the entering bullet were afterwards discharged by the urethra. The existence of a wound of the kidney is denoted by the presence of blood in the urine, a frequent desire to micturate, pain and sense of weight in the lumbar region, and retraction of the testicles, accompanied, if the injury is at all severe, by excessive pros- tration, nausea, and vomiting, deadly pallor of the countenance, clammy perspiration, and coldness of the extremities. All these symptoms, however, may be fallacious ; but if, superadded to them, there is an escape of urine at the wound, no doubt can remain re- specting the true character of the lesion. Useful information may sometimes be obtained from an examination of the situation and direction of the wound. In the treatment of these lesions the first thing to be done is to remove any foreign matter that may be present, and the next, to limit, as much as possible, the resulting in- flammation. All officious probing is, of course, avoided, nor is the opening dilated, unless it is imperatively necessary. The posture of the patient should be such as to render the wound the most depending part of the body, in order to facilitate drainage and the ready passage of the urine. If plethora exist, blood should be taken freely from the arm and by leeches from the loin and abdomen, the bowels evacuated by gentle cathartics, and the heart’s action subdued by veratrum viride or aconite, in combination with morphia. Diu- retics must be rigidly abstained from, and thirst must be allayed with ice. The use of the catheter will be required if the bladder is filled with clotted blood, obstructing the flow of urine. If the renal lesion is complicated with peritoneal, nothing should be permitted to pass the bowels for many days. Urinary infiltration, erysipelas, and abscesses consequent upon the injury must be treated upon general principles. ATlien the kidney protrudes through an incised wound in the loin and cannot be re- placed, it should be removed, an operation which has been successfully practised by Brandt, Marvaud, and Hamilton. 2. Lacerations—Ruptures of the kidneys may be produced by falls, blows, or kicks, and are generally associated with serious injury of the abdominal viscera, with fracture of the ribs and pelvic bones, and with contusion of the skin and muscles, although occa- sionally there is no mark whatever of external violence, not even the slightest ecchymosis. The rent may be confined to the cortical substance, or it may extend through this into the tubular, or even into the pelvis and calyces. Sometimes, indeed, the organ is literally crushed or split in two. The accident is commonly attended with considerable effusion of blood into the sur- rounding connective tissue, and sometimes even into the peritoneal cavity. The symp- toms generally resemble those of a wound of the kidney; the urine is bloody, and the distress in the lumbar region excessive. The period at which death occurs varies from a few minutes to several hours, days, or weeks. The injury, however, is not always fatal. In favorable cases the gap is gradually repaired, and the patient recovers. The treatment must be chiefly by leeches, blisters, fomentations, rest, and anodynes. 3. Contusions—A mere contusion of the kidney sometimes proves to be a very serious accident, leading to violent, if not fatal, inflammation of its substance, attended with great constitutional disturbance. The urine is generally bloody, the lumbar region is more or less profoundly eccliymosed, and the patient is unable to move about in bed. The accident is often followed by peritonitis, and by extensive abscesses in the connective tissue around the injured organ. A very slight blow upon the loin is capable of causing death when the kidney contains a ragged calculus, the sharp points puncturing the blood- vessels. The treatment must be conducted upon the same principles as in wounds and lacerations of this organ. 4. Fistules—Wounds, lacerations, contusions, calculi, and abscesses of the kidney are occasionally succeeded by a renal fistule, occupying, for the most part, the lumbar region, but sometimes the gi-oin or abdomen. The affection, which is chai'acterized by a con- stant discharge of pus and fetid urine, always evinces a peculiar obstinacy, although a number of cases have been reported in which it disappeared spontaneously. Dr. Her- mann Demme, of Bern, during the Italian campaign in 1859, saw not less than three instances of renal fistule, consequent upon gunshot injui-y, recover in this way. Efforts at a cure should be aided by attention to cleanliness, stimulating injections, and cauteri- zation with nitrate of silver. Laying open such sinuses, and scraping away the unhealthy CH AP. XVI. AFFECTIONS OF THE KIDNEYS AND URETERS. 657 granulations, is often productive of benefit in placing the parts in a more favorable condi- tion for gradual repair. When these and other means fail, and life is rendered miserable, the only chance of relief is nephrectomy, an operation which, although one of danger, has been performed successfully in a number of instances. 5. Inflammation Inflammation of the kidneys may be acute or chronic, the latter being by far the more frequent of the two. As an idiopathic affection it is extremely rare. The most common exciting causes are external injury, the presence of renal calculi, irritating diuretics, stricture of the urethra, enlargement of the prostate gland, and chronic disease of the bladder. In some cases it is provoked by the gouty or rheumatic diathesis. The inflammation may be limited to the proper renal tissue, or it may at the same time involve the pelvis and calyces, thus constituting what is termed pyelitis. The most prominent symptoms of acute nephritis are sharp, spasmodic, or dull, heavy, deep-seated, aching pains in the loins, increased by pressure and motion, and extending along the spermatic cord, up the back, down the thigh, and into the pelvis; retraction of the testicles; scanty, high-colored urine; irritability of the bladder, with a frequent de- sire to micturate; pyrexia; great thirst, restlessness, nausea, vomiting, and, in most cases, constipation of the bowels. If the urine be examined with the microscope, blood, pus, and renal casts may generally be detected. If permitted to progress, the disease either passes into suppuration, or it assumes the chronic form. The treatment consists, mainly, in perfect quietude of mind and body, general and local bleeding, fomentations of the loins, mercurial purgatives with morphia, antimony, or veratrum viride, and cooling drinks. If the attack prove obstinate, a large blister may be applied to the affected region. When the disease is manifestly of a gouty or rheumatic nature, the most suitable remedies are colchicum and Dover’s powder, with alkaline drinks. Chronic nephritis is generally dependent upon organic disease of the urethra, bladder, or prostate gland, attended with permanent obstruction to the free evacuation of the urine. In consequence of the obstacle thus occasioned, the ureters are habitually dis- tended with urine, and are eventually transformed into subsidiary reservoirs, in which the fluid accumulates in such a manner as to produce serious pressure upon the renal tis- sues, and ultimately their partial, if not complete, destruction. The suffering in chronic nephritis is usually much milder than in the acute form. The pain is less severe, and seldom extends to any distance among the neighboring structures; there is no retraction of the testicles; the bladder is irritable and impatient of its con- tents ; and the general health, perhaps long impaired, gradually declines, the patient losing flesh, sleep, appetite, and strength. By and by hectic fever sets in, attended witli frequent fits of headache, drowsiness, and vomiting, and life is finally worn out by sheer exhaustion. Sometimes death is caused by suppression of urine, preceded and accom- panied by coma and convulsions ; at other times, by the sudden supervention of acute nephritis, an event generally announced by rigors, violent fever, and delirium, with great increase of the local distress. The urine in chronic nephritis is commonly alkaline, turbid, and loaded with calcareous matter and ammoniaco-magnesian phosphates; not infrequently it is albuminous, tinged with blood, or mixed with pus, flakes of lymph, and renal casts. The kidney after death is found to be variously altered; generally softened and disor- ganized, atrophied or enlarged, and converted into cysts, or into a single pouch destitute of secreting tissue. The capsule is usually opaque, thickened, and easily separable, but firmly adherent to the fat and connective tissue of the loin. The treatment of chronic nephritis is commonly unsatisfactory. In all cases an at- tempt should be made to ascertain, as soon as practicable, the nature of the exciting cause, the removal of which will often, of itself, be sufficient to cure the disease. Tonics and alterants, with a regulation of the diet and bowels, will, generally, prove highly beneficial. Fatigue and sexual excitement should be avoided; opium will be required to allay pain and promote sleep; and the surface should be well protected with flannel. Many cases will be improved by the warm bath, by change of air, and by alkaline or acid preparations in combination with uva ursi, lupuline, or balsam of copaiba. 6. Suppuration Suppurative nephritis, pyelonephritis, and pyonephi*osis may be occasioned by ordinary inflammation, tuberculosis, external injury, or the presence of a renal calculus. Sometimes it is produced by the irritation consequent upon disease of the bladder, enlargement of the prostate gland, or stricture of the urethra. The abscess may be seated on the outer surface of the organ, immediately beneath its fibrous envelop, in its proper substance, or in the pelvis and calyces, especially when it depends upon 658 DISEASES OF THE URINARY ORGANS. CHAP. xvi. obstruction of the ureter. The disease may be acute or chronic. In chronic abscess, the kidney is sometimes completely destroyed, the parenchymatous structure being re- placed by a thick, laminated, multilocular sac, intersected by hard, fibrous bands. Abscess of the kidney is sometimes dependent upon disease of the spinal marrow, or upon the nerves which are detached from it. The subjects are usually affected with paralysis of the lower half of the body, accompanied with pain and tenderness of the sacrolumbar region, irritability of the bladder, and a phospliatic condition of the urine. The kidney sometimes suffers from abscesses in pyemia, after injury of the head, com- pound fractures, dislocations, smallpox, carbuncles, lithotomy, lithotrity, and stricture of the urethra. In 2161 autopsies performed at St. George’s Hospital, London, Dr. Chambers found metastatic abscesses in the kidneys in 12 cases, in the lungs in 106, and in the liver in 22. When pus collects in the loose adipose tissue surrounding the kidney, the abscess takes the name of perinephritic. Such an abscess may arise from the same causes as a renal abscess, as disease of the kidney, the irritation of a renal calculus, external injury, strains, exposure to cold, and acute general diseases, and the quantity of matter thus found is sometimes very great. Of 166 cases analyzed by Trieden, 70 per cent, occurred in males, and nearly 16 per cent, in children. The symptoms resemble those of suppurative nephritis and pyelitis, but these affections may be excluded by examination of the urine, that fluid being secreted in normal quantity, and being free from blood, casts, and pus in perinephritic abscess. Dr. Holloway, of Louisville, lays great stress in the diagnosis upon the inclination of the body toward the affected side, and the narrowing or lessening of the costo-iliac space, the last rib being almost in contact with the upper border of the ilium. Slight flexure of the thigh is not infrequently present; and Gibney, who has carefully studied the disease in children, believes that in a number of reported recoveries from coxalgia without lameness or deformity, the disease is really a perinephritis. The matter contained in these abscesses may be perfectly homogeneous, thick, opaque and yellowish, like healthy pus, or it may be intermixed with various kinds of foreign ingredients, as lymph, blood, urine, sabulous matter, renal casts, and even calculous con- cretions. Occasionally it is serous, or sero-purulent, lactescent, whitish, or greenish- white, thin or thick, viscid or curdy. In the scrofulous form of the disease it always exhibits the characters peculiar to an abscess of that nature. The pus, which varies in quantity from a few drachms to several quarts, may be entirely inodorous, or intensely fetid. In a preparation in my possession, taken from a man, twenty-six years of age, there were upwards of two gallons of thick, yellow pus. The kidney was converted into an immense sac, exceedingly vascular, about the thickness of the human skin, and studded internally with numerous calcareous deposits. The ureter was completely occluded, and the proper renal substance entirely destroyed. The disease, which had existed for several years, was attended with great pain and excessive emaciation. The renal abscess generally opens into the pelvis of the kidney, its contents being thence discharged along with the urine. More rarely the matter finds its way to the external surface, into the cellulo-adipose tissue of the loin, or into the intestinal canal. It may also be evacuated into the peritoneal cavity, or even burst into the bronchial tubes, from which it may subsequently be discharged by coughing, or instead of finding an out- let, it may remain in the kidney, and parting with its more watery particles, be ultimately converted into a dry, putty-like substance, consisting of degenerated pus globules, inter- mixed with phosphate and carbonate of lime. The symptoms of renal abscess do not differ essentially from those which attend sup- puration in the other viscera. There is generally severe pain in the corresponding loin, extending down the spermatic cord, groin, thigh, and sacrum, the urine is high-colored and scanty, the patient finds it difficult, if not impossible, to walk and turn in bed, intense febrile disturbance is present, with gastric irritability2 and, at length, violent rigors come on, preceded by throbbing pain, and followed by copious sweats. If the matter passes off by the urine, its characteristic appearances may always be readily detected in that fluid, and in most cases a distinct swelling, exquisitely tender on pressure, and gradually enlarging in size, may be perceived in the lumbar region, especially when the pus is pent up. When the disease is of a scrofulous nature, the symptoms are generally more mild, and several months commonly elapse before the abscess acquires much bulk. When an acute renal abscess opens or points externally, the event is invariably preceded by an erysipelatous blush of the surface, and by an oedematous condition of the subcutaneous connective tissue. In chronic or scrofulous renal abscess, instead of these phenomena, there CHAP. XVI. AFFECTIONS OF THE KIDNEYS AND URETERS. 659 is, on the contrary, in general merely a glossy appearance of the skin, along with more or less enlargement of the subjacent veins. The diagnosis of renal abscess is usually readily determined by its peculiar symptoms, and by a careful study of the history of the case. The chief risk of error is in the chronic or strumous form of the disease, which might, even in the hands of a cautious observer, be mistaken for a malignant tumor, a cyst, or a psoas abscess. The presence of pus in the urine is of great significance in connection with a fluctuating tumor in the loin, although not positively decisive. Rigors are of frequent occurrence in the phleg- monous abscess, and are among the most valuable signs of the disease. A pcrinephritic abscess cannot, in general, be distinguished from an abscess in the renal substance. The prognosis is commonly unfavorable; a case may, it is true, occasionally recover, but generally the disease terminates fatally, whatever may be its nature. When the abscess opens externally, the patient may live for some time with a renal fistule. The treatment of this affection must, at first, be strictly antiphlogistic, and afterwards supporting. When the matter is tending externally, its approach to the surface may often be expedited by the application of a blister. As soon as fluctuation becomes apparent, or even before if there be excessive local and constitutional suffering, a free incision should be made, to afford thorough vent to the pent-up fluid. Drainage should be promoted in the usual manner, and the cavity of the abscess should be frequently washed out with antiseptic fluids. Of 16 nephrotomies, the operators having been Bryant four times, and Lente, Baker, Rosenberger, Lange, Williams, Callender, Crane, Van Buren, Weir, Lucas, Puzey, and Roddick, each once, 13 recovered, and 3 died, and two, both of which were successful, were subsequently subjected to nephrectomy on account of a permanent fistule, which forms in one-fourth of all examples. The operation is far more favorable than extirpa- tion of the organ. Thus, of 21 nephrectomies for suppurative lesions, including one of abscess consequent upon gunshot wound, three of tubercular abscess, and four of pyone- phrosis with renal fistule, 12 recovered, and 9 died. Of 19 operations through the loin 10 Were successful, and both of the laparotomies recovered. The operators were Barden- heuer and Czerny, respectively, in three instances, Thornton in two, and Van Buren, Dumreicher, Couper, Raffa, Clementi, Stockwell, Barwell, Frattina, Lucas, Lange, Baker, Golding Bird, and Peters, each once. When a tumor of the loin is suspected to be a perinephritic abscess, it should at once be explored, and, if pus be found, evacuated, and treated on general principles. Unless this be done, the matter will burrow in various directions, seeking a spontaneous outlet, and thereby placing life in jeopardy. 7. Calculi Calculi of the kidney may be developed either in the parenchyma of the organ, or in the calyces, infundibules, or pelvis, a drop of blood or a particle of inspis- sated mucus generally serving as their nucleus. Their formation often begins at an early period of life, either as the result of external injury, disease of the spinal cord, or of a peculiar diathesis of the system ; and they usually consist of the same chemical elements as calculi of the bladder. The most common species of renal concretion is the uric, which is usually of a light brownish color, and of a spherical, oval, or conical shape, with a finely tuberculated sur- face. Next in point of frequency is the oxalic, of a dark complexion, and of an irrregu- lar, rounded figure, with a rough exterior, similar to that of a, mulberry. The ammoniaco- magnesian calculus is uncommon in the kidney; it generally occurs in connection with one or the other of the preceding species, as an external layer, from a line to half an inch in thickness. The pure phosphatic concretion is also rare, and is met with chiefly as a consequence of injury of the spinal cord. Dr. Scott Alison has reported a case of what he calls blood calculi of the kidney, in a man dead of phthisis. The concretions were of a black color, from the size of a cori- ander-seed to that of a small horse-bean, and were essentially composed of blood, of tol- erably firm consistence. The number of renal concretions varies very much, there being often as many as six, ten, or even a dozen. The oxalic calculus is generally solitary. Their volume is usually in an inverse ratio to their number. In shape, they are, for the most part, round or oval. A solitary renal concretion occasionally pretty accurately represents not only the general outline of the kidney, but also of the calyces and infundibules. The effects which a concretion exercises upon the substance of the kidney are often most disastrous, especially when it is very bulky or has been long retained. Gradually 660 DISEASES OF THE URINARY ORGANS. CHAP. XVI. the parenchymatous substance is absorbed, until, at length, perhaps, nothing remains but the fibrous envelop of the organ, converted into a thick, indurated sac, partially filled with pus, serum, or sero-purulent fluid. The corresponding ureter may be closed, as well as variously changed in structure, and serious morbid alterations are often met with, as a direct consequence of the renal, in the bladder and prostate gland. Persons affected with renal calculus generally suffer more or less severely in the loin and pelvis, the pain, which is dull and aching—sometimes sharp, stabbing, boring, or neuralgic—radiating about in different directions—being liable to serious exacerbations from the slightest exposure, or irregularity of diet; the general health is habitually de- ranged ; the stomach is teazed with flatulence and indigestion ; the bowels are costive ; the system is extremely susceptible to atmospheric vicissitudes ; the countenance is wan and sallow; and there is a frequent desire to void urine, which is usually materially altered in its physical and chemical properties. In many cases, pure blood is passed, especially after rough exercise. Ultimately hectic irritation ensues, and the patient dies from sheer exhaustion, an abscess having, perhaps, previously formed, and pointed in the loin, or discharged its contents along the ureter. Occasionally the immediate cause of death is suppression of urine, or shock from the sudden obstruction of the ureter by the foreign body. The concretion, even if comparatively small, as when it does not exceed the volume of a pigeon’s egg, or an almond, may sometimes be readily detected, especially in lean sub- jects, after thorough evacuation of the bowels, by firmly grasping the lumbar region, immediately below the last rib, with the fingers of one hand resting upon the anterior border of the erector muscle of the spine, and making counterpressure with the thumb, while the fingers of the other hand are passed up and down over the intermediate surface in front. In this way it is very difficult for any hard substance, irregularity of surface, or distension from fluid, to escape discovery. The patient, during the examination, should lie on his back, with the limbs well flexed, to relax the abdominal muscles; an anaesthetic being given if there is much pain or nervous agitation. The treatment in retained renal calculus is, in general, altogether palliative, consisting of the abstraction of blood by cups and leeches, the warm bath, and the administration of anodynes. Horseback exercise must be avoided, the diet carefully regulated, the bowels constantly kept open, and the skin well protected with flannel. In some cases relief can be secured only by nephrotomy, or excision of the affected organ. Nephrotomy for calculus combined with suppuration of the kidney has been performed in at least 9 cases, with 6 deaths, and 3 recoveries, the operators having been Dawson, Ingalls, Baker, Clark, Mynter, Callender, Richardson, Couper, and Haward. Dismissing the doubtful cases of Marchetti, Paul, and the French archer, the first authentic instance of the removal of a stone from an otherwise healthy kidney occurred, in 1880, in the hands of Mr. Henry Morris, although Gunn, Durham, Lucas, each once, and Annandale, in two cases, had cut down upon, and Barbour had incised, the organ, without finding a calculus. Nephrolithotomy, as the operation for removing a renal calculus from the normal kidney is now termed, has been practised by Morris, Haward, Butlin, Beck, and Bardenheuer, every case having terminated successfully. The most interesting of these is that of the Ger- man surgeon, one small stone having been extracted from the ureter and four from the kidney on account of anuria and commencing uremia in a woman twenty-seven years of age, who was suffering from an abscess of the opposite kidney. Signs of suppression of urine having set in on the fourth day, the wound was opened, and the three stitches removed from the ureter, which was then divided and united to the outer margin of the lumbar incision. The patient was doing well one month later. Although an accurate diagnosis is not always possible, the operation is a perfectly justifiable one, since any doubt may be cleared up by exploration with a needle after the organ is exposed. If no stone be found, the patient will not have incurred any material risk, as is shown by the six examples in which the organ w’as cut down upon or incised, and all of which re- covered. When the existence of a calculus is complicated by suppurative hydronephrosis, cystic degeneration, dilatation, or contraction of the organ, nephrectomy appears to be a safer procedure than nephrotomy. Thus, of 13 extirpations, under these circumstances, per- formed by Barker twice, and by Urbinati, McClelland, Barwell, Bardenheuer, Godlee, Rosenbach, Heath, Muller, Lange, Czerny, and Simon, each once, 6 recovered, 6 died, and the result in 1 is uncertain, the successes being 16.67 per cent, greater than after mere incision and drainage. The ten lumbar operations were attended with five recov- eries and live deaths, while the three laparotomies yielded one recovery, and two deaths. CHAP. X VI . AFFECTIONS OF THE KIDNEYS AND URETERS. 661 Renal concretions often descend into the bladder. Their progress along the ureter is sometimes slow and painful; at other times, rapid and almost free from suffering. The amount of the local distress is often greatly influenced by the nature of the concretion, and by the degree of resistance offered by the ureter. A small, smooth calculus usually causes little inconvenience; while a large or rough one often occasions exquisite torture. The process of descent, which generally occupies from twelve to forty-eight hours, is characterized by excessive nausea and vomiting, great restlessness and jactitation, pain in the back, groin, and thigh, retraction of the testicles, numbness along the spermatic cord, a sense of constriction at the umbilicus, and tenderness of the hypogastrium, with cold- ness of the extremities, rigors, and a feeling of excessive prostration. The urine gradually accumulating behind the calculus, the ureter is slowly dilated, and the concretion at length reaches the bladder, from which it is either ejected, or it remains there until it is removed by operation. As soon as the passage is completed, the pain and sympathetic irritation subside, the patient frequently falling into a tranquil and refreshing sleep. The descent of the calculus may be expedited, and rendered less painful, by the abstraction of blood from the arm, the loins, or hypogastric region, by large doses of morphia, along with castor oil and turpentine, and by the hot bath, fomentations, and anodyne injections. The free use of chloroform, by inhalation, will also prove highly beneficial. 8. Hydronephrosis or Renal Dropsy Enormous quantities of urine occasionally col- lect in the kidney, from obstruction of the urinary passages, and the consequent conver- sion of the organ into a mere membranous pouch, sac, or shell, capable of holding many quarts of fluid, and constituting what is technically called hydronephrosis. The disease, although generally limited to one kidney, occasionally involves both organs, and, what is remarkable, the patient, in such an event, may live for years, and void daily the ordinary quantity of urine, notwithstanding the complete destruction of the tubular structure. Inflammation, renal calculi, displacements of the uterus, and the pressure of morbid growths, are the most common exciting causes of the malady, leading to occlusion of the ureter, followed by the gradual disorganization of the renal substance, and the conver- sion of the kidney into a membranous sac, either single or multilocular; commonly the former. Many cases have been recorded in which it was congenital, 20 out of 52 cases collected by Dr. Roberts being of that nature, giving rise to great difficulty in parturi- tion. The ureter is often prodigiously enlarged, tortuous, and convoluted. The diagnosis of renal dropsy is seldom difficult. The chronic march of the disease, the steady wasting of the flesh and strength, and the existence of a tumor, fixed, soft, and fluctu- ating on pressure, in the iliac, or ilio-lumbar region, hardly admit of misinterpretation. As the enlargement progresses, it gradually extends over the abdomen, and encroaches more or less upon the contained viscera. The pressure exerted upon the diaphragm is sometimes so great as to cause serious embarrassment in respiration, especially during recumbency and after eating. The colon usually lies in front of the tumor, and emits a clear sound on percussion. The subcutaneous veins are often remarkably distended. Occasionally the sac suddenly gives way, followed by the escape, by the ureter, of the greater portion of its contents ; and such an event always affords the best evidence of the true nature of the complaint. Whenever any doubt exists in regard to the diagnosis, the proper plan is to employ the exploring-needle. The period at which death occurs, when the disease is permitted to pursue its course undisturbed, varies from two to six, eight, or ten years. In the congenital form of hy- dronephrosis, life is usually destroyed much sooner. Experience having shown that the fluid is not amenable to absorption, the only chances for relief are tapping, nephrotomy, and nephrectomy. In performing the first of these operations an aspirating needle must be introduced at the posterior part of the tumor, beyond the range of the colon, which, as before stated, generally courses over its anterior surface, and might, therefore, be penetrated, if the precaution were disregarded. If the remedy prove useless, the emptied sac may be injected with iodine ; or, resisting this, the sac may be opened through the loin, and its sides attached to the edges of the incision, and con- tinuously drained. This procedure, which constitutes nephrotomy, has been successfully resorted to six times by Lawson Tait, twice by Czerny, and once, each, by Simon, Le Den- tu, and Weir, and there are, doubtless, other cases on record, including, some fatal ones, which have escaped me. In at least one-fourth of all instances a permanent fist.ule re- mains, which is the only drawback to the operation, and which may demand subsequent extirpation of the organ, as in the case of Le Dentu. Of 9 nephrectomies performed for uncomplicated hydronephrosis by Czerny twice, and Billroth, Thornton, Savage, Kehrer, Baum, Heywood Smith, and Day, each once, and of 1 for fistule following nephrotomy 662 DISEASES OF THE URINARY ORGANS. chap, xvi. for dropsy of the organ, in the hands of Le Dentu, 6 recovered, 3 died, and the result is uncertain in 1. All of the recoveries followed the abdominal incision, which was practised seven times; while death attended that procedure in one, the lumbar incision in one, and once when the nature of the operation was doubtful. 9. Hydatids Hydatids of the kidney are extremely uncommon. Usually developed in the parenchymatous substance, or in the excretory passages of the organ, and some- times lodged just beneath the capsule of the gland, they vary in size from a hempseed to that of an orange, and in number from one to several hundred. Men are more liable to them than women, and they have been met with at both extremes of life, although their favorite period of attack seems to be between the thirtieth and fortieth years. Of their causation, nothing definite is known. The older hydatids generally contain clusters of young ones, either loose or adherent to their inner surface. The outer cyst often possesses great firmness, and it may even be partially calcified, or incrusted with chalky matter. When very large or numerous, which, however, is rarely the case, these bodies may com- pletely destroy the renal tissues, and so give rise to the same morbid states as a serous cyst or a chronic abscess. They may remain pent up in the situation in which they are originally developed, or they may escape into the pelvis of the kidney, and be evacuated along with the urine. Occasionally they make their way through the lumbar region into the intestines, or even into the lungs. In no instance on record have they, as far as I know, discharged themselves into the peritoneal cavity. The only positive evidence of the existence of hydatids in the kidney is the presence of hooklets, laminated shreds, broken fragments, or milky detritus in the urine, detectable with the microscope. Sometimes entire vesicles, either alone or mixed with disintegrated ones, are discharged. All such appearances are, of course, perfectly diagnostic, especially when associated with a fixed tumor, of variable size and shape, in the loin, or in the ilio- lumbar region. When the aceplialocysts are large or numerous, the tumor will not only be of considerable bulk, but it will be likely to fluctuate distinctly on pressure, and to yield the peculiar characteristic thrill, known as the hydatid fremitus, perceptible both by the ear and the touch. “ In order to evoke these signs,” says Dr. Roberts, “ the fingers of the left hand should be laid upon the tumor, and tapped sharply with the fingers of the right. A thrill is then communicated to the overlaid fingers, which has been compared to the vibrations of a repeater watch held in the hand. A similar sensation is communi- cated to the ear when the stethoscope is applied and the tumor tapped with the fingers.” The tumor varies in size from that of an orange to that of an adult’s head, and, as it pro- gresses, it gradually displaces the adjoining viscera. The colon generally lies in front of the tumor, but in some cases it runs along its inner or outer side. More or less pain always attends the discharge of these bodies ; it is often very acute, especially in the loin, and along the course of the urethra, and is generally accompanied by rigor, nausea, and colicky spasms. When the hydatids reach the bladder, the pain shifts from the kidney to this organ, and to the urethra, and the patient is not unfrequently seized with retention of urine. The tumor in the hank is usually of a rounded, ovoidal shape and more or less elastic to the feel; fluctuating distinctly in some cases, slightly in others, and in others, again, not at all. The discharge of vesicles or disintegrated cysts take place at irregular, and often at very distant, periods ; at one time spontaneously and at another under the influence of external injury, as a blow, kick, or fall. A favorable termination of the disease is by no means uncommon, the hydatids gradually dying, and passing into the pelvis of the kidney, whence they are evacuated through the bladder and the urethra. The death occasionally results from constitutional irritation. The best remedy for destroying and dislodging these parasites is oil of turpentine in diuretic doses. Advantage has occasionally been derived from the use of nitrate of potas- sium and iodide of potassium. Attempts have been made to kill the hydatids with elec- tricity, but without success. When the tumor points externally, the proper plan is to puncture it, and let out its contents, the trocar being introduced behind in such a manner as not to wound the peritoneum. The cyst may afterwards be injected with a weak solu- tion of iodine, or washed out from time to time with a solution of permanganate of potas- sium or carbolic acid, so as to excite obliterative inflammation. During the passage of the hydatids along the urinary passages, anodynes must be freely administered to relax the system and to relieve pain. Spiegelberg, of Breslau, in 1867, attempted nephrectomy, but the removal of the kidney was incomplete, and the patient, a woman forty-two years of age, died. 10. Parasites—The strongle, a slender, cylindrical worm, from two to six inches in CHAP. XVI. AFFECTIONS OF THE KIDNEYS AND URETERS. length, and of a light grayish color, has occasionally been found in the pelvis and infundi- bules of the kidney. Sometimes it makes its way into the parenchymatous substance, causing suppuration, atrophy, and other mischief. The parasite produces much distress in the kidney, but affords no distinctive symptoms. AVhen its presence is suspected, expulsion may be attempted with turpentine, cubebs, and balsam of copaiba. 11. Tumors—The kidney is liable to various morbid growths, cystic and solid, benign and malignant. Rhabdomyoma, fibroma, adenoma, angioma, and lymphoma are occasion- ally met with, but the most common growths are cysts, sarcoma, carcinoma, and sarcomatous carcinoma. o. Cysts—The cystic kidney or cystic degeneration of the kidney, originating in dila- tation of the uriniferous tubes and of Bowman’s capsules, usually affects both organs, and is met with more frequently as a congenital affection than in adult life. In the foetus the sac frequently attains an enormous bulk, and proves an insuperable obstacle to delivery. The symptoms of the disease are obscure ; the urine, of low specific gravity, is often albumi- nous, and the functions of the kidney may be so much impaired as to lead to uremic poisoning. These signs, along with the presence of a tumor, which is most prominent in the anterior and lateral boundaries of the lumbar region, point to, but do not positively indicate, the nature of the disease. The treatment is essentially that of hydronephrosis. AVhen aspiration and injections of iodine fail to effect a cure, the organ may be extirpated, as has been done in five instances, of which four proved fatal, respectively, by Esmarch, Meadows, Czerny, Campbell, and Burgess, by the ventral incision. Marsh, in 1881, attempted extirpation through the loin, but the removal was incomplete, and the patient perished. Leopold has recorded a successful removal, by laparotomy, of a kidney for a hemorrhagic cyst, the precise origin of which could not be determined. 13. Malignant Growths—Under the term cancer, Rohrer has collected 115 examples of primary malignant tumors of the kidney, of which over 39.58 per cent, occurred within the first ten years of life, 58.33 per cent, before the fortieth year, and 41.66 per cent, after the age of forty. AVeigert, Hasse, Bednar, Moreau, Braidwood, and others, have met with so-called cancer, as a congenital affection; but it may be confidently asserted that carcinoma is never witnessed in early life, and that at least two-thirds of all examples recorded as cancer should be classed as sarcomas. The truth of this statement is greatly strengthened by the fact that of 18 cases of extirpation of the kidney for tumors, the structure of which was determined by minute examination, 14 were sarcomatous, 2 car- cinomatous, 1 adenomatous, and 1 cystic fibromatous. Hence, as in the present state of our knowledge, it is impossible to describe sarcoma and carcinoma as distinct affections, they will be considered under the clinical phrase of malignant growths. The tumor often acquires an enormous bulk, especially in young subjects, as in an in- stance recorded by Roberts, in which a growth of this kind, removed from the body of a child, weighed thirty-one pounds. The disease is more frequent in males than in females, generally comes on without any assignable cause, is usually confined to one side, and termi- nates fatally at a period varying from a few months to several years, the duration being much shorter in children than in adults, the average in the former being between seven and eight months, and in the latter about two years and a half. The general health is usually rapidly impaired, the body becomes emaciated, the strength declines, the limbs swell, and the countenance assumes that peculiar sallow appearance so expressive of the malignant nature of the disease. Malignant disease of the kidney usually makes its appearance in small, whitish nodules, which, increasing in volume and number, gradually coalesce, and at length transform the organ into a soft, pulpy mass, of a brain-like color and consistence. The tumor, in the advanced stage of the disease is irregularly lobulated, the fibrous envelop loses its identity, and the pelvis and ureter are occluded by the new structure. A section of the morbid growth occasionally presents a large clot, composed of loose, concentric layers, similar to those in a rapidly formed aneurism. Now and then large cavities, filled with bloody serum, either alone or mixed with softened tissue, are contained in it, and serve to diver- sify its character. The diagnosis of this disease is not always easily determined, inasmuch as it is liable to be confounded with various other affections, not only of the kidney itself but of the other pelvic and also of the abdominal viscera, as renal and hepatic cysts, hypertrophy of the spleen, omentum, and mesenteric glands, lumbar, stereoraceous and abdominal abscesses, accumulations of fecal matter in the colon, aneurism of the aorta, and tumors of the ovary, 664 DISEASES OF THE URINARY ORGANS. CHAP. XVI. uterus, and Fallopian tube. On the right side an enlarged liver may complicate the dis- ease and obscure the diagnosis. The most reliable phenomena, diagnostically viewed, are, the existence of a fixed tumor in the flank, and the presence of blood or of blood and fragments of the neoplasm in the urine. When these phenomena are associated, there can be no reasonable doubt as to the true nature and seat of the malady. Unfortunately, however, this is not always the case. Thus, of the 115 cases analyzed by Rohrer, there was neither tumor nor hematu- ria in 36, or 31.30 per cent.; in 12, or 10.43 per cent., there was hematuria alone ; in 42, or 36.52 per cent., there was a tumor without hematuria; and in 25, or 21.73 per cent., there were both tumor and hematuria. The tumor, originally situated in the flank, between the crest of the ilium and the margin of the ribs, gradually extends in different directions, pushing aside the different organs of the abdomen, and sometimes filling almost its entire cavity. Its surface is more or less lobulated, irregular in consistence, and remarkably tolerant of manipulation. An important feature of the tumor is its fixity, and consequent inability to shift its place or move about. The skin by which it is covered is often tra- versed by large veins, of a dark, bluish color, but in other respects it is unchanged. The morbid mass early contracts adhesions to the surrounding parts, especially to the bowels ; and the descending colon invariably lies immediately in front of it, immediately beneath the wall of the abdomen. Hence, while all the rest of the tumor furnishes a dull sound on percussion, that portion which corresponds with the colon is always more or less resonant. The absence of serious vesical disorder should not be overlooked, as it affords valuable negative information. The history of the case is also highly important. In two instances of this disease, one recorded by Langstaff and the other by Bristowe, distinct and persistent pulsation existed in the tumor. The treatment of malignant growths of the kidney is, of course, entirely palliative. All that can be done is to relieve pain and to support the strength. The attendant hemorrhage is best controlled by acetate of lead and tannic acid, in union with opium. Ergot, too, is a remedy of great value, to which may be added, in case of anemia, some preparation of iron. Nephrectomy may be resorted to as a final remedy, but the outlook is gloomy. Thus, of 19 operations for sarcoma and carcinoma, of which five were performed by Czerny, two by Kocher, and one, each, by Wolcott, Langenbuch, Ilueter, Jessop, Byford, Martin, Lossen, Barker, Bardenheuer, Hieguet, Liicke, and Adams, 7 recovered, 9 died, and in 3 the result is uncertain. Of 12 abdominal sections, 4 recovered, and 8 died, while of the 4 determined lumbar operations 3 recovered and one died. A floating kidney was the seat of the neoplasm in three instances, and in one it was combined with hydro- nephrosis. In one of Kocher’s fatal cases the removal was incomplete; in one of Czerny’s the hemoi’rhage was so profuse as to demand ligation of the aorta, and the patient died in ten houi’s; while in the case of Liicke, which was also fatal, the bleeding from the torn vena cava was arrested by temporary compression. y. Other Neoplasms—The remaining morbid growths of the kidney are mainly of intei’est in connection with extii’pation of that oi’gan. Of 4 cases of nephrectomy, of which one was for adenoma, one for cystic fibi-oma, and two for neoplasms of an unknown nature, in the hands of Peaslee, Czerny, Whitehead, and Thomas, 3 died, and 1 l’ecovered, all having been ventral operations. In addition to these cases, Spencer Wells removed a normal kidney adhei’ent to a uterine tumor, Billroth extirpated a sound kidney which was attached to a reti-operitoneal myoma, and Archer excised a kidney which he lacerated in the removal of an ovarian cyst. All were examples of lapai’otomy, and the patients of Wells and Billroth died. 12. Floating Kidney The kidney, in consequence of the abnormal laxity of its attach- ments, is sometimes displaced, forming a movable, floating, or wandering tumor which is readily detected thi-ough the walls of the abdomen. It is most frequent in women between the twentieth and forty-fifth year. Of 96 cases analyzed by Ebstein, 82 were in women and 14 in men ; the right organ being affected in 65, the left in 14, and both kidneys in 12, of the 91 cases in which this point is noted. The affection is induced by i*elaxation of the abdominal wall after gestation, pendulous belly, displacements of the uterus, hernia, hydi’onephrosis, perinephritic abscess, and the pi-essure of perirenal tumors. Anemia is a frequent predisposing cause, by the removal of the fat in which the organ is imbedded. When the affection is congenital there is some abnormity in the relations of the perito- neum, or in the length or ari'angement of the renal vessels. A luxated kidney is usually attended with a sense of weight and di*agging pain, most perceptible in standing and walking, and during the menstrual period. Now and then it gives rise to symptoms of incarceration or strangulation, as indicated by severe suffering, CHAP. XVI. AFFECTIONS OF THE KIDNEYS AND URETERS. 665 anxiety, vomiting, scanty, high-colored, and bloody urine, and fever, along with tenderness on pressure. The symptoms increase in severity for four or five days, when they begin to subside, the first sign of recovery being an abundant secretion of urine. These phenomena have been referred by Landau and Hosier to torsion of the renal vessels, but lveppler believes that they are due to twisting of the ureter and the consequent retention of the urine in the pelvis of the kidney. The diagnosis of luxation of the kidney is based upon the detection of a tumor, of the dimensions and configuration of the normal organ, in the hypochondriac or umbilical region, and this view is confirmed by a depression and a tympanitic resonance on percussion over the proper situation of the viscus. Landau asserts that a whistling murmur may be detected when the displacement depends upon torsion of the renal vessels; but this state- ment needs confirmation. ' A floating kidney not unfrequently becomes fixed again, especially if the patient gains fat and assumes the supine posture. As a palliative measure a broad bandage or abdo- minal supporter may be worn ; but if the organ is a source of much suffering and of repeated attacks of incarceration, it may demand removal or fixation in the loin. Ne- phrectomy has been resorted to by Martin seven times, by Langenbuch twice, and by Gilmore, Smyth, Martini, and Merkel, each once. Of the 13 operations, 9 recovered and 4 died. Laparotomy was performed in 11 cases, with 7 cures, and the organ was removed through the loin in 2, both of which were successful. As a substitute for extirpation, Hahn, of Berlin, has recently in two instances forced the kidney, by pressure exerted upon the anterior surface of the belly, into an opening made in the lumbar region as in colotomy, and attached the capsule of the organ to the edges of the wound by catgut ligatures. Although the patients recovered, the organ in each instance was still somewhat mobile. 13. Hemorrhage Renal hemorrhage is usually caused by mechanical violence, as blows, contusions, or the presence of renal calculi ; but it may also be produced by con- gestion of the kidneys, malignant growths, parasites, or diseased conditions of the blood, such as attend scurvy, scarlatina, or typhoid fever. The amount of blood may be small, or so great as to be exhausting. Unless accompanied by marked disorder of the kidney, entire absence of vesical disease, or the presence of renal casts in the urine, along with small spherical particles of epithelium, such a hemorrhage can seldom be satisfactorily distinguished from hemorrhage of the ureters, bladder, prostate gland, or urethra. The treatment must be regulated by the nature of the exciting cause. If plethora exist, bleeding by cups, leeches, or the lancet may be necessary, with more or less active purgation. Acetate of lead and opium, or, what is better, tannic acid, in doses varying from five to ten grains, repeated every three or four hours, are generally the most reliable internal remedies. Alum sometimes answers a good purpose, as do also the different preparations of ergot. In cases of debility, tonics and astringents, as tincture of iron, sulphuric acid, and quinine are indicated. Pounded ice may be applied to the loins, and blisters sometimes afford great relief. 14. Nephrotomy The operation of nephrotomy, which differs from lumbar colotomy in that the kidney is incised instead of the bowel, and that in certain cases the wound is stitched to the incision in the loin, and a drainage tube inserted, has become one of the established procedures of surgery. Of the 40 cases alluded to in the preceding paragraphs, 32 recovered, and 8, or twenty per cent., died. In six of the former, permanent fistules remained, on account of which two were subsequently subjected to ex- tirpation of the kidney. It has been uniformly successful when practised for calculus of an otherwise healthy kidney, and for hydronephrosis, while the mortality has been 18.75 per cent, for suppurating kidneys, and 62.50 per cent, for calculous pyelitis. It is indi- cated, in preference to nephrectomy, for the first three lesions ; while in the latter con- dition there is little choice between the two operations. 15. Nephrectomy The kidney wag extirpated for a malignant tumor, under the im- pression that the patient was suffering from a cyst of the liver, by Dr. E. B. Wolcott, of Milwaukee, in 1861 ; but the first formal operation was performed by Professor Simon, of Heidelberg, in 1869, upon a female who had previously undergone ovariotomy with par- tial excision of the utei-us, in which the left ureter was wounded, followed by a fistule in the wall of the abdomen, and a constant flow of urine. It was to get rid of this distress- ing condition that the operation was undertaken. The kidney was removed through the loin ; the woman made a rapid recoveiy, and died eight years subsequently of pulmonai'y phthisis. Extirpation of the oi-gan is indicated in cases of wound, wandering or floating kidney, 666 DISEASES OF THE URINARY ORGANS. CHAP. xvi. cysts and hydronephrosis, pyelitis, calculus, neoplasms, and fistules communicating with the ureter; but the operation should only be resorted to when the other kidney is sound, and when the life of the patient is endangered or rendered unbearable, after other meas- ures have proved ineffectual. Of 104 cases collected and analyzed by Dr. S. W. Gross, which include those referred to in the preceding paragraphs, and in the subsequent section on affections of the ureter, as well as three unclassified instances under the care of Durham, Spiegelberg, and Bardenheuer, respectively, for a painful healthy kindney, an enlarged and healthy organ, and hematuria and renal colic, 52 recovered, 46, or 44.23 per cent., died, and 6 were still under treatment at the date of the reports. Of the 97 cases, in which the mode of operation and the results are known, 49 were abdominal, with 24 cures and 25 deaths, and 48 were lumbar, with 28 recoveries and 20 deaths, the successes being in favor of the latter by 9.41 per cent. The most brilliant results have followed the extirpation of the healthy organ, or of kidneys not materially altered by disease, as for wounds, mobility, fistules, and wounds of the ureters, and enlargement and pain. Of 24 cases falling under this category, 18 recovered, and 6, or 25 per cent., died. The opera- tion has also been comparatively successful in children, whose ages varied from eleven months to eleven years, eight occurring within the first seven years. Of 9 cases of this kind, 6 recovered, and 3, or 33 per cent., died, the indications for the procedure having been tumors in 5, with 2 recoveries, suppuration in 3, all of which were cured, and hydro- nephrosis, a successful case, in 1. The principal causes of death after nephrectomy are peritonitis, shock and collapse, uremia, hemorrhage, and septicemia and pyemia, the opposite kidney being either badly damaged, or absent in the fatal cases from uremia. Hemorrhage is rarely abundant, but it occasioned death in four instances within a few hours, and in a fifth case on the sixth day, the bleeding recurring from the pedicle. In one of Czerny’s cases the aorta was ligated, and death followed in ten hours, and Liicke tore the vena cava, but arrested the flow of blood by temporary compression, the patient expiring from uremia on the fourth day. Although nephrectomy is a grave procedure, it is perfectly justifiable when all local and constitutional remedies have failed to afford relief, provided the other kidney be sound. The lumbar incision has been attended with somewhat more favorable results than the abdominal; but I am of the opinion that it should be limited to affections dependent upon the presence of a calculus, since in neoplasms, cysts, hydronephrosis, pyonephrosis, and floating kidney, laparotomy admits of removal in every case, and enables the surgeon to deal with complications, such as hemorrhage, and adhesions to the adjacent organs, as they may arise, which cannot always be done through the smaller lumbar wound, in which to gain more space, Czerny, Crede, and Bird were even obliged to resect a portion of the twelfth rib, thereby greatly diminishing the chances of recovery. If, however, lumbar nephrectomy be decided upon, a sufficiency of room may be gained, by following Czerny’s plan of making a transverse cut, one finger’s breadth below the ribs, from the sacrolumbar muscle to the semilunar line. In the abdominal operation the incision may be made in the middle line, or'still better, as practised by Langenbuch, along the outer border of the rectus muscle, so that the kidney may be reached through the outer layer of the meso- colon, which is comparatively free from vessels. Thornton advises that the ureter be first tied and then divided with the view of more readily securing the vessels of the pedi- cle, and that its vesical extremity be fixed outside of the abdominal incision to avoid the ingress of the septic material which it contains into the deep wound. In either operation the kidney should be pulled out of its fatty capsule, except in malignant growths, when it should also be removed. Opium should be withheld after the procedure, since at least two cases appear to favor the idea that its exhibition hastened the fatal termination. The principal morbid alterations of the ureter are deposits of tubercular matter and lymph upon its surface, thickening and attenuation of its walls, and contraction or enlargement of its cavity. Dilatation, as in fig. 476, from a preparation in my collection, is generally produced by the retention of a renal calculus, or by some tumor seated along the course of the tube, and interfering with the egress of the urine. In the male, it is sometimes caused by stricture of the urethra; in the female, by the pressure of a carcino- matous uterus. In a case of this description, which fell under my notice several years ago, the left ureter was fully as large as the thumb, with remarkably thin, transparent walls. Occasionally the tube presents a singularly sacculated arrangement, some portions being greatly expanded, while others are very much contracted. The ureter may be absent, or terminate in a cul-de-sac. When the bladder is wanting, CHAP. XVI. AFFECTIONS OF THE BLADDER. 667 it opens either into the urethra, vagina, or rectum. Occasionally, again, it is reduced to a small, narrow, almost impervious cord, which greatly impedes the passage of the urine. Wounds and lacerations of the ureters are uncommon, and cannot be distinguished as separate and independent lesions. The effects are usually fatal, the most common cause of death being peritonitis and diffuse abscesses in the loin. From a paper, by Mr. Stan- ley, in the 27th volume of the Medi- cal and Chirurgical Transactions of London, giving the particulars of two cases of ruptured ureter, one eventua- ting in recovery, and the other in death, it would appear that such accidents, when not immediately fatal, are sometimes followed by the formation of a cyst or pouch in the con- nective tissue behind the peritoneum, serving as a reservoir for the urine. In both instances, the accumulation of fluid, which possessed all the properties of urine, was so great as to require repeated tapping. The cyst, in the fatal case, extended from the pelvis to the diaphragm, and communicated by a large, irregular aperture with the pelvis of the kidney. Death occurred in the tenth week after the accident, occasioned by a blow from the wheel of a cart. The treatment of a wounded or lacerated ureter does not differ from that in similar injuries of the kidney. The measures must be strictly antiphlogistic, and no time must be lost in evacuating pent up fluid, whether simply purulent, or purulenttand urinous. Nephrectomy has occasionally been practised for wounds and fistules of the ureter. Thus, in a case of extirpation of the uterus for carcinoma in which the disease had ex- tended to the ureter, necessitating its partial removal, and in a similar case in which the ureter was cut, Bardenheuer and Starck each removed the kidney, that of the latter re- covering. For fistules of the canal communicating with the exterior of the abdomen, the uterus, or vagina, Simon, Zweifel, Czerny, and Crede have successfully repeated the operation. All of the six excisions were performed through the loin, and the only fatal case was that of Bardenheuer. SECT. II AFFECTIONS OF THE BLADDER. EXAMINATION OF THE BLADDER AND URETHRA. The urethra and bladder can only be satisfactorily explored with the bougie and the sound, either alone or assisted by the finger in the rectum. The proper methods of con- ducting the examinations will be pointed out in the sections on stricture of the urethra, stone in the bladder, and enlargement of the prostate gland. In ordinary diseased con- ditions of the urinary organs, the examinations, however, should not be limited to mere instrumental explorations. In both sexes, the most intimate sympathies exist between these organs and the neighboring structures, and in order, therefore, to make the investi- gation at all profitable, it should embrace the widest range possible, including, in fact, everything that may have the most remote bearing upon the subject. There is hardly an operation or accident, of any severity, in which the bladder does not suffer more or less from loss of power; and spasm of this viscus and of the urethra is a very common occur- rence in all organic affections of the anus, rectum, and uterus. If, then, a surgeon should restrict his examination to the urinary organs, he would fall far short of his duty, espe- cially in cases of chronic disorders. During the past thirty years various attempts have been made to facilitate the diagnosis of vesical and urethral affections by means of the endoscope through which the interior of these structures could be lighted up and inspected. After a fair trial with this instrument surgeons have very generally concluded that it is practically of little utility. Although strictured, granular, and ulcerated conditions of the urethra may be seen and indicated through its agency, and small portions of vesical calculi and tumors be illuminated, yet the diagnosis of these affections is as readily effected with the ordinary sound or bougie, the use of which is free from the embarrassment and pain Fig. 476. Dilatation of the Ureter and Pelvis of the Kidney. 668 DISEASES OF THE URINARY ORGANS. chap. xvr. attendant upon the employment of the endoscope. From the large size of the tubes and the irritation which they produce, the disease is more likely to be aggravated than relieved. MALFORMATIONS. The urinary bladder is liable to various congenital malformations. Thus, there may be a complete absence of it, the ureters terminating in the urethra, the rectum, the perineum, or the vagina; or the organ may be deficient in front, constituting what is called exstro- phy. A double bladder is a very uncommon occurrence. In a remarkable case, recorded by Dr. Alan P. Smith, of Baltimore, each organ was provided with a separate urethra connected with an appropriate and well-developed penis. One of the bladders contained a calculus. Exstrophy of the bladder, the only abnormity of any surgical interest, is generally com- plicated with certain defects of the genital apparatus, and is much more common in males than in females. Of 16 cases that have come under my notice, all, except 2, were males. Of 9 cases observed by Mr. McWhinnie, of London, 7 were males, and 2 were females. Mr. John Wood has met with upwards of 20 cases, of which only 2 were females, and of 68 cases collected by Mr. Earle, only 8 were females. The urinary tumor, situated in the lower part of the abdomen, is generally somewhat ovoidal or globular. Its volume is greatly influenced by the age and position of the sub- ject. In the child, it rarely exceeds that of a walnut, while, in the adult, it may be as large as a fist, or a goose’s egg. Yery small, when the subject is recumbent, it becomes very prominent when he stands up, coughs, sneezes, or exerts himself. The surface of the tumor is of a bright red color, and is constantly covered with mucus, which thus pro- tects it, in some degree, from the injurious impression of the atmosphere. In elderly sub- jects, and occasionally even in young ones, it is sometimes partially invested with a cuta- neous pellicle, in consequence of which it is much less sensitive, irritable, tender, and liable, than under ordinary circumstances, to bleed. The orifices of the ureters, gene- rally situated at the inferior part of the tumor, are each marked by a small, conical emi- nence, from which the urine constantly dribbles, rendering the person uncomfortable to himself, and disgusting to those around him. The distance between the two apertures ranges from one to two inches, according to the age of the subject. The penis, abnormally short and flattened, is bent backwards, and furnished with an imperfect prepuce. The cavernous bodies, attached below to the ischium, as in the natural state, are small and narrow, and are not always united along the middle line, except just behind the head of the penis. This organ is sometimes imperforate, while at other times it presents a gutter along its upper surface for the lodgment of the lower half of the urethra. When this is the case, the posterior part of the canal displays the verumontanum, the mouths of the ejaculatory ducts, and the orifices of the prostatic canals. From the pecu- liar conformation of the penis and urethra, the individual is necessarily impotent. The prostate gland is generally in a rudimentary state. The seminal vesicles are also very diminutive, and are invariably situated behind the inferior part of the tumor. The ejacu- latory ducts pursue their natural route, but are unusually small. The scrotum is sometimes absent; at other times it exists merely in a rudimentary state. In the latter case, it may contain the testicles, while in the former these organs are either lodged in the groins, or in a cutaneous bag at each side of the tumor. The testicles are either normal, wanting, or much diminished in volume. The bodies of the pubic bones are absent, the pelvis is unusually broad and flat, and the groins are generally the seat of hernia. Fig. 477, taken when the patient was upwards of twenty years of age, affords an excellent idea of the ordinary appearances of this species of malformation. In the female, equally important changes are noticed in the genital organs. Thus, the clitoris may be absent, or deviate remarkably from the normal standard; the nymph* are small and disjoined, and the labia extend from the sides of the tumor towards the anus, without coalescing behind. The uterus and ovaries are either absent, or they exist in a rudimentary state. Sometimes, however, these organs are fully developed, as is shown by the fact that the woman both menstruates and conceives, as in the interesting cases reported by Thiebault, Ayres, and others. Persons affected with this deformity may, notwithstanding their constant discomfort, live for many years, and even attain longevity. Head, whose case is well known in this country, is now upwards of forty years of age, and in the enjoyment of excellent health. Flajani has recorded a case of seventy, and Quatrefages met with two, respectively forty- six and forty-nine years of age. CHAP. XVI. MALFORMATIONS OF THE BLADDER. 669 In a still-born female child, kindly sent to me by Dr. Bournonville, there was complete absence of the vagina, and the merest vestige of nymphae. The deficiency in the wall of the abdomen at the umbilicus was unusually great. The child was well formed in all other respects. Fig. 477. Exstrophy of the Bladder, n. Everted Biadder. 6. 6. Orifices of the Ureters, e. Penis without Urethra. d, d. Pubic Symphysis, e. Scrotum and Testis. /. Congenital Inguinal Hernia. Exstrophy of the bladder was, until lately, universally regarded as utterly irremediable. In fact, even now, after all the lights of modern science, all that can generally be done is to palliate suffering by attention to cleanliness, and by the use of a closely-fitting urinal, fig. 478. When this cannot be obtained, the part must be kept constantly covered with a thick, soft compress, renewed as often as it becomes wet and disagreeable. The skin around may, if necessary, be protected with cosmoline or zinc ointment. It was proposed some years ago to establish a channel for the conveyance of the urine from the bladder to the rectum, and, in one instance, that of Mr. Simon, of London, the plan was partially successful in diminishing the inconti- nence. The operation consisted in turning the ureters into the bowel, by passing instruments, armed with threads, from the former into the latter, the ends being tightened from time to time until the communication was effected. The boy lived nearly a year, when death ensued from disease of the ureters and kidneys. In the cases of Mr. Lloyd and Mr. Athol Johnson, in which an effort was made to open a direct communication between the bladder and rectum by means of a seton, the patients perished in a few days from peritonitis. Mr. Holmes, with a view of obviating the risk of peritonitis, has devised a plan of con- verting the bladder and bowel into a common cavity, by destroying the intervening tissues of the perineum above the sphincter muscles. The blades of the instrument, which are constructed on the same principles as those of the enterotome, are applied to the blad- der and the rectum, and approximated from day to day until the sloughing process is com- pleted. Ur. Levis, in 1876, endeavored to establish a fistulous communication between the bladder and perineum, by passing a needle armed with a stout wire through the base of'the bladder and behind the scrotum, and gradually enlarging the track by the insertion of bougies until its caliber had attained half an inch. The bladder was then covered with Fig. 478. Urinal. 670 DISEASES OF THE URINARY ORGANS. CHAP. XVI. a large scrotal flap, the penis being left in the new cavity thus formed, and drainage insured by the retention of a soft catheter. Death ensued on the twelfth day from causes uncon- nected with the operation. A second case proved fatal from peritonitis. The most rational plan of relief, undoubtedly, is autoplasty, performed by borrowing the integument from the adjacent parts, and inverting it in the hope that the cutaneous tissue may ultimately assume the properties of the mucous and so adapt itself to its new relations. The flaps are united by suture, and are thoroughly protected during the treat- ment from the contact of the urine. The extensive wound in the neighborhood should be as well closed as the case may admit of, the bowels should be locked up with morphia, which should also be freely used to allay pain, and the walls of the abdomen should, throughout, be maintained in a relaxed condition by placing the patient almost in a sitting posture, with the knees well supported by pillows. The greatest possible attention must also be bestowed upon cleanliness. Of the different operations for covering in the bladder, in this affection, the most eligi- ble for males is that of Dr. F. F. Maury, represented in fig. 479, the flap being made at the expense of the perineum and scrotum, by a curvilinear incision carried from the outer third of Poupart’s ligament across the middle of the perineum, to a corresponding Fig. 479. Fig. 480. Maury’s Operation for Exstrophy of the Bladder. Wood’s Operation for Exstrophy of the Bladder. point on the opposite side, and united, after bevelling its surfaces, by the tongue and groove suture, to an upper short flap, raised by dissection from the abdominal wall just below the umbilicus into which it is inserted. The penis is slipped through a small inci- sion made in the centre of the flap, through which the urine passes off without coming in contact with the edges of the wound. In this way Dr. Maury succeeded in two cases not only in forming an anterior wall for the bladder, but in curing a double hernia by the con- traction of the exposed granulating surfaces. The patients were, respectively, eight and nine years of age. In females the procedure of Professor Wood, fig. 480, is preferable to other methods hitherto devised. An umbilical flap, A, is inverted over the viscus, and covered in with flaps raised from the groins, B, C, their upper edges a b, a' b', coming together in the middle line. Professor Bigelow does away with the umbilical flap, merely protecting the bladder, previously denuded of its mucous membrane as far down as the uterus, with two lateral flaps. Dr. Sonnenberg, of Berlin, has recently extirpated the bladder, transplanted the ureters into the dorsal groove of the rudimentary penis, and closed the defect in the abdominal walls by an autoplastic operation. At the expiration of four weeks the wound had closed excepting a space the size of a dollar, which was filled with healthy granulations. The unfavorable opinion which I expressed in former editions of the value of this operation has been greatly modified by the results obtained within the past few years, since I am convinced, from a personal examination of several cases, that it affords great comfort not only by protecting the sensitive mucous membrane from the contact of the clothing, and preventing excoriation of the surrounding parts, but also by facilitating the adjustment of an apparatus for receiving the urine. The great danger after the operation is erysipelas, likely to eventuate in sloughing of the flaps ; but in addition to this there will CHAP. XVI. WOUNDS OF THE BLADDER. 671 certainly be some risk both of peritonitis and pyemia. Much of this, however, may be avoided by proper preliminary treatment. To Professor Pancoast is undoubtedly due the credit of having been the first, in 1858, to perform a successful plastic operation for the relief of this malformation. The patient, a man, twenty-eight years of age, recovered completely, but died of pneumonia two months and a half subsequently. The operation was repeated, in a modified form soon afterwards, by Dr. Ayres, of Brooklyn, upon a young woman, with highly gratifying re- sults, a urinary canal and an anterior fourchette of the vulva having been established. Simi- lar operations have been performed within the last few years, by Holmes, Wood, Billroth, Barker, Cheever, Bigelow, Hodges, and other surgeons, affording, according to Ashhurst, an aggregate of 55 cases, of which 43 were successful, 4 were failures, and 8 were fatal. AVOUNDS. Wounds of the blader, whether incised, punctured, lacerated, or gunshot, must neces- sarily, from the situation of the viscus, be complicated with lesion of the soft parts by which it is surrounded, and also not unfrequently with fracture of the pelvic bones. The best example of an incised wound of the bladder is the incision, made in the suprapubic and rectovesical operations for stone. In perineal lithotomy, the knife divides the prostate gland rather than the bladder. A good example of a punctured wound is afforded by the use of the trocar in drawing off the urine for the relief of reten- tion from obstruction of the urethra. The symptoms are, the existence of an opening in the lower part of the hypogastrium, groin, or perineum; sudden and acute pain in the situation of the affected organ, extend- ing along the urethra, and often accompanied by slight priapism ; an escape of urine, or urine and blood, at the external wound ; frequent, but ineffectual, attemps at micturition ; violent tenesmus, and hemorrhage from the urethra. The system labors under all the effects of violent shock. When the injury is complicated with perforation of the bowel fecal matter, mucus, bile, or gas, mixed with urine, or urine and blood, may issue both at the external opening and at the urethra. When the pelvic cavity is pierced, the state of collapse, the usual consequence of the accident, is speedily followed by symptoms of peritonitis, of which the patient almost always dies in a few days. When the bladder is wounded through the perineum or above the pubes, at a point where it is uncovered by serous membrane, urinary infiltration is liable to take place, and the probability of the occurrence will be so much the greater if the external opening is disproportionately small, if the track of the wound is narrow and devious, and if the or- gan was much distended at the time of the accident. Gunshot wounds of the bladder, less fatal, perhaps, than punctured and incised, are always extremely formidable, destroying life either immediately or remotely, producing extensive mischief among the soft parts, as well as in the pelvic bones, and leading to the formation of abscesses, sinuses, and fistules, which maylastforan indefinite period. When the ball is impelled with great velocity, it will be likely to enter the organ at one point, and pass out directly opposite at another, thus leaving two apertures, and either lodging in the neighborhood, or issuing upon the surface of the body. If, on the contrary, it move slowly, or be nearly spent, it will make only one opening, and be arrested in the bladder, from which it may afterwards be discharged by the urethra, or by a fistulous passage ; or, what is more probable, it will become incrusted with earthy matter, and thus form the nucleus of a calculus. The lesion is often complicated with fracture of the pelvic bones, injury of the large vessels, and perforation of the rectum, small intestines, uterus, or vagina. In the former case, serious mischief is sometimes done by the osseous splinters which the ball makes and detaches in its course towards the bladder, and which not unfre- quently find their way into the interior of this organ, where they may rise even to more disastrous consequences than the ball itself. Wadding, pieces of cloth, or portions of the patient’s dress, may accompany the ball. Gunshot wounds of the bladder, made with the old round bullet, were formerly fre- quently recovered from. Thompson met with not less than 14 cases of this kind after the battle of Waterloo, and Guthrie refers to 6 similar examples, in 3 of which the bullet entered above the pubes. Larrey, who met with a number of instances of gunshot wounds of the bladder in Egypt and Syria, affirms that they generally terminated favorably. This, however, is not the experience of recent military surgeons, for wounds inflicted upon this organ by the conical ball nearly always cause death. Now and then, however, an 672 DISEASES OF THE URINARY ORGANS. CHAP. XVI. exception occurs, as in the case of a young man, reported to me by Dr. J. F. Koerper, who was struck by two Minie balls, one of which entered the right buttock, nearly mid- way between the great trochanter and the sacral fissure, and emerged at the left groin, traversing, apparently, the lower part of the bladder, which had not been emptied for upwards of eight hours. Urine began to issue at the gluteal wound soon after the acci- dent, and for six days it passed off entirely by this route. It then gradually resumed its natural channel, but it was not until after the end of a month and a half that the fistu- lous track was finally closed. The man never had any bad symptoms. In a case men- tioned by Dr. F. H. Hamilton, the individual had seven wounds, from three of which, made apparently with buckshot, all the urine escaped for ten days. It then ceased to pass off by the posterior openings, but continued to flow from the anterior for six weeks. The recovery was complete. One of the great causes of death in gunshot injuries of the bladder, involving the pelvic bones, where the patient does not perish from the immediate effects of the lesion, is pyemia. The prominent indications of treatment are, to prevent the extravasation of urine, and to guard against undue inflammation. Unfortunately, the first of these accidents often takes place at the moment of the injury, and consequently, before the surgeon has an opportunity of interfering. When the reverse is the case, the bladder should instantly be evacuated, the patient placed almost semierect in bed, and a gum-elastic catheter per- manently retained to allow the urine to pass off as fast as it descends from the uretei-s. In a word, the organ should be kept constantly empty and contracted for the first few weeks, or until there is reason to conclude that the wound is closed and that all risk of infiltra- tion is over. In the more favorable cases most, if not all, of the fluid escapes through the accidental passages, thereby greatly promoting recovery, as in an instance in the hands of Dr. William Hunt, of this city, in which the bladder was perforated by a sharp stick which entered the viscus through the perineum near the coccyx. When the urine is extravasated around the neck of the bladder the perineal section should at once be per- formed. Inflammation is prevented by local bleeding, calomel and opium, fomentations, and vesication of the abdomen. Anodynes are given in full and sustained doses, both by the mouth and by the rectum, to mitigate pain and spasm of the bladder, promote sleep, and diminish the renal secretion. Hardly any drink is admissible ; the diet must be very light and bland, and the bowels must be disturbed as little as possible during the first fortnight. Abscesses, the result of urinary infiltration, are opened by early and free in- cisions. Nothing can be gained by an attempt to extract the foreign body in injury produced by firearms ; for the very moment it is inflicted the urine escapes, and the bladder, contract- ing upon itself, destroys the relations between the external and internal wounds. If the ball has fallen into the bladder, it may, if not too large, either pass ofl' spontaneously, as in the cases recorded by Larrey, Baudens, and Bonnet, or it may be removed with the forceps, otherwise, especially if it cause severe symptoms, it must be cut out through the perineum by an operation similar to that of lithotomy. This may be done immediately, or within a short period after the accident, if the ball has entered beneath the pubes, for the reason that the organ will not only be freed thereby of a disagreeable intruder, but also because there will be less risk of urinary infiltration. Mr. Dixon has published an analysis of 13 cases, in which the lateral operation of lithotomy was performed for the removal of bullets, 10 being successful, and 3 fatal. Baudens, in a similar instance, relieved his patient by the suprapubic operation. Hilda- nus has recorded the particulars of a case in which a bullet remained in the bladder for thirty years. Pieces of wadding, of cloth, and of bone, introduced into the bladder, either alone, or jointly with a bullet, are occasionally voided by the urethra. More generally, however, if the patient survive the immediate effects of the accident, they are retained, and be- come the nucleus of a calculus. The presence of such bodies is usually easily detected with the sound. When the bladder has been transfixed, or wounded through the peritoneum, the acci- dent is almost inevitably fatal. All the cases that occurred during the late war had this termination. In view of this event, the surgeon, as suggested in former editions of this work, should not hesitate to open the abdomen at the middle line, and sponge out the ex- tra vasated urine. The earlier this is done of course the better. The case is necessarily a bad one, but as the operation offers the only chance of success it should be performed at all hazard as speedily as possible. The smallest quantity of urine, if allowed to remain, CHAP. XVI . RUPTURE OF THE BLADDER. 673 will be sure to cause fatal peritonitis. Dr. Harrison, of Dublin, in a case of this kind saved his patient by means of the rectal puncture, the fluid having settled in the pelvic cul-de-sac. Incised wounds of the bladder, attended with free opening of the wall of the abdomen, should be closed as speedily as possible with the carbolized catgut ligature, the ends being cut off close to the knot. Such an accident occasionally occurs during ovariotomy, and the extirpation of the uterus, and a number of instances have been reported in which life was preserved by this treatment. RUPTURE. The urinary bladder is liable to laceration or rupture. When the accident takes place from overdistension of urine from paralysis of the muscular fibres of the organ, hypertro- phy of the prostate gland, or obstruction of the urethra, there is always some degree of softening of the different coats, thus predisposing them to the occurrence. In such a case, any unusual, sudden, or violent exertion may produce it. The most common cause of laceration, however, is external violence, and it is worthy of remark, both in a surgical and medico-legal point of view, that it may occur from the most trivial injury. Any force suddenly applied to the hypogastric region, while the bladder is distended, as a smart blow, a kick, or a fall, will frequently suffice to produce it, sometimes without leaving the slight trace upon the surface of the body ; not, perhaps, even any discoloration. The accident is liable to happen in females during parturition, from the pressure of the child’s head, when the patient has neglected to empty the blad- der. It may also be occasioned by fracture of the pelvic bones, the ends of the frag- ments being forcibly driven into the walls of the organ, as in a case which I saw along with Dr. John W. Lodge, in a young man, who was hurt by a mass of sand caving in upon him while at work in a quarry. No marks of external injury existed, but the pubic and ischiatic bones were most extensively fractured, especially the former. The promi- nent symptoms were, severe pain in the lower part of the abdomen, groins, and sacrolum- bar region, excessive nausea and vomiting, great swelling of the perineum, scrotum, and right thigh, from urinous infiltration, and inability to empty the bladder. Death occurred two weeks after the accident, from peritonitis and gangrene. The perineum and scrotum, as well as the tissues in front of the prostate gland and the rectum, were nearly entirely destroyed, and the penis was almost completely severed from its attachments at the pubic symphysis. Occasionally, as in a case reported by Dr. Thomas G. Morton, there is a con- siderable quantity of urine extravasated into the intermuscular spaces of the Avail of the abdomen with very little in the peritoneal cavity. Of 37 cases of rupture of this organ by external violence, collected by Ilouel, 15 involved the posterior and 12 the anterior wall, 3 the sides, and 2 the summit; 3 were double, and in 2 the situation is not stated. Rupture of the posterior wall nearly always extends through the peritoneum, whereas, in the other forms of the accident, this mem- brane generally remains intact. Of 78 cases, analyzed in 1851, by Dr. Stephen Smith, the posterior Avail suffered in 50, the anterior wall in 9, and the neck in 6. The cause of the rupture in 48 was direct violence ; in 15, concussion ; in 4, parturition ; and in 4, stricture of the urethra. Sixty-seven of the cases were males, and eleven Avere females. Death, in the majority of the patients, occurred within the first five days ; 5 recovered, and 1 lived six weeks. Of 166 cases collated and analyzed by Dr. Max Bartels, the peri- toneum was involved in 98, and not lacerated in 54, the state of that membrane being undetermined in 14. In 84 of the intraperitoneal ruptures the rent Avas situated at the fundus in 40, in front near the fundus in 9, posteriorly in 33, and at the side in 2. In 50 of the extraperitoneal cases the rupture involved the neck in 19, the anterior Avail in 23, the posterior wall in 2, and the side in 6. Of the entire number 149 died and 17 recovered. In laceration of the front of the bladder, the urine, if the opening be large, escapes rapidly, and spreads widely beneath the peritoneum; sometimes as high up, on the one hand, as the umbilicus and the kidneys, and, on the other, as low down as the thigh, by passing through the obturator foramen. In spontaneous rupture from o\rerdistension, the bladder generally gives way in its posterior wall, without involvement of the peritoneum, and the consequence is that the urine accumulates under this membrane as in a kind of subsidiary pouch. The injury usually reveals itself by well marked symptoms, both general and local. Violent pain is instantly experienced in the hypogastric region, the face is pale and ghastly, the pulse is small, rapid and fluttering, the respiration is hurried and difficult, 674 DISEASES OF THE URINARY ORGANS. CHAP. XVI. the extremities are cohl, and the surface is covered with a clammy perspiration. The patient occasionally falls down in a state of insensibility, and not unfrequently he feels as if something had suddenly given way in his abdomen. There is, in nearly all cases, a constant desire to urinate, with an inability to pass a single drop of water. A small quantity of blood often flows off' by the urethra. These symptoms are soon followed by nausea and vomiting, intense thirst, excessive restlessness, and an expression of great suf- fering, with swelling and tenderness of the abdomen. Rupture of the bladder, as above stated, is nearly always fatal; usually in from three to five days after its occurrence. The immediate sources of danger are, hemorrhage, shock, peritonitis, perivesical cellulitis, and uremia, generally promptly collapsing the system. The treatment must be conducted in accordance with the general principles laid down under the head of wounds of the bladder. The only reliance is upon the catheter, or cystotomy, anodynes, and supporting measures, with proper drainage. In 1851 I sug- gested the propriety of opening the abdomen through the linea alba, and sponging out the extravasated fluid, a suggestion which was successfully adopted in 1862, by Dr. Walter, of Pittsburgh, and subsequently, but with fatal results, by Mr. Willett, and Mr. Heath. Dr. Walker, of Boston, and Dr. Erskine Mason, of New York, each performed lateral cystotomy, and saved their patients. INFLAMMATION. Cystitis generally begins in the mucous membrane, and presents itself under two varie- ties of form, the acute and the chronic. Of these, the first is exceedingly infrequent, while the second is sufficiently common, and often entails a vast amount of suffering. 1. Acute Cystitis Acute inflammation rarely occupies the whole mucous surface of the bladder; on the contrary, it usually occurs in irregular, circumscribed spots, from the size of a twenty-five cent, piece to that of the palm of the hand. The portions of the or- gan most frequently affected are the neck and bas-fond. During its progress the inflam- mation often spreads from the mucous membrane to the subjacent connective tissue, and from thence to the muscular tunic. The peritoneal investment is rarely implicated in any considerable degree, however serious the attack. The principal causes of acute cystitis are wounds of the bladder, calculous concretions, gonorrhoea, rough horseback exercise, the inordinate use of heating drinks, venereal ex- cesses, enlargement of the prostate gland, stricture of the urethra, congenital smallness of the external meatus, injury sustained during parturition, stimulating diuretics, suppres- sion of the cutaneous perspiration, irritating injections, and the protracted retention of urine. Cystitis, consequent upon an extension of gonorrhoea, generally comes on during the height of the discharge, as a direct result of the use of stimulating food and drink, severe bodily fatigufe, suppression of the cutaneous perspiration, or irritating injections. Occa- sionally, however, it sets in at a comparatively late period, when nearly all discharge has disappeared, and the patient considers himself almost well. The parts usually affected are those immediately behind and below the prostate gland, which not unfrequently par- ticipates in the morbid action. The more important anatomical characters are, increased vascularity, loss of transpa- rency, softening, deposits of lymph, and discoloration, with alteration of the natural secre- tion. The disease is generally ushered in by dull, obscure, deep-seated pain, or, rather, a kind of gnawing uneasiness, in the region of the bladder, which, rapidly increasing in inten- sity, soon extends to the neighboring organs. At this early stage there is little or no constitutional disturbance; or, if any, it manifests itself merely by slight chills, alterna- ting with flushes of heat, some thirst, and a little excitement of the pulse. The patient now begins to experience frequent calls to void his urine, which is expelled either in small quantities, or drop by drop, accompanied with violent straining, distressing spasm, and a peculiar scalding sensation at the neck of the bladder and along the course of the urethra. The hypogastrium is distended, painful, and so exquisitely tender as to render even the weight of the bed-clothes intolerable. The limbs are drawn up, and the body is bent forward to relax the abdominal muscles, and relieve the tension of the bladder. The urine is scanty, thick, ropy, turbid, reddish, or tinged with blood, and loaded with mucus and lithates. After a few days suppuration occurs, and then the fluid invariably contains more or less pus and fibrin. The pain, always so distressing a symptom, shoots along the testicles, groins, thighs, and spermatic cords, to the sacrolumbar region, where CHAP. XVI . INFLAMMATION OF THE BLADDER. 675 it is often almost insupportable. The bladder, never entirely freed of its contents, gradu- ally ascends above the pubes into the hypogastrium, forming an elastic, globular tumor, exquisitely sensitive under the slightest pressure, and readily detectable by sight and touch. When the disease is fully developed there is always more or less constitutional derange- ment, as indicated by the frequency and hardness of the pulse, the anxious countenance, and the coated appearance of the tongue. In the more severe attacks, nausea and vomit- ing, with severe precordial oppression, are rarely absent. Sometimes there is complete suppression of urine. Considerable diversity occurs in the symptoms of cystitis, dependent upon the particu- lar seat of the morbid action. When the neck of the bladder is mainly affected, excessive pain and a sense of weight and fullness are experienced in the anus and perineum, there is an incessant desire to micturate, and severe scalding is felt along the urethra, particu- larly distressing as the last drops of urine are voided. When the anterior wall is inflamed there is great tenderness on pressure and percussion, with a sense of constriction in the hypogastric region. When the disease occupies the bas-fond of the organ, the rectum always suffers severely, the patient is harassed with constant straining and tenesmus, and there is exquisite tenderness on pressure of the perineum. Acute cystitis usually runs its course with considerable rapidity. It seldom continues beyond the sixth or eighth day without terminating in resolution, tending to suppuration, passing into gangrene, or assuming a chronic type. The leading indications in the treatment are, first, to subdue symptomatic excitement, and, secondly, to quiet local irritation. For accomplishing the first, the remedies mainly relied upon, in the incipient stages of the complaint, are general and topical bleeding, aperients, and diaphoretics, aided by absolute recumbency and a rigidly antiphlogistic regi- men. A diet restricted to milk is generally highly beneficial. The bowels, if distended, should be early moved by some mild laxative, as castor oil, Rochelle salt, sulphate of mag- nesium, or, what is better, by an enema of cold water, thin gruel, or soapsuds. If the bil- iary and other secretions are deranged, a dose of calomel may advantageously be given. All drastic cathartics must be avoided, as they tend not only to excite the inflamed struc- tures, but to increase the quantity of irritating matter in the urine. As soon as proper depletion has been practised, diaphoretics are to be given, one of the most useful of which is the antimonial and saline mixture, in union with full doses of morphia and aconite. Dover’s powder is beneficial when the skin is already in a relaxed or perspirable condition. If the stomach is irritable, the effervescing draught is prefera- ble to everything else. The action of these medicines may be favored by tepid drinks, the hot vapor-bath, and hot fomentations to the hypogastrium and genitals. Diuretics are improper. When the urine is acrid, high-colored, or very scanty, a small quantity of nitrate of potassium, or spirit of nitrous ether, may be administered, to modify the renal secretion and to allay vesical irritation. In the latter stages of the disease a strong infu- sion of uva ursi and hops will prove highly advantageous, especially if combined with morphia and bicarbonate of sodium, or morphia and balsam of copaiba. The use of bal- sam of copaiba is particularly indicated in the gonorrhoeal form of the complaint. Among the more important local remedies for arresting cystitis and tranquillizing the affected organ, are anodyne suppositories, fomentations, and the hip-bath. Leeching the perineum is often extremely serviceable. The pain in the back is relieved by anodyne lotions, by cups, either wet or dry, and by blisters, applied to the sacrolumbar region. Cer- tain modifications of treatment are made, according to the nature of the exciting cause of the disease. Retention of urine is promptly relieved with the catheter, but the instru- ment must not, for obvious reasons, be retained in the bladder. 2. Suppuration and Abscess A discharge of pus, or muco-purulent fluid, from the lining membrane of the bladder, although sufficiently common in chronic cystitis, is infre- quent in the acute form of the disease. The discharge, moreover, is usually of brief con- tinuance, as well as small in quantity, while in chronic cystitis it often lasts for a long time and is occasionally remarkably profuse. The matter, instead of being furnished by the free surface of the mucous membrane, occasionally presents itself as a small abscess, situated in the submucous connective tissue, or between the muscular and serous tunics. It may occur in any part of the viscus, but is most frequent at the neck, as a solitary deposit. Although in the great majority of cases the abscess points inwards towards the cavity of the bladder, it may also open into the rectum, the sigmoid flexure of the colon, the ileum, the vagina, or the abdominal cavity. 676 DISEASES OF THE URINARY ORGANS. chap, xvi. Sometimes the matter is diffused through the connective tissue of the coats of the viscus, which, in consequence, exhibit a soft, oedematous aspect. Suppuration of the bladder may be the result of idiopathic inflammation, either acute or chronic, external violence, or the presence of some foreign body, as a calculus, bougie, or catheter. In the latter case, the abscesses are generally developed under the influence of protracted irritation, operating directly upon the tunics of the organ. The occurrence of suppuration is always denoted by well marked symptoms. The most important are frequent rigors, alternating with flushes of heat; an increase of thirst, anxiety, and restlessness ; dull, aching, throbbing pain ; and a feeling of weight and full- ness in the perineum and pelvis. The mind generally wanders, and, in many cases, there is confirmed delirium. These symptoms, however, may be simulated by other diseases, both of the bladder and of the neighboring organs. In abscess, the diagnosis is some- times determined by the sudden appearance in the urine of a large quantity of pus, after a violent effort at micturition or an attempt to draw off the urine. Infiltration of pus into the coats of the bladder cannot be distinguished during life. The prognosis of suppuration of the bladder is usually favorable, except when it ends in abscess, when the danger is always imminent. Much, however, must necessarily, under such circumstances, depend upon the nature and extent of the mischief. The treatment is by antiphlogistics, in the earlier stages of the disease, and, subse- quently, by tonic and invigorating measures. Abscesses, pointing externally, must be opened with the knife. 3. Gangrene Acute inflammation of the bladder seldom ends in gangrene, as the morbid action which gives rise to it is generally easily arrested by the early and vigorous employment of antiphlogistic measures. The occurrence is particularly to be apprehended when the disease is marked by great violence, has been induced by external injury, or takes place in old, dilapidated subjects. The occurrence, however induced, is announced by great prostration of strength ; sudden cessation of pain; coldness of the extremities; small, weak, frequent, fluttering pulse; profuse, clammy, and offensive perspiration; cadaverous expression of the coun- tenance; mental confusion, delirium, and coma; hiccup, twitching of the tendons; and, towards the close, by colliquative diarrhoea and involuntary discharge of the feces. The urine is of a dark-brownish or blackish color, emits a peculiarly fetid, sickening odor, and is effectually retained by the dead, crippled, or paralyzed organ. On dissection, the mucous membrane is found to be blackish, livid, or purple, very soft, easily torn, and bathed with a thin, sanious fluid, of an excessively offensive odor. Gangrene of the bladder is sometimes followed by a rupture of its coats, and by the escape of its contents. Such an event is most likely to happen when there has been protracted retention of urine, with inordinate distension, and it may occur either very suddenly, or slowly and gradually, as a result of ulceration. Whether the urine escapes into the cavity of the abdomen, or into the connective tissue of the pelvis, death is equally certain. The treatment is easily told. The object should be to prevent the lesion rather than to attempt to cure it after it has been established. When gangrene is inevitable, the indication is to support the system, and by means of quinine, ammonia, brandy, opiates, and nutritious food, assist the patient in throwing off the effects of the local disorder. Distension of the bladder is relieved with the catheter. 4. Ulceration—Ulceration of the bladder is amongst the rarest accidents to which this organ is liable. The ulcers are usually neither numerous nor large. Their most common appearance here, as in the bowels, is that of depressed breaches of continuity of the mucous membrane, of a circular or oval form, with slightly elevated edges. Occa- sionally, the edges are hard, thick, fissured, and puckered. Occurrences like these are most common in old, chronic cases. The bottom of the erosion is originally formed by the submucous connective substance; but as the disease progresses, it may destroy the mus- cular fibres, and even the serous investment, leading, perhaps, eventually to perforation, and to the escape of urine into the abdominal cavity. Or, instead of this, adhesions may take place between the bladder and the neighboring viscera. In the great majority of instances, the ulceration is distinctly traceable to chronic cystitis. Paralysis of the bladder, injury of the spinal cord, and organic lesion of the kidneys are very apt to induce the affection, from the changes which they create in the composition of the urine. Calculous concretions and earthy deposits often occasion ulceration solely by the pressure which they exert upon the mucous membrane. Some- times the disease is the result of the softening of tubercular matter, and then the mus- CHAP. XVI . INFLAMMATION OF THE BLADDER. 677 cular fibres are occasionally as completely denuded as if they had been dissected with the knife. Ulceration of this organ, as a result of a syphilitic taint of the system, is very uncommon. Cases of it have been described by Ricord, Virchow, Vidal, Tarnousky, and others. The disease, which may arise during any stage of constitutional syphilis, is occasionally complicated with ulceration of the urethra, and may occur at any period of life. There is nothing peculiar as to the size, number, shape, or depth of the ulcers. The symptoms of ulceration of the bladder do not differ essentially, in the early stage of the disease, from those of subacute or chronic inflammation. Even at a later period, they are not always well marked. The most prominent are pain and uneasiness in the pelvis, with anal and vesical spasm, frequent micturition, and an offensive state of the urine. The pain is of an acute, burning, or scalding character. The inclination to mic- turate is not incessant, but in paroxysms, which gradually increase in frequency, and are attended with intense suffering. The urine is commonly acid, slightly albuminous, voided in small quantity, and loaded with thick, ropy mucus, which, as the fluid cools, adheres firmly to the bottom of the receiver. As the destruction of the lining membrane pro- ceeds, the mucus gradually diminishes, and finally almost entirely disappears. In the advanced stages of the complaint, the fluid is excessively offensive, of a dark color, occasionally like coffee-grounds in appearance, and often mixed with pus, blood, shreds of lymph, and even the debris of the affected membrane. An ammoniacal state of the urine is not uncommon at this period. Hemorrhage in considerable quantity may occur when the ulceration opens a bloodvessel. As the disease progresses, the sympathies and functions of the urinary organs are com- pletely subverted, and the patient’s health is materially impaired by the local derangement. Sometimes, however, on the other hand, the symptoms are comparatively mild, and but little distress is experienced in the urinary apparatus. This is more particularly true when the disease is of a tubercular character. The diagnosis is not only difficult, but sometimes impracticable. The affections for which the disease is most liable to be mistaken are simple cystitis, catarrh, and stone. From the first, it may generally be distinguished by its obstinate persistence, by the greater extent and violence of the local distress, by the incessant desire to void the urine, by the more frequent recurrence of spasms, by the more severe burning or scalding along the urethra, by the presence of pus in the urine, and, lastly, in the more aggravated forms of the complaint, by the absence of mucus. In catarrh, the characteristic symp- tom is a copious secretion of thick, tough, ropy mucus, with a turbid appearance and an ammoniacal smell of the urine. The local and constitutional distress are less severe than in ulceration, the desire to micturate is not so frequent, there is less sensibility of the urethra, and there is often complete intermission of the vesical disturbance, the pa- tient remaining comparatively comfortable for days and weeks. In ulceration, the symp- toms are persistent, the disease steadily proceeding from bad to worse. Syphilitic ulce- ration of the bladder cannot be distinguished from ordinary ulceration of this organ. In stone, the pain is most severe immediately after micturition, and is generally much aggravated by rough exercise; the urine is more frequently bloody; there is less irritabi- lity of the urethra; and the intervals between the paroxysms are longer than in ulcera- tion. If doubt exists, the sound is used, cautiously and gently, lest, if the case be one of ulceration, it increase the local inflammation, and thus endanger life. In ulceration there is sometimes a discharge of the debris of the mucous membrane, which never happens in simple cystitis, catarrh, and calculous disorder. The pain also is much greater, and the desire to pass water more frequent. When perforations exist, a discharge of gas, fecal matter, ingesta, and other substances, along with the urine, leaves no doubt respecting the nature of the disease. The treatment is most unsatisfactory, At the commencement of the complaint the measures must be strictly antiphlogistic; by the abstraction of blood by leeches, mild aperients, light but nutritious diet, and rest and recumbency. The most suitable internal remedies are balsam of copaiba, uva ursi, hops, hyoscyamus, bicarbonate of sodium, mineral acids, and tincture of chloride of iron, either alone, or variously combined. Anodynes, in full doses, are indispensable for quieting the bladder, and procuring sleep. In the syphilitic form of the disease, the iodides should be freely employed. Of the measures addressed directly to the affected surface, the best, undoubtedly, are such as are of an anodyne character, as infusion of poppy, opium, hop, aconite, and cicuta, or tepid water, either simple or medicated, with carbolic acid, tannic acid, sulphate of zinc, creasote, or nitrate of silver. Lime-water, black wash, and weak solutions ol iodine have occasionally proved advantageous. The best mode of introducing them is by means 678 DISEASES OF THE URINARY ORGANS. CHAP. XVI. of a gum-elastic bag, carefully adapted to the end of a medium sized flexible catheter. The quantity of any injection should not exceed, at first, an ounce; if it be anodyne, it should be retained as long as possible; if astringent, or irritating, not more than a few minutes. No form of counterirritation is likely to be of the least service. Finally, the only really rational treatment in ulceration of the bladder unquestionably is to open the organ through the perineum in order to place it in a state of thorough repose until the sores are completely cicatrized. In the male, difficulty may be experienced in keeping the wound open sufficiently long to attain this end, but this might be overcome by means of dilators, or tubes, worn to prevent reunion of the wound. In the female, who is particularly liable to perforative ulceration of the neck of the bladder, the late Sir. J. Y. Simpson succeeded perfectly in two cases in effecting a speedy cure, after the failure of a great variety of other means, by slitting up, upon a grooved staff, the posterior fourth of the urethra and about one inch of the posterior wall of the viscus. Dr. Bozeman, in 1860, in a case of most extensive ulceration of the bladder, made a large opening into the vesico-vaginal septum, and eventually completely relieved his patient. Emmet, Parvin, and others have also performed the operation successfully. 5. Chronic Inflammation, Catarrh, or Cystorrhcea.—Catarrh of the bladder, tech- nically denominated cystorrhcea, is an inordinate secretion of white glairy mucus, essen- tially dependent upon chronic inflammation of the lining membrane. It is analogous in its character to gleet, leucorrhoea, and kindred affections, and is merely a symptom of a more serious disease. It is most common in elderly subjects, and is nearly always due to some obstacle to the evacuation of the urine, as stricture of the urethra, vesical calculus, enlargement of the prostate gland, or paralysis of the bladder. It is a constant attendant upon sacculation, ulceration, hypertrophy, and morbid growths of the organ. Once established, it is easily aggravated or reinduced by exposure to cold, excesses in diet, irritating injections, duretics, overdistension of the bladder, neuralgia, retrocession of gout, repulsion of cutaneous eruptions, local injury, and disease of the adjoining parts, as the anus, rectum, vagina, and uterus. The disease generally comes on in a slow, gradual, and insidious manner. The inflam- mation which accompanies it, and which is always the immediate cause of the peculiar discharge, is of a chronic character, and, in the first instance, of a very mild grade. It is for this reason that the term subacute has sometimes been applied to it. The charac- teristic symptoms are, an inordinate secretion of mucus, an altered condition of the urine, frequent and difficult micturition, pain in the region of the affected organ, as well as in the adjoining parts, and more or less constitutional derangement. The quantity of mucus mixed with the urine varies remarkably in different cases and in different con- ditions. In the incipient stages, and in the milder forms of the affection, it is generally small, not exceeding, perhaps, a few drachms in the twenty-four hours. At a more advanced period, the quantity is often considerable, and in some instances it is truly enormous. The secretion is usually very thick, ropy, and viscid, and, after standing for some time, it always adheres firmly to the bottom of the receiver. During the progress of the disease the urine always becomes highly acrid, so that the bladder can hardly tolerate its presence, even for a few minutes. It generally emits an ammoniacal odor, is of a dirty, turbid, or blackish color, is rapidly decomposed, both in and out the bladder, and is nearly always mixed with epithelial, fibrinous, purulent, and phosphatic matter. If a silver catheter be used late in the disease, it usually comes out of a bronze, brownish, or black color, owing to to the presence of a minute quantity of sulphuretted hydrogen. Renal casts are nearly always present when the disease is accom- panied by serious involvement of the kidneys. The pus in cystorrhcea may proceed from various sources, as the bladder, ureters, prostate gland, and even the kidneys, which are often sadly involved in the mischief. Its presence is always to be regarded with great attention, as it is commonly indicative of serious disease of the organs from which it is derived. The urine is voided frequently, in small quantity, and with more or less difficulty. Generally it passes off in interrupted jets, in a small, feeble stream, or in drops accompanied by violent spasm and straining. When it is loaded with thick, ropy mucus, the difficulty is much increased, and the patient is obliged to have frequent recourse to the catheter. The discharge which accompanies this disorder might possibly be confounded with a discharge of semen; but this can only happen when this fluid flows into the bladder, and mixes with the urine, as in stricture of the urethra, or enlargement of the prostate gland. The distinction is that, in catarrh, the discharge is always greater and more constant, as well as more ropy, tenacious, and offensive, the local suffering is more severe, and there CHAP. XVI. INFLAMMATION OF THE BLADDER. 679 is a more frequent desire to micturate. In spermatorrhoea, the matter is voided in small quantity, and at remote intervals; it has a peculiar odor, is of a light color, and is par- tially insoluble in water, in which it floats in shreds. If any doubt exist it will readily be solved by the microscope. Fig. 481. Columniform Bladder. The prognosis in cystorrboea varies with many circumstances which hardly admit ot precise detail. Much will necessarily depend upon the age and constitution of the patient, the duration of the disease, and the condition of the bladder and of the associated organs. In its incipient stages it is sometimes not difficult of cure ; but when, com- mencing gradually, it has at length come to disorder the whole system, the issue is rarely favorable. The morbid alterations are variable. In the .early stage, and in the milder forms of the disease, the mucous mem- brane usually presents slight marks of inflammation, with little or no lesion of the other tunics. After some time, however, the muscular fibres become hypertrophied, and exhibit the peculiar retiform arrangement delineated in fig. 481, from a specimen in my collection. Occasionally a large bar-like ridge lies immediately behind the neck of the bladder, offering a considerable obstacle to the passage of the catheter. The fibrous lamella is also much thickened, as well as increased in den- sity, and the mucous membrane, par- ticularly the portion which corresponds with the bas-fond of the organ, is often thrown into large heavy ridges. In some instances the lining membrane is _ ulcerated, incrusted with lymph, or protruded across the muscular fibres, in the form of one or more pouches. The walls of the bladder are frequently from five to ten times the natural thickness. The kidneys, ureters, and prostate gland are generally implicated in the mischief; sometimes to a fatal extent. The sacculated appearance of the bladder, so frequent an accompaniment of chronic inflammation, is well shown in fig. 482, from a preparation in my private cabinet. It is Fig. 482. Section of the Bladder and Prostate, a. Mucous Surface of the Bladder, b. b. Lateral Lobes of the Prostate, e. Middle Lobe. d. Large Cyst or Pouch, partially laid open, and com- municating with the Bladder by a small Orifice. 680 DISEASES OF THE URINARY ORGANS. CHAP. XVI. formed by a projection of the mucous coat across the hypertrophied muscular fibres, and varies in size, from a pigeon’s egg to a cavity nearly as large as the bladder itself. It always contains urine, and, occasionally, also calculi. In a case of sacculated bladder, in a man eighty-four years old, reported by Professor W. W. Greene, the adventitious pouch contained nearly one gallon of limpid urine, and was so large as to encroach very seriously upon the abdominal viscera. Treatment In the treatment of this affection, it is of greatest importance to ascertain the nature of the exciting cause. Stricture of the urethra must be removed, stone in the bladder extracted, hypertrophy of the prostate gland, and disease of the neighboring or associated organs mitigated, before any reasonable hope can be indulged of a permanent cure. Antiphlogistics are imperatively demanded whenever there is violent pain with fre- quent micturition, even if there be no marked constitutional disturbance. When the lancet is inadmissible, from twenty to thirty leeches should be applied to the perineum, the inside of the thighs, and the lower part of the hypogastric region. The topical bleeding should be followed up with warm baths, fomentations, and warm enemas. The bowels are opened with saline cathartics, or, if the secretions be much deranged, with calomel and jalap. All articles tending to irritate the rectum must be carefully avoided. The most perfect quietude, both of mind and body, must be enjoined; the diet should be as light and bland as possible, consisting largely of milk, demulcent drinks freely used, and the urine drawn off every six or eight hours with a soft catheter. When, by these means, the violence of the disease has been subdued, there is no remedy equal to balsam of copaiba, given in the form of emulsion, in doses not exceed- ing ten, twelve, or fifteen drops, three or four times in the twenty-four hours. Its nau- seating, griping, and purging tendencies should be counteracted by morphia. When the patient is teazed with pyrosis or acid eructations, the medicine may advantageously be conjoined with bicarbonate of sodium, or sodium and potassium. The terebinthinate preparations are sometimes useful. Pareira brava and buchu have also been much extolled, although very unjustly, as they are generally quite inert. Uva ursi has a specific tendency to the urinary organs, and is particularly serviceable in chronic inflammation attended with excessive morbid sensibility of the neck of the bladder. It may advantageously be conjoined with lupuline, and, in the class of cases just mentioned, with bicarbonate of sodium and potassium. A combination of some of these articles is often beneficial. Indeed, the effect is usu- ally much more conspicuous when thus given than when they are used separately. I have long been in the habit of administering, with the happiest effect, a combination of buchu, uva ursi, and cubebs, sometimes in the form of infusion, but more generally in that of tincture, several times a day, in conjunction with a small quantity of bicarbonate of sodium. Occasionally, a few drops of balsam of copaiba, tincture of chloride of iron, or dilute nitric acid, may advantageously be added to each dose of these medicines. The iron, given by itself, sometimes answers an excellent purpose, especially when there is flatulence with indigestion and anemia. When the disease is associated with a gouty or rheumatic state of the system, colchieum is proper, in union with a full anodyne at bed- time. Benzoic acid sometimes affords relief when everything else fails. It should be given in pill form in doses of five to ten grains thrice a day. In all cases of vesical catarrh, the urine should be subjected to the usual tests. If it be found to be acid, carbonated alkalies should be freely exhibited, and acids if it be alkaline. To allay pain and induce sleep, anodynes are indispensable in almost every stage of the disease. They should be given in full doses, alone or with other medicines, either hypoder- mically, by the mouth, or by the rectum. Dover’s powder is generally well borne by the stomach, and rarely fails to be productive of benefit. The dose should seldom be less than fifteen grains. It is particularly valuable when there is unusual dryness of the skin. Counterirritation, by issue, and by tartar emetic pustulation, is inconvenient, often painful, and generally of questionable efficacy. I now seldom employ it. Blisters, ex- cept at the commencement of the complaint, or when there is a sudden aggravation of the discharge, seldom afford much relief. They should never be employed without being well sprinkled with morphia, otherwise their beneficial effects will be sure to be counter- balanced by the injurious impression which they sometimes make upon the neck of the bladder. An emollient poultice lightly sprinkled with mustard often affords temporary relief, and a similar remark is true of flannel cloths wrung out of hot water and laudanum. The remedies addressed dix-ectly to the suffering organ itself are irrigations, astringent CHAP. XVI. INFLAMMATION OF THE BLADDER. 681 and other injections, and cauterization. In all cases, especially in such as are dependent upon enlargement of the prostate gland, or other mechanical obstruction, the urine must be drawn off at stated periods, at least three or four times in the twenty-four hours, with a soft, gum-elastic catheter, otherwise all other means will fall short of their full effect. Irrigation of the bladder is, in many cases, a valuable auxiliary to the other means already pointed out. It is particularly serviceable when there is an abundant discharge of thick, tenacious mucus, attended with atony of the muscular fibres of the bladder. The operation is performed, with the greatest possible gentleness, with tepid water, in- jected with a Davidson syringe, or a glass tank with a gum-elastic tube, through a double catheter, care being taken not to permit any air to enter, as it would inevitably cause severe pain. In the absence of a double catheter, an oi'dinary gum-elastic instrument may be used ; but, in such an event, only about an ounce of fiuid should be passed in at a time, the operation being repeated until the organ has been thoroughly cleansed. Un- less this precaution be adopted the opei-ation will be sure to occasion great disti-ess, if not positive mischief, from sudden ovei'distension of the viscus. A very complete but expen- sive apparatus, acting on the principle of the syphon, for evacuating and irrigating the bladder, the invention of Dr. Francis H. Williams, of Boston, is described in the Boston Medical and Sui'gical Journal for June, 1881. The contrivance of Keyes, of New York, fig. 483, answers an admirable purpose. Fluids of various kinds, astringent, anodyne, and alterant, are sometimes introduced into the bladder, for the purpose of making a direct inx- pi*ession upon the inflamed surface. The articles most commonly used are alum, zinc, borax, iodine, nitrate of silver, creasote, opium, morphia, lau- danum, cicuta, bichlox'ide of mercui’y, and nitric, hydrochloric, and carbolic acid. Whatever the substance may be, a cardinal rule is to throw it in, at first, in as dilute a state as possible. As the affected surface becomes moi’e tolerant, the strength may gradually be in- creased and the retention more prolonged. For want of this precaution great injury is often in- flicted, and a remedy, otherwise calculated to be beneficial, brought into disi’epute. The article which, on the whole, I have myself found most efficacious is nitrate of silver, in the proportion of one-fourth, one-third, or one-half a grain to the ounce of tepid water, in union with one drachm of tincture of opium, the bladder having previously been well emptied and washed out, especially when the bas-fond is filled with putrid pus and mucus. The fluid should be retained until it causes pain, uneasy sensations, or a feel- ing of distension, when it should pi’omptly be evacuated. I have never employed strong injections of nitrate of silver in this disease, as from twenty to thirty grains to the ounce of water, as advocated by some, having always been afraid of the result of such hei'oic practice. Professor T. G. Richardson, of New Orleans, however, who has employed this mode of treatment, moi-e or less exten- sively without any ill effects during the last twenty years, bestows upon it the highest encomiums. He usually begins with twenty gi'ains to the ounce of water, which, at the end of a week, is increased to thirty, forty, or even sixty grains, accoi’ding to the impres- sion made by the first injection. The fluid is never retained longer than eight or ten seconds, and sometimes not even more than two or three, especially when it is productive of excessive pain. The tenesmus caused by it usually passes off in a short time under the free use of demulcent drinks, aided by a hypodermic injection of morphia. If the suffering is uncommonly severe or protracted the bladder should be well washed out with warm water or some mucilaginous fluid. Cases have been reported to me in which the effects of these injections were so violent as to cause serious apprehension for the ultimate safety of the patient, the great danger being from shock and peritonitis. Cauterization with solid nitrate of silver is occasionally practised. I have tried it in Fig. 483. Keyes’s Apparatus for Washing Out the Bladder. DISEASES OF THE URINARY ORGANS. CHAP. XVI. a number of instances, but without any decided benefit. It is chiefly applicable to those cases in which the catarrh is dependent upon inflammation of the neck of the bladder, and must be employed with the greatest possible caution, otherwise it will assuredly aggravate the morbid action. In obstinate cases, when all other means have failed, the neck of the bladder should be opened in the same manner as in the lateral or median operations of lithotomy, to place the organ in a state of repose, and to afford a free outlet to the mucus and pus as fast as they form. The operation, originally suggested by Mr. Guthrie, of London, but first performed, in 1850, by Professor Willard Parker, of New' York, may justly be regarded as one of the established resources of surgery. Of 47 examples analyzed, in 1880, by Dr. R. F. Weir, 23 w'ere cured, 7 relieved, 4 were failures, and 13 died, the fatal result having been due in ten to advanced renal disease in elderly subjects. When the case is hopeless Professor Agnew' has suggested the establishment of a urinary fistule in each iliac region, by separating the ureters from the bladder, and attaching their x-enal extremities to the wall of the abdomen. The diet must be of a light, farinaceous character. Between the paroxysms, or when convalescence is fairly established, animal broths, fresh fish, oysters, and the lighter kinds of meat, may be used. Condiments are inadmissible, and even salt should be sparingly employed. Vegetable acids, subacid fruits, w'ine, spirits, and fermented liquors are pre- judicial. The best drink is cold water, either alone or with sound Holland gin. Some- times great benefit arises from the steady use of Vichy water. Exposure to cold must be carefully avoided. Flannel is worn next the skin, both summer and winter; riding on horseback is interdicted; sexual intercourse is abstained from ; and the bladder, for a long time, is emptied daily at stated intervals. When the kidneys, ureters, and prostate gland are seriously affected, no remedy has the power of checking this distressing malady. All that can be done is to enjoin perfect tranquility, a light but generous diet, anodynes by the mouth, rectum, or hypodermically, the warm bath, and attention to the bowels. IRRITABILITY OR MORBID SENSIBILITY. The characteristic symptom of this disease is frequent micturition. The urine is voided every few hours, perhaps, indeed, every few minutes, and the process is commonly at- tended w'ith more or less pain, spasm, and burning at the neck of the bladder and along the urethra. The fluid may be perfectly natural, both in its physical and chemical pro- perties ; or it may be increased or diminished in quantity, and variously altered in quality. In general, it is acid, high-colored, and surcharged with mucus, of a whitish or grayish aspect. The urethra and the prostate gland are usually unnaturally sensitive to the touch, and a very common accompaniment of the affection, especially in young men, is a tendency to erections and seminal discharges. In time, the general health, perhaps originally good, gradually suffers. The disease is most frequently met with in children and youths of a nervous, irritable disposition. It is also sufficiently common in persons who are predis- posed to attacks of gout and rheumatism. Irritability of the bladder may be arranged under different heads, according to the causes by which it is induced, as—1st. Disease of the urinary apparatus. 2d. Altered states of the urine. 3d. Diuretic medicines. 4th. Disorder of the genital organs. 5th. Derangement of the alimentary canal. 6th. Lesion of the brain and spinal cord. 7th. General debility. 8th. Exposure to cold and heat. 9th. Disease of the pelvic viscera. In hemorrhoids, fistules, epithelioma, and polyps of the rectum, the bladder is always more or less irritable ; sometimes, indeed, exquisitely so. In boys a tight and elongated foreskin is a common cause of this disease. The pathology of this disease is not well understood. The most plausible conclusion, perhaps, is that the complaint consists in an exaltation of the nervous sensibility of the mucous membrane, similar to that occasionally witnessed in the eye, fauces, larynx, and other mucous canals. When the disease depends upon local causes, as stone in the bladder, stricture of the urethra, or enlargement of the prostate gland, the anatomical changes are more distinct, and afford a more satisfactory solution of the true nature of the case. Very frequently the irritability is purely reflex or sympathetic. The prognosis is variable. The idiopathic form of the complaint, although frequently very obstinate, generally, after a time, yields to a well-directed course of treatment. When the disease occurs in weak, scrofulous subjects, it is always remarkably refractory. The irritability of the bladder of young children, attended with nocturnal incontinence of CHAP. XVI. IRRITABILITY OR MORBID SENSIBILITY. 683 urine, sometimes disappears spontaneously towards the approach of puberty. When dependent upon local causes, of a curable nature, relief may generally be obtained. In the treatment of this complaint, so Protean in its character, a strict inquiry should, in every instance, be instituted into its origin, and the practice regulated accordingly. When the irritability depends upon congestion or inflammation, the application of leeches to the perineum, the hip-bath, and, in plethoric subjects, venesection, are indicated. Laxatives, a properly regulated diet, the internal use of balsam of copaiba, and anodyne injections, should not be neglected. If the disorder depend upon an acid state of the urine, alkalies must be used, and the one which I usually prefer is bicarbonate of sodium, either alone or in union with potassium. Colchicum will be beneficial, especially if given in combination with morphia and spirit of nitrous ether, when the patient is of a rheu- matic or gouty habit. The best form of exhibition is the wrine, in the dose of one drachm every night at bedtime. When the disease has been induced by the improper employment of diuretics, a discontinuance of the remedies, and the liberal use of diluents, the hip-bath, hot fomentations, and a full anodyne by the mouth or rectum, will, in general, speedily arrest it. All venereal excesses must be abandoned, and means taken to remove the disastrous effects thereby produced. Of these, the most important are quinine and the chalybeate tonics, blue mass and rhubarb as a purgative, light but generous alimentation, cold ablu- tions, the cold shower-bath, and exercise in the open air. When the neck of the bladder and the prostatic portion of the urethra are hyperaesthetic, the most reliable local agent is the introduction of the conical steel bougie. If spermatorrhoea be present, nothing short of cauterization will be likely to answer. In this form of irritability of the bladder, good effects often result from the exhibition of bromide of potassium, in doses of twenty to thirty grains thrice in the tv'enty-four hours, in union with five grains of hydrate of chloral and six or eight drops of tincture of belladonna. When the irritation is due to disorder of the digestive organs, particular attention must be paid to the correction of the secretions; the diet should be carefully regulated, and the bowels should, from time to time, be duly evacuated. If symptoms of worms be present, anthelmintics are indicated, of which calomel, spirit of turpentine, and chenopodium are the most valuable. In those forms of the complaint which are dependent upon piles, ulcers, fistule, and other organic changes of the rectum and anus, there can, of course, be no hope of relief without striking at the root of the evil. Tumors must be removed, ulcers cauterized or incised, and sinuses laid open. Mere distension of the rectum by gas and fecal matter is a common cause of vesical irritability, leading to a frequent desire to void the urine. Such cases, of course, suggest their own treatment. Dentition has been known to cause irritability of the bladder fol- lowed by strangury, and promptly relieved by lancing the gums. Carbonic acid gas, as a local sedative, occasionally exerts a very happy influence in relieving pain and checking the disposition to frequent micturition, the effect being some- times more anodyne than that of strong opiates, while it is destitute of the disagreeable consequences which so often follow the exhibition of the latter articles. Irritability of the bladder, dependent upon lesion of the brain and spinal cord, must be treated upon general principles, the bromides, chloral, and opiates being among the more valuable therapeutic agents. In the vesical irritability which is so common in young girls, at or soon after the age of puberty, and which is probably of a mixed character, depending partly upon spinal irritation, and partly upon disorder of the uterine functions, much benefit will be derived from a proper regulation of the bowels, chalybeate tonics, particularly Griffith’s mixture, Plummer’s pill, the shower-bath, and daily exercise in the open air. In protracted cases, the uterus should be examined, as the cause may depend upon displacement, inflammation, or ulceration of that organ. In boys, with a tight and elongated prepuce, the only remedy is circumcision. In the vesical irritability known as strangury, caused by the absorption of cantharidine, prompt relief is generally afforded by a full enema of laudanum, assisted by the adminis- tration of spirit of camphor, in doses of fifteen to twenty drops, repeated every half hour, and by hot cloths applied to the genitals and hypogastrium. A third of a grain of morphia used hypodermically often acts like a charm. When the disease has been induced by general debility, an invigorating diet, nutritious drinks, and tonics, especially quinine, bark, and the different preparations of iron, with exercise in the open air, are indicated. If the disease has been induced by cold, and the patient is robust and plethoric, vene- 684 DISEASES OF THE URINARY ORGANS. CHAP. XVI. section, carried to syncope, will generally afford prompt relief, especially if it be aided by diaphoretics, as a combination of antimony and morphia, or Dover’s powder, a brisk cathartic, anodyne injections, and hot fomentations. The neuralgic form of the disease is best controlled by quinine, strychnia, and arsenic, in union with morphia, aconite, or belladonna. Sometimes the wine of colehicum proves highly efficacious. In most of the varieties of morbid sensibility of the bladder here described, there are few articles of the materia medica which afford such prompt relief, after removal of the exciting cause, as belladonna, administered either by itself or in union with some of the remedies above specified. The best form of exhibition, according to my experience, is the juice, in doses of about five drops, repeated three or four times in the twenty-four hours. Sometimes the medicine may be advantageously introduced into the bladder, injected under the skin, or thrown into the bowel in the form of enema. Another remedy, worthy of trial in such cases, is the bromide of ammonium, in doses of twenty to thirty grains, in a suitable quantity of water, from half an hour to an hour after each meal. Its efficacy will be materially enhanced if it be combined with chloral. In nearly every form of irritability of the bladder, there are few agents that are more reliable than paregoric, given in doses of one and a half to two drachms once or twice in the four and twenty hours. Its impression is generally rapid and marked. Administered persistently, I have known it to effect a permanent cure after the failure of other and more potent medicines. When the irritability is complicated by spasm of the bladder, and the case is rebellious to ordinary measures, the organ should be put at rest by a median or lateral perineal incision. In the female, I have repeatedly succeeded in effecting permanent relief by rapid dilatation of the urethra and neck of the bladder ; and equally gratifying results have been obtained by Howe, Teale, Heath, and others. NEURALGIA. Neuralgia of the bladder is a nervous affection, characterized by violent suffering, which is generally referred to, and most severe at, the neck and bas-fond of the organ. It pre- sents itself in two varieties of form, in one of which, the more common, the suffering is more or less steady and persistent, often remitting, but seldom intermitting ; in the other, it is distinctly pai’oxysmal, recurring daily or every other day, about the same period, usually early in the evening or towards morning. The pain, which is often of the most racking, agonizing nature, is reflected to the neighboring parts, and is accompanied with a sensation of heat and burning in the urethra, with a frequent desire to pass water, the urine being thrown out in jets, or in a small, tiny stream. The attack gradually goes off, leaving no other inconvenience than a feeling of soreness or aching in the neck of the bladder, perineum, and posterior part of the urethra. The general health eventually becomes affected. In obstinate cases, there is a thin gleety discharge, with great soreness in the perineum and hypogastric region. The urine is commonly natural. The diagnosis is not always very clear. The attacks, especially when very severe, bear the closest resemblance to the paroxysms produced by a calculus. Hence, in doubtful cases, sound- ing of the bladder is advisable. The causes of vesical neuralgia are often wholly inappreciable. The disease is most common in persons of a nervous temperament. Veneral excesses, masturbation, stric- ture of the urethra, disorder of the prostate gland, stone in the bladder, and organic dis- ease of the kidneys, uterus, anus, and rectum, are all capable of producing it. What influence miasm may exert upon its development is not ascertained, but it is, doubtless, a very frequent cause of the complaint. The disease, although exceedingly painful and distressing, seldom terminates fatally. Its long continuance, however, or its frequent recurrence, may render the patient miserable for life. The treatment must be regulated by the nature of the exciting cause. When it is con- nected with an inflammatory state of the system, prompt and efficient bloodletting is the proper remedy, especially at the commencement of the attack. Purgatives are particu- larly useful when the affection is associated with derangement of the digestive apparatus. If the tongue is much coated, the best article will be calomel, followed by castor oil. After this, a blue pill given every other night, will serve to keep the bowels sufficiently open. When the disease is plainly of a miasmatic character, the most suitable remedy is quinine, either alone or in union with arsenic, strychnia, aconite, and morphia. During the violence of the paroxysm, large doses of narcotics are frequently indispensable. Of CHAP. XVI. GOUT AND RHEUMATISM. 685 these, the most efficacious are the salts of morphia, either alone or combined with nauseants and tincture of aconite, according to the state of the vascular system. An emetic of ipecacuanha at the approach of the attack will sometimes cut it short. Much benefit will also accrue, in many cases, from the use of the warm bath. In persons of a gouty, rheu- matic habit, no remedy will be so likely to be successful as colchicum. In the more aggravated and intractable varieties of the malady, counterirritation over the perineum, the suprapubic region, the sacrum, or the inner part of the thighs, is worthy of trial. The best forms are the moxa and the caustic issue. When the neuralgia depends upon stricture of the urethra, foreign bodies in the bladder, hemorrhoids, fissure, or some other disease of the anus, none but the most transient amelioration can be expected from any mode of treatment, until the exciting cause has been removed. The strictest attention should be paid to the diet. Everything tending to disorder the digestive apparatus, and induce acidity and flatulence, should be avoided. Dyspepsia should be relieved by tonics, as iron and quinine. Occasionally, great relief follows the use of large doses of subnitrate of bismuth, taken an hour after each meal. Exposure to cold is avoided; flannel is worn next the surface; and sexual intercourse is prohibited. GOUT AND RHEUMATISM. The bladder, like the stomach, bowels, heart, kidneys, and other organs, is liable to gout and rheumatism, either as orginal and independent affections, or, as is more fre- quently the case, as consequences of the translation of these diseases from some other struc- tures. Thus, it is not uncommon for a person who has gout or rheumatism of the foot or knee to be seized during the progress of the attack with gout or rhematism of the bladder. Occasionally, the vesical malady comes on so suddenly, and at a time, perhaps, when such a degree of relief is experienced in the part originally involved, as to leave no doubt that the attack consists merely in a transfer of morbid action from one place to another. Although these affections may occur at any period of life, indeed, even in very young children, they are most common in elderly subjects, especially in males who have long been addicted to all kinds of excesses in eating and drinking, and whose constitution has been still further impaired by repeated attacks of gout and rheumatism in other parts of the body. Women suffer less frequently than men, simply, perhaps, because they are not so often exposed to the exciting causes of these diseases. An attack of vesical gout or rheumatism is generally brought on under the influence of cold, disorder of the digestive organs, overstimulation, want of exercise, or venereal ex- cesses. Occasionally, it is provoked by stricture of the urethra, enlargement of the prostate gland, disease of the kidneys, the presence of a vesical calculus, or an acrid state of the urine. It may also be induced by organic affections of the uterus, vagina, anus, and rectum. The symptoms are very similar to those of neuralgia. The bladder is not only exces- sively irritable, with a constant inclination to expel its contents, but more or less painful and tender on pressure of the hypogastrium. The suffering is most severe in the pelvic region, from which, however, it radiates about in different directions, especially into the lumbar region, in the course of the spermatic cords, down the thighs, and around the anus and perineum. Occasionally a good deal of fever is present, but cases occur in which there is not the slightest arterial excitement or other evidence of pyrexia. The tongue, however, is generally considerably coated, the appetite is impaired, and the bowels are constipated. Marked alteration always exists in the urine. Most commonly the fluid is very scanty, of high specific gravity, and of a smoky aspect, from the presence of lithic acid, renal casts, and a redundancy of mucus. In some cases, the secretion, instead of being acid, is highly alkaline, ropy, putrescent, albuminous, or even purulent. When the muscular coat of the bladder is seriously involved in the disease, retention of urine is apt to occur. The diagnosis of these diseases is sometimes very difficult. The affections with which they are most liable to be confounded are neuralgia and spasm of the bladder, however induced. The most important signs of distinction are the mode of the attack, and the presence or absence of similar suffering in other parts of the body. If the vesical seizure occurs coincidently with an attack of gout or rheumatism in a joint, it may fairly be as- sumed that it is of a similar character, and this conclusion will be greatly strengthened if, soon after the vesical seizure, the articular one is either very much relieved, or completely dispelled. In doubtful cases, a careful examination should be made of the urine. Much difficulty will often be experienced in distinguishing between gout and rheumatism of 686 DISEASES OF THE URINAKY ORGANS. chap, xvi. tlie bladder, although, practically speaking, this is really a matter of very little moment. Perhaps the best test is the one suggested by Dr. Garrod, of London, consisting in the detection of uric acid in the serum of the blood in gout. To determine this fact, a small quantity of serum is put into a watch-glass, and treated with from five to ten drops of acetic acid. A small skein of worsted is then immersed in the fluid, and the glass placed at rest for a few hours under cover to protect it from dust. If uric acid exist, crystals will be found adhering to the threads. It should be borne in mind that the symptoms of these diseases are sometimes closely simulated by stone in the bladder. The prognosis is generally favorable. The vesical disease may, it is true, last, with various intermissions, for a long time, but, in the end, it will usually be found to be amenable to judicious medication. In the treatment of these affections, so closely allied in their nature and origin, the principal reliance must, in the first instance, be upon purgatives, to relieve the bowels, and correct the secretions, and afterwards upon colchicum, aided by anodynes and alka- lies. When the violence of the attack has thus been considerably abated, great benefit will generally accrue from the steady use of Dover’s powder, opiate suppositories, and mild sinapisms to the hypogastrium and sacrolumbar region. If the patient is robust and plethoric, blood may advantageously be taken from the arm, while, if the reverse be the case, the use of tonics and stimulants will be indicated. The diet must, of course, be properly regulated, and all sources of excitement carefully avoided. If the attack is very rebellious, a large blister, applied to the lower part of the spine, will be useful. PAltALYSIS. Paralysis or atony of the bladder may arise from various causes, some of which are seated in the organ itself, others in the cerebro-spinal axis, and others, apparently, in the mind. Thus, the organ is often palsied by external injury, as a blow or kick upon the hypogastrium, or the pressure of a child’s head in parturition ; inflammation of its dif- ferent tunics; or overdistension of its muscular fibres from protracted retention of urine. Compression of the brain and spinal cord is always followed by loss of power of this organ. Want of tone in the general system may induce the disease, as is so often wit- nessed during the progress of encephalitis, apoplexy, and fever, especially typhoid. The bladder first loses its sensibility, and then the urine, ceasing to make its accustomed impression, continues to accumulate, without awakening any desire to evacuate it, until the muscular fibres are so completely overstretched as to render them incapable of con- tracting. The excessive use of morphia is occasionally followed by paralysis of this organ. Severe injuries, amputations, the ligation of hemorrhoidal tumors, and various other operations are liable to be followed by transient paralysis of this organ. Lying-in females are often unable to pass their urine for several days after delivery. Hysterical women are sometimes unable to void their urine, owing, apparently, to paralysis of the bladder, but in reality to a want of mental power to excite the muscles of the organ to contraction. Senile paralysis of this organ, as it is termed, is most common in elderly, indolent men, who indulge too freely in the pleasures of the table, and who habitually neglect the calls of nature. The paralysis usually comes on in a slow, stealthy manner. One of the first symptoms which attract attention is a slight difficulty in starting the urine. As the disease advances, the muscular contractility is still further impaired; and the water, instead of being ejected in a bold, full stream, falls between the patient’s legs or upon his shoes. At length more or less complete want of power ensues, varying greatly in dura- tion, and occasionally ceasing only with life. In paralysis from injury of the spinal cord, the urine is usually highly alkaline, very dark or turbid, of an ammoniacal odor, and sur- charged with thick, ropy mucus. Phosphatic matter soon makes its appearance, and the lining membrane speedily becomes inflamed, if not ulcerated, followed by a discharge of blood and pus. Persons thus affected are very liable to calculous diseases. The prognosis of vesical paralysis depends upon the nature of its causes, the character of the treatment, and the age of the patient. If the bladder has been very greatly and protractedly distended, it will necessarily be a long time, if ever, before it can regain its full vigor. The treatment of an affection depending upon so many and such opposite causes must necessarily be of a very diversified character. The urine, as a rule, should be drawn off at least three times a day. Occasionally the catheter may be temporarily retained, espe- CHAP. XVI. PARALYSIS OF THE BLADDER. 687 cially when there is more or less severe pain with spasm of the neck of the bladder and a frequent desire to pass water; or the patient is at an inconvenient distance from his attendant. When the accumulation is very great, or has continued for several days, the best plan is not to evacuate all the fluid at once. The use of the instrument is discon- tinued as soon as the organ has regained its expulsive power. To impart tone to the bladder various remedies may be used. A brisk cathartic, con- sisting of calomel and jalap, or of calomel and compound extract of colocynth, often pro- duces the most prompt and happy effect, and should be employed as soon as possible after the organ has been relieved of its burden. The medicine may be repeated, in small doses, at first every other day, and afterwards twice a week. Emetics are sometimes of signal benefit. They are particularly valuable when the paralysis is coincident with disorder of the digestive organs, and torpor of the general system. They are, of course, contraindicated in the traumatic form of the disease. After the bowels have been well evacuated, and the secretions restored, remedies cal- culated to make a more direct impression upon the nervous system are employed, strych- nia, cantharides, and arnica occupying the head of the list. An excellent formula, when they are given in combination, is the sixteenth of a grain of strychnia, and the eighth or tenth of a grain of cantharides, with from three to five grains of extract of arnica, three times in the twenty-four hours, care being taken to watch the effect. If spasmodic twitchings, strangury, or gastric irritability ensue, it is an evidence that the medicines have been carried far enough, or that some modification is required. In paralysis of the bladder, consequent upon typhoid and other fevers, masturbation, and general exhaustion, few' remedies are so serviceable as arnica. Ergot is also a valuable agent in the treat- ment of this affection, of the efficacy of which I can speak favorably from personal expe- rience. The best form of administration is a very strong tincture, or the fluid extract, the dose being a drachm three times a day, in an effervescing draught of citrate of ammonium. In the inflammatory form of the disease, characterized by pain and spasm of the neck of the bladder, with a constant desire to urinate, and more or less febrile commotion, the treatment must be strictly antiphlogistic and anodyne. When general debility exists, tonics are indicated, preference being commonly given to the chalybeate preparations, combined, if necessary, with quinine, strychnia, arnica, and other articles. Counterirritation is a useful auxiliary to the other remedies. A succession of blisters over the dorsolumbar region often proves highly beneficial, by stimulating the spinal cord. The vesicated surface may be sprinkled every twelve hours, over a space of about the size of a dollar, with half a grain of strychnia. The actual cautery is a most powerful and suitable agent, especially in the more rebel- lious forms of vesical paralysis. The best place for applying it is about the junction of the last lumbar vertebra with the sacrum ; in traumatic cases, however, depending upon injury of the spine, the issue should sometimes be made much higher up. The sore should be a large one, and a free discharge should be maintained for several consecutive months. Counterirritation by seton is not to be recommended. Frictions over the perineum and hypogastrium with veratria ointment and stimulating embrocations, as turpentine and ammonia, are sometimes serviceable. The cold douche is a remedy of great potency in many cases of this disease, and so also is slapping of the back and hypogastrium with the end of a fringed towel, wrung out of cold water. They are most powerful stimu- lants, and sometimes rouse the dormant energies of the bladder when almost everything else has failed. Galvanism is particularly indicated in senile palsy, attended with par- tial paraplegia. No very satisfactory observations have yet been made in regard to direct medication in the treatment of vesical paralysis. Paul, of iEgina, and some modern practitioners have advised astringent injections; and Deschamps states that he has effected cures with cold water thus employed. In a very obstinate case, resisting every known method of treat- ment, both general and local, for ten weeks, relief was speedily effected by injections of strychnia. The proper dose of the article, when thus administered, is from one-sixth to one-fourth of a grain, dissolved in two ounces of tepid water, and repeated not less than twice every twenty-four hours. In hysterical paralysis, the mind, as previously stated, is affected rather than the bladder. The want of power is, no doubt, sometimes real, but oftener it is feigned. Such cases are always promptly relieved by assafcetida, valerian, and morphia, or, what is better, chloral and the bromides, aided by the catheter. These remedies, however, are merely 688 DISEASES OF THE URINARY ORGANS. CHAP. XVI. palliative. To effect a permanent cure, the treatment must be directed to the improve- ment of the mind and of the general health by means of tonics and alterants, change of air, and other means. HEMORRHAGE. Hematuria, or a discharge of blood from the bladder, although not of frequent occur- rence, is generally a source of disquietude to the patient, from a belief, not altogether unfounded, that it is a symptom of evil import. The bleeding occurs in both sexes, and at all periods of life. Men, however, are more liable to it than women ; and it is like- wise more common in old and middle-aged subjects than in children and adolescents. It appears under two varieties of form, the idiopathic and traumatic. The former, which is infrequent, is met with chiefly in elderly persons of a weak, lax habit of body, or in such as are affected with scurvy, or anemia. It sometimes occurs in association with, or as a sequence of, rubeola, smallpox, plague, and typhoid fever. The traumatic form is usually the result of a wound of the bladder, or of the rude and forcible use of instruments. Persons affected with stone are very liable to suffer from hematuria, especially after any rough exercise. Worms in the bladder have been known to occasion profuse and even fatal hemorrhage. Violent concussion of the body, severe exercise on horseback, and venereal excesses, may be enumerated as among the more common causes. A considerable hemorrhage of the bladder occasionally results from the use of drastic cathartics and irritating diuretics. Ulceration of the mucous and submucous connective tissues is nearly always accompanied by bleeding, and one of the most characteristic signs of papillary, sarcomatous, and erectile tumors, is a considerable flow of blood. Finally, vesical hemorrhage is sometimes vicarious of the menstrual flux, and of suppressed hem- orrhoidal discharges. It also, although rarely, marks the crisis of other diseases. Blood, recently effused into the empty bladder, is of a natural appearance; whereas, if it has been retained for some time, or mixed with the urine, it will be found to be of a dark-brownish, turbid, or smoky hue. In its consistence, it may be liquid, semifluid, or completely solid. The symptoms of vesical hemorrhage are a discharge of blood from the urethra, either alone or in combination with urine, and accompanied, if the quantity is at ail considerable, by a frequent desire to micturate, spasm at the neck of the bladder, and a burning sensa- tion along the course of the urethra. When the blood coagulates nearly as fast as it is poured out by the bladder, it may lead to retention of urine. Copious effusions of this kind may eventually be followed by exhaustion. As hemorrhage of the bladder is liable to be mistaken for hemorrhage of the kidneys, ureters, prostate gland, and urethra, the diagnosis is sometimes extremely difficult, if not impracticable. In case of direct injury of the bladder, there need be no doubt. In the idiopathic form of the hemorrhage, however, great uncertainty must frequently exist. In such an event, the history of the case, and the absence of disease or injury of the asso- ciated organs, may assist the diagnosis. In renal hemorrhage, the disruption is usually dependent upon injury or structural lesion of the kidneys, and is, therefore, generally pre- ceded and accompanied by symptoms referable to these organs. The blood is of a pale, pink, or claret complexion, and either entirely fluid, or partly fluid and partly coagulated ; it is never voided in a pure state, as it often is when it proceeds from the bladder, prostate gland, or urethra. The microscope also readily detects blood casts, consisting of blood moulded in the uriniferous tubes, and washed out by the urine. Moreover, the epithelium which accompanies it does not occur in flat scales, as when it emanates from the bladder, but in small, spherical particles. Sometimes the blood is voided in whitish, cylindrical clots, but, unless they are associated with renal casts, they are of no diagnostic value. When the bleeding proceeds from the ureters, it is usually due to the presence of a calculus, which gives rise to the symptoms associated with the passage of concretions along these conduits. Hemorrhage of the urethra is generally produced by external violence, the passage of a calculus, or the venereal orgasm, and the blood commonly passes off in small vermiform clots, without any material change of color, or any desire to void the urine. In many cases, the blood is discharged in drops, or in a small stream. In the treatment of the traumatic variety of hemorrhage, the ordinary hemostatics are, of course, indicated, and should be employed without delay. Accessible arteries are ex- posed and tied, or, when this is impracticable, compression and cold applications are used. All offending causes are sought for, and, if possible, removed. When the bleeding pro- ceeds from a sarcomatous, papillary, or erectile tumor, palliation alone is attempted. In CHAP. XVI. TUMORS OR MORBID GROWTHS. 689 such cases, the main reliance is upon opium and lead, gallic acid, alum, ergot, and per- chloride of iron, with acidulated drinks, rest in the i*ecumbent posture, and cold applica- tions to the perineum and hypogastrium. The use of the catheter should be avoided. In vesical hemorrhage dependent upon papillary excrescences of the bladder, I have often succeeded in affording prompt relief by a good dose of calomel and rhubarb, followed by alum and opium, with sulphuric acid and infusion of roses as a common drink. In idiopathic hemorrhage of the bladder, gx-eat attention must be paid to the system. Vascular action is reduced, the bowels and secretions are carefully regulated, the diet must be light and unstimulating, and the drinks should be cooling and acidulated. Abso- lute rest in the recumbent posture is of essential importance. The most useful remedies are gallic acid, acetate of lead and alum, combined with opium. Tannic acid, elixir of vitriol, and tincture of ergot also prove highly efficacious. In hemorrhage caused by anemia, chalybeate tonics ai*e indicated, the best forms being the tincture of the chloride, the sulphate, and the tannate of iron. In bleeding of the biadder, vicarious of the men- strual flux, emmenagogues and aloetic purgatives are required. In all cases, the action of internal remedies is promoted by refrigerant applications to the pei'ineum, inside of the thighs, and hypogastric region. Cold enemas are also beneficial; and a lump of ice intro- duced into the rectum sometimes acts like a charm. Leeching and cupping over the sac- rum are useful, when pain and spasm exist. Direct medication, by astringent injections, occasionally proves serviceable. If the blood coagulates so as to distend the bladder, removal by injections of cold water, or, what is better, vinegar and water, should be attempted, the clots having previously been broken up with a silver catheter. When all other means fail, and the symptoms are so urgent as not to admit of further delay, the only resoui-ce is to open the bladder, as in lithotomy. TUMORS OR MORBID GROWTHS. 1. Benign Tumors The bladder is liable to papillary, fibrous, myxmatous, and myo- matous growths, occuri’ing chiefly in young subjects ; sometimes, indeed, within less than two years afterbirth. Of 63 cases collected and analyzed, in 1881, in a monograph upon the subject, by Dr. Stein, of New York, 30 were papillai’y, 3 myomatous, and 30 myxoma- tous and fibrous, their number being nearly equal. Fig. 484. Fig. 485. Benign Vesical Papilla. a. The papillary tumor is met with particularly in the trigone of the bladder, where it forms a soft, villous growth, similar, in every respect, to papilloma of the rectum, varying in size from a pea to a pullet’s egg; it is generally solitary, but the growth may occur in such considerable numbers as to cover the greater part of the inner surface of the viscus, as shown in fig. 484, from Civiale. It consists of enormously hypertrophied, dendritic, Multiple Papilloma of the Bladder. 690 variously branched, and very vascular villi, which are composed of a basement membrane of very delicate fibrous tissue, inclosing one or more thin-walled capillary vessels, as in fig. 485, from Bryant, and covered by a more less dense layer of columnar, or spheriodal and polyhedric epithelial cells, and which are liable to pour out a considerable quantity of blood, under the influence of acrid urine, ulceration or instrumental contact. The dis- ease is most frequent in middle-aged and elderly subjects, and its existence is rendered probable by symptoms of vesical irritability, with occasional attacks of retention of urine, and hematuria, more or less profuse, as a constant or frequently recurring sign, without any obvious cause. Conclusive evidence of its true nature is afforded by the discharge of detached vascular tufts, which present the minute appearances shown in fig. 485. The prognosis of the affection, if left to pursue its course without surgical interference, is of the worst possible description, since death almost invariably follows from sheer loss of blood or the combined effects of hemorrhage and pain. (3. Fibroma and Myxoma—Fibroma and myxoma generally present themselves as polypoid outgrowths, in comparatively young subjects, and with about the same frequency in both sexes. They vary in size from a cherry to a fist, have a predilection for the trigone, and are rarely multiple. The symptoms are chiefly of a mechanical character, the most prominent being difficulty in micturition, sudden stoppage of the flow of urine, and frequent attacks of painful retention, along with protrusion of the tumor into the prostatic portion of the urethra of the male, and into the vulva of the female. Hemorrhage is infrequent, and there is seldom any pain. sc. Myoma—Pure muscular tumors of the bladder are very uncommon, the only case, so far as I know, met with during life being, that of Volkmann, in which that surgeon removed the growth by epicystotomy, followed by death. Two post-mortem specimens have been described by Chiarri. 2. Sarcomatous Tumors—As verified by minute examination, sarcoma is one of the rarest of the neoplasms of the bladder, having been met with only by Yon Langenbeck, Ger- suny, Billroth, Beck, Heath, Marchana, Thornton, and Stimson. The symptoms are not characteristic; but it may be stated, as a general rule, that it is a disease of middle age ; and that its presence is marked by frequent and painful urination, strangury, and hematuria. In the treatment of the non-carcinomatous tumors in the male, the bladder should be laid open as in the common operations of cystotomy, and their removal effected with the scissors, the sharp spoon, the forceps, or ecraseur, the choice of the instrument depending upon the extent of their attachments. If the growth be voluminous it should be reached by epicystotomy. Of 12 cases analyzed by Dr. S. W. Gross, 7 recovered, and 5 died. Of 9 perineal operations, 3 were fatal; and of 3 suprapubic operations, in two of which the perineum was also opened, 2 died. In the female, epicystotomy may be required when the tumor is unusually large ; but opening the bladder is generally uncalled for, since on ac- count of the greater shortness and dilatability of the urethra, and the absence of the prostate, access to the organ is ren- dered easy through the dilated urethra. Of 24 cases, ana- lyzed by Dr. S. W. Gross, 8 were fatal, but in only one was death fairly attributable to the procedure, the case being that of Yon Langenbeck, in which, after death from peritonitis on the fourth day, the bladder was found to have been perforated by the forceps. Of the 18 operations through the urethra, 13 recovered, and 5 died ; while of 6 in which the urethra or the vesico-vaginal septum was divided, 3 recovered, and 3 died. 3. Carcinomatous Tumors The bladder is liable to the firm and soft varieties of epithelioma. Of colloid and melanosis, as occurring in this organ, hardly any cases have been recorded. I have myself seen only one example of the latter, the patient being a man, fifty-eight years of age. The disease, which presented itself in the form of five or six little nodules, coexisted with melanosis in nearly all the principal organs of the body, and did not manifest itself by any signs during life. A striking feature in many cases of carcinoma of the bladder is the excessive proliferation of the papillary layer of the mucous membrane, giving rise to the so-called “ villous carcinoma,” a term, however, which should be abolished, as it only leads to confusion. As in ordi- DISEASES OF THE URINARY ORGANS. CHAP. XVI. Fig. 486. Carcinomatous Vesical Papilla. TUMORS OR MORBID GROWTHS. CHAP. XVI. nary papilloma, the villi are greatly enlarged, but their connective tissue is largely infiltrated with epithelium and cell cylinders, as represented in fig. 486, reduced from Demme, a peculiarity of structure which readily distinguishes carcinomatous from simple hyperplastic formations. The firm variety of epithelioma of the bladder is extremely uncommon. It is chiefly observed in men between the ages of forty-five and sixty, at the neck and bas-fond of the viscus. It occasionally coexists with epithelioma in other organs, as the liver, uterus, breast, or prostate gland. During its progress the associated structures are liable to become implicated. In the female, epithelioma often occurs as a secon- dary affection from extension of the disease from the vagina and uterus. In the male the organ occasionally suffers in a similar manner in connection with carcinoma of the rectum. There are no signs by which epithelioma can be distinguished from other diseases of the bladder. The most reliable evidences are the peculiar lancinating character of the pain, the progressive emaciation, the wan and sallow state of the countenance, the age of the patient, the excessive burning at the neck of the organ and in the urethra imme- diately after micturition, hemorrhage, and the occasional discharge of small fragments of the new growth. These, if examined with the microscope, will be found to display the usual characteristics of such formations, and will, of course, at once remove all doubt respecting the nature of the disease. Reliance, however, must not be placed on the ap- pearances of cells voided with the urine, since the transitional forms of the epithelium lining the genito-urinary tract are so similar to those of carcinoma that the distinction is impossible. When a solid mass, after proper preparation, presents the ordinary minute features of carcinoma, or small shreds, representing enlarged and infiltrated papillm, can be detected, the diagnosis is unequivocal. Negative testimony is afforded by sounding. No positive conclusion can be drawn from the frequent micturition, the condition of the urine, and the presence of mucus, pus, or puriform fluid. The suffering in this disease is generally so excessive as to require enormous doses of morphia, both by the mouth and rectum, for its relief. In one of my cases, the pain was more severe than I had ever witnessed in any other affection. Towards the close of the disease, anodynes produced so little effect that the patient, a gentleman, forty-four years of age, was obliged to be kept almost constantly under the influence of chloroform. The dissection revealed ulcerated epithelial disease of the bas-fond of the bladder. The soft form of epithelioma, encephaloid, or fungus hematodes of the bladder, usually runs its course with great rapidity, destroying life in from nine to twelve months. Any portion of the organ may be affected with it, but its most common situation is just behind the neck, between the mouth of the urethra and the outlets of the ureters. It may occur as a solitary tumor, projecting into, and almost filling up the bladder, or in the form of small nodules, from the volume of a pea up to that of a walnut. Occasionally the disease is associated with urinary calculi, which are either partially embedded in the morbid growth, or else they lie loose in the bladder. The most characteristic symptoms are, uneasiness about the neck of the bladder, fre- quent micturition, a bloody state of the urine, a discharge of small fragments of the growth, and a peculiar cachectic state of the countenance. When all these phenomena are present, hardly any reasonable doubt can be entertained respecting the nature of the case. Nevertheless, the bladder should always be thoroughly explored with the sound. If no calculus be detected, it will be an additional proof of the existence of encephaloid, especially if the operation be followed by considerable hemorrhage. The tumor is often detectable by the finger in the rectum; and a microscopic examination of the suspected matter generally affords useful information. Mitigation of suffering is all that can be aimed at in this disease, and this is best effected by incising the bladder freely through the perineum. Pain is relieved with anodynes, and the hemorrhage, which always attends the ulcerative stage, is checked with perchloride of iron and opium, acetate of lead, alum, tannic acid, ergot, and similar articles. When the discharge is obstinate or unusally copious, astringents may be thrown into the bladder. 4. Hydatids Hydatid cysts are occasionally met with in the bladder. Dr. J. A. McKinnon, of Selma, Alabama, in the case of a female, induced violent contraction of the organ and the expulsion, within an hour, of about a pint of cysts ; and Dr. Eldridge, of Yokohama, has recently recorded an example, also in a female, of spontaneous dis- charge of these bodies, the symptoms having been those of severe cystitis. 692 DISEASES OF THE URINARY ORGANS. CHAP, xvii TUBERCULOSIS. Tubercular disease of the bladder commonly occurs in the form of minute granulations, similar to those found in the bowels and lungs. Their number is generally small, and they are by far most frequently met with in the neck and bas-fond of the organ in the superficial layers of the mucous membrane. After the heterogeneous matter has existed for some time, it begins to soften, and is finally entirely broken down and expelled, leav- ing, in its stead, a small, roundish ulcer, with thin, ragged, and undermined edges. Tuberculosis of the bladder is generally, if not invariably, associated with tuberculosis in other parts of the body, especially the kidney and the prostate gland. Its coexistence with phthisis is uncommon. There are no symptoms by which the existence of tubercular disease of the bladder can be positively determined during life. As long as the deposit remains in a state of crudity, there is, in general, merely a slight degree of irritability of the mucous membrane, with increased frequency of micturition. When softening has commenced, the peculiar matter of tubercle is discharged along with the urine, in which it may occasionally be detected, if not with the naked eye, at all events with the microscope. The ulceration attending this disease occasionally spreads over the whole mucous surface, which is gradually removed in as clean and perfect a manner as if it had been dissected off with a knife. Several specimens, illustrative of this condition, are contained in my private collection. When the case has reached this point, the suffering is most excruciating, there being a constant desire to pass water, and the patient being rapidly worn out by the conjoint influence of pain and want of appetite and sleep. Palliation by anodynes, in full and sustained doses, and opening the bladder through the perineum or vagina, are all that the disease admits of. CYSTOCELE OR HERNIA. When the bladder protrudes from the pelvic cavity, it constitutes what is denominated a cystocele. A hernia of this description is sometimes complicated with a bubonocele or rupture of the groin, which it may either precede or follow. Occasionally the dislocated organ contains a stone. The cystic hernia is destitute of a proper sac, except when the rupture is of long stand- ing, or of great bulk, when the fundus of the bladder may drag the peritoneum down into the scrotum. The swelling is always formed, in great measure, by the superior portion of the viscus, and is, generally, of small size, although, occasionally, it has been known to attain the magnitude of a fist. The tumor is soft, elastic, fluctuating, and varies in size according to the amount of urine contained in the protruded part. When examined in a dark room, with the aid of a candle, it appears translucent, very much like a hydrocele. The diagnosis is a matter of great importance, as a tumor of this kind has occasionally been cut into by mistake. The most decisive symptom is the change which the swelling undergoes in its volume during micturition. As the water flows off, the tumor decreases, or entirely disappears, to recur again, however, as soon as the urine reaccumulates in the protruded part. A cystocele has not the doughy, inelastic feel of an omental hernia, nor the soft, gaseous feel of an intestinal one, nor does it return with that peculiar gurgling noise which accompanies the ascent of the latter. The treatment of cystocele, seated in the groin or scrotum, does not differ from that of intestinal hernia. When the tumor is reducible, it should be kept up by means of an appropriate truss; but when the viscus has contracted adhesions, and no longer admits of reposition, the patient must be contented with wearing a suspensory bag. The urine which accumulates in the lower part of the sac must be discharged by raising and com- pressing the tumor during micturition. In the event of retention, relief must be sought with the catheter, or, this failing, by puncture. Calculi must be extracted by incision. RETENTION OF URINE. The symptoms of retention of urine are generally well marked, even at an early stage of the complaint. In this respect, however, there is, as might be supposed, considerable diversity in different cases, depending mainly upon the natural tolerance of the bladder, and the character of the exciting cause of the disease. In paralysis of the muscular fibres of the organ, attended with loss of sensation, the accumulation may make great progress, and yet the individual not be aware of his real condition. A slight discharge of urine, CHAP.. XVI. RETENTION OF URINE. 693 perhaps, occasionally takes place ; or if, as often happens, incontinence is soon superadded to the original disorder, the fluid dribbles off incessantly, and thus both patient and physician are lulled into a false security. When, on the contrary, the retention is inflam- matory, more or less pain, and frequent inclination to void the urine, with inability to do so, attend the complaint, and at once declare its true nature. The characteristic symptoms are, the existence of a hard, pyriform, circumscribed tumor, corresponding with the middle line, more or less tender on pressure, fluctuating, not affected by change of posture, and gradually increasing in volume; a frequent desire to void the urine, which, if passed at all, is discharged in drops, or small jets, never in a full stream, or in any considerable quantity; uneasiness and a sense of weight in the pelvic region, soon followed by pain and spasm; straining, forcing, or tenesmus at every attempt at micturition; at first absence of fever, and then rigors, alternating with flushes of heat, and, in the latter stages of the complaint, excessive restlessness, hot skin, small and frequent pulse, distressing headache, an indescribable sense of oppression, urinous breath arid perspiration, typhomania, and a Hippocratic condition of the countenance. In addition to these signs, which none but a heedless practitioner can mistake, there is also generally, after the first few days, a constant dribbling of urine, and the dis- tended bladder may easily be felt by the finger introduced into the rectum or the vagina. It is to this form of the affection that I applied, many years ago, in my Treatise on the Urinary Organs, the term incontinence of retention, in the hope that, by an antithe- tical expression, particular attention might be attracted to it. The bladder being dis- tended to its utmost capacity, more or less dribbling is produced, simply by the pressure of the atmosphere, all expulsive power being lost. Such an expression is far more appro- priate than that of “engorgement” of the bladder, originally employed by Baron Boyer, and since adopted by Sir Henry Thompson, as it points at once to the true nature of the complaint and the means necessary for its relief. Death in these cases usually occurs in from three to five days from the commencement of the disease, from uremic poisoning. As the distension progresses, the kidneys are gradually paralyzed so as to be unable to secrete urine, the elements of which are, conse- quently, retained in the blood, and thus occasion a low, typhoid state of the system, from which few patients ever recover. It has been supposed that, under these circumstances, more or less of the urine in the bladder is absorbed, and carried into the circulation, but this is not at all probable. In ascites, with which this affection is most liable to be confounded, the abdominal tumor is diffused, not circumscribed, and changes its form and situation with the position of the body; there is little, if any, tenderness on pressure and percussion; the sense of fluctuation is more distinct; the progress of the disease is more tardy; the urine, although more scanty than in health, is voided several times in the twenty-four hours, generally without pain or difficulty; there is commonly anasarca of the lower extremities; the skin is remarkably dry and harsh; and there is usually an absence of febrile disturbance, and always of typhomania and of urinous perspiration. If any doubt exist, the introduction of the catheter will at once dispel it. A distended bladder has occasionally been mistaken for a suprapubic abscess. Colot refers to two such cases as having come under his own observation; and several examples of a similar kind have been reported by more recent writers. On the other hand, a pelvic abscess has sometimes been mistaken for a distended bladder. A very remarkable instance of this description is recorded by Dr. George McClellan, in his work on surgery, as having occurred in a man twenty-three years of age, under the joint care of Dr. Physick and himself. A large, fluctuating tumor existed in the lower part of the hypogastrium, feeling and looking precisely like an overdistended bladder, accompanied by all the symp- toms of a painful retention. Only a tablespoonful of urine, however, followed the intro- duction of the catheter. The finger, inserted into the bowel, came in contact with what seemed to be an enormous enlargement of the bas-fond of the bladder, and, on making counterpressure above the pubes, a distinct undulatory movement was detected. The catheter was used again and again with no better result. During the last operation blood appeared in the eyelets of the instrument, and the man felt conscious that something had given way. A trocar was now plunged into the supposed vesical tumor above the pubes, followed by the escape of a large quantity of sero-purulent fluid instead of urine. Death occurring within a few hours after the last operation, it was found that the disease was an immense pelvic abscess, caused by the lodgment in the vermiform process of the colon of a date-stone, swallowed two years previously. Dr. Smith, of Massachusetts, has reported a curious case, in a man, eighty-two years 694 DISEASES OF THE URINARY ORGANS. chap. xvi. of age, in which distension of the bladder, simulating retention of urine, was caused by an enormous accumulation of fat around that organ, folding it, as it were, upon itself in such a manner as to form two cavities, the upper and larger of which contained nearly a pint of fluid. A catheter readily entered the lower pouch during life, but only a little urine, mixed with blood, was obtained. In advanced pregnancy a distended bladder has sometimes been mistaken for dropsy. In a case mentioned by Fodere a trocar was thrust into the child’s head across both walls of this viscus, under the supposition that the disease was ascites. In the latter period of gestation, the bladder, in consequence of the resistance offered by the gravid uterus, is spread out, as it were, over the anterior surface of the organ, forming, when distended with urine, a flattened tumor in front at the sides of the abdomen, which, fluctuating under percussion, might thus lead to a serious error of diagnosis. The treatment of retention of urine is, in the first instance, by the catheter ; for the indication is to relieve the distended organ without delay, before the part and system have sustained serious mischief. When there is great accumulation, amounting to several quarts, it will be most safe, as a rule, not to empty the bladder completely at a single operation, but gradually, lest the stimulus of distension being removed, syncope or hemor- rhage of the bladder should ensue, although neither contingency is at all probable. The catheter is introduced, and half the fluid is evacuated, to afford the overstretched fibres an opportunity of contracting and regaining their power. Some hours afterwards the instrument is again used, and then the remainder of the urine is withdrawn. When this precaution is neglected, or unavoidable, the abdomen should be supported with a compress and a broad roller. Another important rule is, not to permit the patient, especially if he be old or exhausted, to stand up during the operation, lest, the heart’s action failing, he should die from syncope. A large opiate should be given just before or immediately after the operation, unless contraindicated by cerebral oppression. An overdistended bladder sometimes bursts from the sheer pressure of its contents, or from the pressure exerted upon it by the diaphragm, as in the violent straining during parturition. A similar effect may be produced by the careless employment of instru- ments. However induced, the symptoms are always exceedingly distressing and strongly marked. The patient is instantly seized with agonizing pain, and a feeling as if some- thing had suddenly burst, followed by the immediate subsidence of the vesical tumor and a general enlargement of the abdomen, especially if the previous local distension was unu- sually great. Sometimes a distinct sense of fluctuation is perceptible. The pulse rapidly sinks, the surface becomes covered with a cold, clammy perspiration, and death com- monly ensues within the first thirty-sixty hours, from the conjoined effects of collapse and peritonitis, the accident being invariably fatal. Sometimes, again, the distended organ gives way by ulceration, generally through the rectum or perineum, followed by fistulous openings, which it is usually very difficult, if not impossible, to close. Retention of urine may be produced, 1st, by mechanical obstruction ; 2dly, by paraly- sis ; 3dly, by spasm ; 4thly, by inflammation ; 5thly, by gout and rheumatism ; Gthly, by pelvic tumors; and 7thly, by the effects of miasm. Women are liable to a peculiar form of retention of urine, to which the term hysterical is usually applied. 1st. The first class of causes may affect either the urethra, the bladder, or the head of the penis. The urethra may be obstructed by an organic stricture, a calculus, a small tumor, clotted blood, plastic matter, or inspissated mucus. A catheter, bougie, or other foreign body may break off in the canal, and thus become an impediment to the egress of the urine. In organic stricture relief is generally obtained by the silver catheter, or by threading Gouley’s small tunnelled catheter, fig. 487, over a filiform whalebone bougie ; if these fail, the only resources are puncture of the bladder and tapping the membranous urethra at the apex of the prostate gland, or behind the seat of the obstruction, as shown in fig. 488. In the latter procedure, instead of cutting from without inwards, the artificial outlet for the urine is made with greater safety and precision by a simple puncture in the middle line with a straight or slightly curved bistoury. The patient being in the ordinary lithotomy position, and the tip of the left index-finger being passed into the rectum and brought in contact with the apex of the prostate, the point of the knife is entered at the raphe, five or six lines in front of the anus, and thrust upwards and backwards, as if to strike the bulb of the finger, the latter of which guides it into the urethra, the opening in the tube and the soft parts being enlarged during the withdrawal of the instrument. chap. xvi. RETENTION OF URINE. 695 Through the free outlet thus made the urine gushes in a full stream, and continues to dribble for thirty-six or forty-eight hours, when it is passed voluntarily. The retention of a catheter in the wound is entirely unnecessary. This operation, which is as simple Fig. 487. Fig. 488. as it is effectual, was first practised by Mr. Molins, of London, in 1652, and was soon after repeated by Wiseman. It seems, however, to have been lost sight of until 1815, when Mr. Grainger, of Birmingham, called attention to it, and it has since been successfully performed by numer- ous surgeons in this country and in Europe. An impacted calculus may generally he pushed back into the bladder, or extracted with the urethra-forceps. When these means are unsuc- cessful, it is removed by incision. Pieces of bougie and other foreign bodies are managed on the same principle. Clotted blood, lymph, and inspissated mucus are easily displaced by the catheter, or forced out by the urine. When the sides of the urethra are glued together by adhe- sive matter, the obstacle can only be overcome by the gentle use of the instrument. Retention occasioned by congenital occlusion of the urethra is gene- rally easily remedied with the knife and catheter. In retention depend- ent upon simple narrowing of the canal, steady and judicious dilatation is indicated. The obstacle may be exterior to the urethra, as an abscess in the perineum, a deep-seated collection of blood, an effusion of lymph, or a malignant tumor. Carcinoma of the penis, contusions of the perineum, and extravasation of urine, the effect of injury or stricture, are frequently followed by the worst forms of retention. When the obstacle is seated externally, and bulges inwards, so as to occlude the canal, the knife supersedes the catheter. Extravasated blood is treated by sorbefacients, as ace- tate of lead, chloride of ammonium, or spiritous embrocations. In contusions of the perineum, without rupture, the catheter is used ; but when the accident is attended by laceration, a large incision is made to save the tissues from urinary infiltration. The obstruction may, secondly, be seated in the bladder. Of this class of causes, the most frequent are hypertrophy of the prostate gland, coagulated blood, inspissated mu- cus, lymph, and urinary concretions. The gravid uterus, or any other pelvic tumor, may, by compressing the neck of the bladder or the commencement of the urethra, give rise to a similar effect. The most common form of obstruction of the bladder, productive of retention of urine, is hypertrophy of the prostate gland. The enlargement may involve the entire organ, or it may be limited to one of its lateral lobes, or even to its mammillary process. The obstacle thus occasioned is usually temporary, but it is liable to be reexcited by the slight- est exposure to cold, irregularity of diet, horseback exercise, sexual indulgence, or neglect to empty the bladder. Great obstacle to micturition, and even complete retention of urine, may be caused by centric enlargement of the prostate, without any material increase of weight or bulk of the lateral lobes. The tendency of such a development is to encroach upon and diminish the caliber of the corresponding portion of the urethra, and, conse- Tapping the Urethra in the Perineum. Gouley’s Tunnelled Catheter. 696 DISEASES OF THE URINARY ORGANS. CHAP. XVI. quently, to interfere more or less with the evacuation of the urine and the passage of instruments. The treatment is by the catheter ; and one of silver is generally far preferable to one of gum-elastic. It should be at least twelve inches in length, and with a curve forming an arc equal to one-third of the circumference of a circle five inches and a half in diameter, otherwise it may fail to reach the distended reservoir. When the instrument comes in contact with the enlarged gland, the surgeon introduces the left index-finger, well oiled, into the rectum, and, placing it against the beak, he guides it into the bladder, by pushing it gently towards one side, or upwards towards the pubes, at the same time that he urges the handle on with the right hand. In order to empty the bladder entirely, it is neces- sary, as the point of the catheter cannot reach the cavity behind the gland, to raise the patient’s hips, or to turn him on his belly, so as to force the urine out of its hiding place; or, instead of this, a Squire’s vertebrated catheter may be used, or the coiled silver prostatic catheter of Dr. S. W. Gross, fig. 489. In very old men, with inordinate enlargement of Fig. 489. S. W. Gross’s Prostatic Catheter. the prostate in its longitudinal direction, the silver catheter may be advantageously replaced by a stiff gum-elastic instrument, at least twelve inches in length, one which has been kept on an over-curved stylet, fig. 490, so as to enable the point to pass the more readily Fig. 490. Overcurved Gum Catheter. over the obstruction. In some cases it is necessary to bend back the shaft of the instru- ment so that it shall resemble somewhat an italic S procumbent; while in others, the soft, elastic, angular catheter of Mercier, represented in fig. 491, is essential to success, especi- Fig. 491. Prostatic Gum-elastic Catheter. ally if" false passages have been made, since, during its introduction, the point is always in contact with the roof of the urethra. In retention from abscess of the prostate, the point of the catheter, as it is urged along, must be kept in close contact with the roof of the urethra, especially as it approaches the arch of the pubes, otherwise it will be liable to become entangled, and thus cause serious suffering, if not great mischief. Cysts of the prostate, due to congenital occlusion of the orifice of the sinus pocularis, and the accumulation of the secretion of the numerous small glands which open on its inner surface, is an occasional cause of retention of urine in the new-born child. The introduction of a silver catheter will suffice to evacuate the cyst and relieve the bladder. Retention of urine from coagulated blood in the bladder is a very serious occurrence. When the quantity is very large, relief must be sought by an opening in the perineum, similar to that in lithotomy. Ordinarily, however, evacuation should be attempted with a full-sized catheter, with four large eyelets, aided by injections of warm water, and an CHAP. X VI . RETENTION OF URINE. 697 exhausting syringe. Sometimes the object may be accomplished with a large silver catheter, the orifice of which is completely occluded with an obturator attached to the vesical extremity of a stylet, removed the moment the instrument reaches the bladder. Such an instrument, which I devised in 1850, and which I have often used with admir- able effect, is represented in fig. 492. The usual hemostatic means are also employed. Fig. 492. Author's Blood Catheter. When the blood lias been recently effused, it is best to wait from six to eight or ten hours, until the fluid has subsided to the bottom of the bladder, when the supernatant urine may generally be withdrawn without difficulty. Retention caused by inspissated mucus, plastic matter, worms, or calculous concre- tions, is, in general, easily relieved with the catheter. When it depends upon the pressure of the gravid uterus, it can only be remedied by rectifying the position of the displaced organ. Retention of urine is sometimes produced by pressure of the rectum upon the neck of the bladder. Anything having a tendency to cause inordinate distension of the bowel may give rise to such a condition. In 1842, a man died at King’s College Hospital, London, after having labored for four days under retention of urine, attended with enormous distension of the bladder. The dissection revealed the presence in the rectum of a pint of gray peas, which had been swallowed nearly a week before, without masti- cation, and which had experienced no alteration in their transit, except that they had become swollen by the absorption of the moisture of the bowel. In a case described by Dr. W. H. Westcott the obstruction was caused by six ounces of cherry stones, which prevented the passage of the catheter. Another cause of retention of urine from pressure upon the neck of the bladder is the gravid uterus, sometimes as early as the third or fourth month of uterogestation, before the organ has risen out of the pelvis; but more frequently during the latter stages. The subject has recently attracted the special attention of Dr. Broussin, who has published a valuable paper on it in the Archives de Medecine. The obstruction may be occasioned by an imperforate prepuce. When this is the case, relief is sought by a free incision. In the female, it is sometimes caused by a vascular tumor in the orifice of the tube, when excision is, of course, the proper remedy. In lying-in women, serious obstruction to the evacuation of the urine is often occasioned by the bruised and swollen condition of the urethra, consequent upon the passage of the child’s head or the maladroit use of the forceps. Retention may depend upon priapism, induced by inflammation of the penis from gonorrhoea or external injury, by excessive cerebral irritation, as in lesion of the brain, or by the inordinate use of cantharides. However this may be, recourse is at once had to the catheter, attention being afterwards paid to the removal of the exciting cause. 2d. The bladder may be unable to expel its contents from paralysis of its muscular fibres, as in apoplexy, injury of the spine, overdistension of the organ, and the effects of fever, contusions, lacerated wounds, and capital operations. The use of anodynes, in large doses, sometimes induces temporary vesical paralysis. In low forms of fever, especially when delirium is present, in compound fractures and dislocations, in lacerated wounds, in contusions of the abdomen, in strangulated bernia, and in injuries of the brain and spinal cord, frequent inquiry should be made into the condition of the bladder, in order to guard against retention, or to relieve it speedily, if it be found to be unavoidable. The liability of this variety of retention to be followed by incontinence cannot be too forcibly or too frequently impressed upon the mind of the reader. Retention from paralysis is relieved with the catheter, and it is better to introduce the instrument frequently than to permit it to remain. When the return of contrac- tility is slow and imperfect, our chief reliance must be upon gentle but steady purgation, the exhibition of strychnia, ergot, cantharides, and tincture of the chloride of iron, 698 DISEASES OF THE URINARY ORGANS. CHAP. XVI. electricity, the cold shower-bath, vesication of the sacrolumbar region, and irritating frictions to the spine. When the loss of power is dependent upon the use of anodynes, cold applications to the head, hypogastrium, perineum, and genitals will usually suffice to afford relief. Retention from paralysis of the bladder, whether induced by traumatic or internal causes, often ceases very suddenly of its own accord, or under the use of mild remedies. A mere change of posture sometimes answers the purpose, especially in retention from injury and protracted parturition. There is a variety of retention of urine which is occasionally met with in hysterical females, and which is seemingly dependent upon a deficiency of volition rather than upon paralysis of the muscular fibres of the bladder. The affection, which is generally tempo- rary, may last for days and weeks. In a case recently under my care, it had persistently continued for upwards of three years, during which the urine was drawn off regularly twice every twenty-four hours. Purgatives, antispasmodics, and chalybeate tonics, are the remedies mainly to be relied upon. Cold water enemas, or cold water poured upon the sacrolumbar region in a continuous stream, from a height of three or four feet, often afford speedy relief. The catheter must, if possible, be avoided. Chloral and bromide of potassium should be freely used. Moral treatment is often the most successful. Too much kindness only tends to prolong the case. In the patient here referred to the threat- ened application of the actual cautery promptly effected a cure. It is to this form of retention of urine that the term “ stammering of the bladder,” first used by Sir James Paget, is more particularly applicable, consisting in a want of har- mony between the extrusor and sphincter muscles of the organ, attended with inability to void the urine. In a remarkable case of this kind, in the hands of Professor T. G. Rich- ardson, of New Orleans, in a young girl, eighteen years of age, after the failure of a great variety of means, speedy and permanent relief was afforded by the division of the anterior wall of the urethra from the neck of the bladder to the orifice of the tube. The spasm of the sphincter muscle, which was no doubt the immediate cause of the “ stam- mering” here, was effectually broken up by the operation, the neck of the bladder being thereby placed in a state of repose, and in a condition for its future cooperation with the muscular fibres of the organ. A curious freak in passing water, apparently of a mental character, is occasionally noticed in boys and men. The former, if uncommonly modest, cannot relieve them- selves in the presence of their companions, and adults sometimes experience a similar dif- ficulty. Habit, too, exercises a singular influence over this function, as is exemplified in the story of the sailor, who was so accustomed to pass his water over the railing of the ship into the sea, that, when on shore, he was obliged to avail himself of the aid of a bucket of water. 3d. Retention of urine from spasm of the neck of the bladder, or of this organ and of the urethra, is commonly produced by cold, suppression of the cutaneous perspiration, the irritation of ascarides, hemorrhoidal tumors, stone in the bladder, disorder of the digestive apparatus, the use of fermented, vinous, or alcoholic drinks, and the effects of eantharides. The warm bath, hot fomentations, and the inhalation of chloroform, fol- lowed by the free use of camphor and morphia, or morphia alone, either by the mouth, the rectum, or the hypodermic syringe, generally afford prompt relief. Cold applications sometimes answer better than warm. Standing with the naked feet upon the cold floor often readily overcomes the spasm and enables the water to flow. A lump of ice intro- duced into the rectum occasionally acts like a charm, and similar effects frequently follow the application of this agent to the perineum and suprapubic region. When the symp- toms are urgent, the catheter is used. In retention, from the absorption of eantharides, known as strangury, the most effect- ual remedies are anodyne injections, hot fomentations, and the exhibition of liquor potassas in half drachm doses every hour, along with the liberal use of dilutents. 4th. Retention may be produced by inflammation of the urethra and the neck of the bladder, characterized by a frequent desire to urinate, with an inability to pass more than a few drops of water at a time; a sense of smarting, burning, or scalding in the urethra and the head of the penis; violent straining ; a feeling of weight about the anus; and throbbing in the perineum. Occasionally, the urine is mixed with blood and pus. The treatment is by anodynes, leeches, and other antiphlogistic remedies, and the use of the catheter. In inflammatory retention, accompanied by spasm of the bladder and urethra, prompt relief is occasionally obtained from the inhalation of chloroform. 5th. The disease is sometimes caused by gout and rheumatism, especially in elderly, CHAP. XVI. CATHETERISM. broken-down individuals long addicted to the pleasures of the table, and to inordinate sexual indulgence. The attack is either coincident with gout and rheumatism in other structures, or it shows itself as a retrocedent affection. In either event, the most suitable remedies are Dover’s powder, colchicum and morphia, purgatives, alkalies, and the hot bath. 6th. The retention may depend upon the pressure of a pelvic abscess, a solid tumor, or a serous, blood, or hydatid cyst, developed between the bladder and the rectum. Boyer has recorded an instance in which the obstacle was formed by an exostosis of the pelvic bone ; the tumor compressed the neck of the bladder, and prevented the passage of the catheter. Mr. Thomas Bryant, of London, met with a case of retention of urine caused by an immense mass of hydatids which almost completely blocked up the pelvic cavity and pushed the bladder up into the iliac fossa, beyond the reach of the instrument. After three fruitless efforts to perforate the organ with the trocar, an incision was made through the perineum upon the morbid growth, which contained three quarts of hydatids. The man, who was fifty years of age, and who had not voided more than an ounce of urine at any one time for many months, died at the end of the seventh day. The treatment of such obstructions must be regulated by the peculiar nature of the case. Finally, there is a periodical form of the disease which comes on at a particular time, very much like an attack of intermittent fever, and is evidently dependent upon similar causes. It is met with chiefly, if not exclusively, in miasmatic regions. The treatment must, of course, be by quinine, either alone, or in union with arsenic and other antiperiodic remedies. CATHETERISM. The introduction of the catheter, although apparently very simple, is one of the most delicate operations in surgery. It requires skill of the highest order, as well as the most intimate knowledge of the anatomy of the urinary organs. My conviction is that few men perform it well. Catheters are cylindrical tubes, of variable composition, size, and shape. The best for ordinary use are made of silver, and are, for an adult, about nine inches and a half long, by two lines and a half in diameter ; they are perfectly smooth, light, and bent at the vesical extremity to accommodate them to the natural curve of the fixed portion of the urethra, which corresponds to rather less than one-third of the circumference of a circle three inches and a quarter in diameter. An instrument, the axis of the point of which forms a right angle with the axis of the shaft, fashioned to this curve, will be found to be better adapted to the average, well formed, adult urethra, than one which is not con- structed on these principles. In children, and adults in whom the general development is below the average, the curve of the urethra is more acute, and hence the curve of the catheter must be increased, or describe an arc of a smaller circle. In corpulent persons, on the other hand, the curve of the urethra being diminished, that of the instrument should form a segment of a larger circle. The extremity, which is rounded off, but closed at the point, and nearly of the same thickness as the rest of the instru- ment, has an oval hole on each side, as exhibited, in fig. 493, a quarter of an inch long, and about a line in width, for the entrance of the urine. Instead of this arrangement, this part of the tube issometimes pierced with numerous aper- tures, as in fig. 494; an arrangement highly objectionable on account of their liability to become clogged with blood and mucus. For the removal of urine, mixed with these substances, I have had a catheter constructed with eight eye- lets. The catheter, represented at page 697, with the opening at the extremity, and provided with a closely-fitting conical stopper, secured to a stylet, is also well adapted to this object, as the orifice remains closed until the tube is fully in the bladder. The other extremity, usually called the handle of the instrument, is open, and is provided on Fig. 493. Fig. 494. Different Forms of Catheters. 700 DISEASES OF THE URINARY ORGANS. CHAP. XVI. each side with a small ring, for securing it in its place when it is necessary to retain it in the bladder. The French pocket catheter consists of two pieces, united by a screw, and is adapted for either sex. The gum-elastic instrument, so much lauded by some practi- tioners, I seldom employ, except in inordinate enlargement of the prostate gland, as it is extremely liable to bend whenever it meets with the slightest resistance, and is also very easily injured by the urine. It is, however, proper to add that the soft, pliant catheters of the French manufacturers, figs. 495 and 496, especially those with bulbous extremi- ties, pass into the bladder with the greatest ease, and can with safety be intrusted to the Fig. 495. Fig. 496. French Gum-elastic Catheters. patient or to his nurse. Indeed, they cannot be too favorably recommended to inexpe- rienced practitioners, and bunglers, in whose hands the slightest obstacle to the introduc- tion of metallic instruments is liable to be attended with the formation of false passages. The best of the soft instruments is that of Davidson, made of very flexible red rubber, and provided with an eye or opening in the centre of the vesical end. Every surgeon should have an assortment of catheters of different dimensions, that he may be prepared for any emergencies that may arise. For washing out the bladder, for the removal of mucus, pus, or blood, or for introducing fluids, a double catheter, fig. 497, is necessary. Fig. 497. Catheter for Washing out the Bladder. When the object is to throw up fluids, medicated with acids, as the nitric, hydrochloric, or carbolic, a silver instrument is required. When the urethra is entirely sound, a tolerably large catheter, one that will gently dis- tend the parietes of the tube, is selected. An instrument of this size is not so likely to be arrested by the folds and follicles of the mucous membrane, or to impinge against the margins of the opening in the triangular ligament. Previously to inserting it, it should be well warmed and oiled. The catheter may be introduced while the patient is standing, sitting, or lying ; and it is important, whatever posture may be selected, that the thighs should be moderately separated from each other, and flexed upon the pelvis, to relax the abdominal muscles.- In the first case, the patient leans with his back against the wall, and inclines his chest slightly forwards, so that he may not change his position during the operation. The sur- geon may take his place either at the front or side. If he sit, the breech should project over the chair, and the body be directed backwards. The position of the operator is the same as before. The most convenient posture, however, is the recumbent. The patient lies on his back, near the edge of the bed, the head being supported by a pillow, and the knees, slightly separated from each other, somewhat raised. The surgeon, standing at the left side of the bed, takes the penis in the left hand, and raises it to a right angle with the body to efface the curve which it forms at the pubes. The catheter, held in the right hand, between the thumb and first two fingers, is inserted into the orifice of the urethra, its concavity being directed towards the abdomen with the handle nearly in contact with the middle line. The instrument is now passed on until it reaches the sinus of the bulb, which lies upon the anterior surface of the triangular ligament, rather deep in the peri- neum. To disengage it from the sinus, the handle is changed from the horizontal direc- tion into the vertical, at the same time that the point is slightly retracted. By this CHAP. XVI. CATHETER ISM. 701 manoeuvre, the curved portion is brought under the arch of the pubes, and immediately opposite the opening in the triangular ligament. By depressing now the handle of the instrument so as to bring it into a straight line the point readily glides over the prostatic part of the urethra into the bladder. In performing this operation not only no force is employed, but tbe whole proceeding is conducted with the utmost care and gentleness. The catheter, held as lightly as possi- ble, is made to glide along, as it were, by its own weight, assisted by that of the hand. The penis should be drawn slightly forwards over the instrument, just sufficient to render the urethra a little tense. Everything like stretching, pulling, and pushing must be avoided. In introducing the straight catheter, the patient lies on his back, the surgeon standing on the right side of the bed, instead of on the left, as in the other case. The penis is held in the left hand, at a right angle with the body, and the instrument is carried down per- pendicularly as far as the sinus of the bulb. To free it from this depression, the point is retracted a few lines, and then, while the penis is lowered between the thighs, it is at once sent onward into the bladder. When, from any cause, the bladder is permanently disabled from expelling its contents, the patient should be taught to introduce the catheter himself, as this will save the sur- geon an immense amount of labor and inconvenience. A few lessons generally suffice to impart the recpiisite information, and it is surprising how well the operation is often executed. The frequency with which the operation is repeated must, of course, vary with the nature of the case, from three to six times in the twenty-four hours. Although I have known men to draw off their urine a dozen times a day for years with perfect im- punity, it may be laid down, as a rule, that, in most cases, when the instru- ment is used for any considerable period, it will gradually set up a slow form of inflammation in the prostate gland and mucous membrane of the bladder, under the effect of which, if proper care be not taken, the patient will ultimately succumb. The natural impediments to the introduction of the catheter are, the lacuna magna, the sinus of the bulb, the margins of the triangular liga- ment, and the orifices of the prostatic ducts. Nearly all these impedi- ments are situated along the under surface of the urethra, and may, there- fore, generally be readily avoided by pressing the point of the instrument, as it glides along, gently upwards. A tolerably large catheter is less likely to become entangled than a small one. The difficulty occasioned by hypertrophy of the prostate gland is usually easily surmounted by the insertion of the finger into the rectum. When the retention depends upon displacement of the posterior part of the urethra, or of the neck of the bladder in consequence of centric hypertrophy of the prostate gland, a gravid or dislocated uterus, or the existence of a pelvic tumor, much ingenuity will frequently be required to accomplish the object. Various contrivances are used for retaining the catheter in the bladder. The one which I usually prefer is the double T bandage, the thigh-pieces of which are fastened in front and behind in such a manner as not to interfere with the anus and the scrotum. The instrument, having been introduced, is secured by two strips of linen, tape, or oiled silk, by tying the middle of each to the ring of the catheter, and the ends to the vertical bands. Another very good plan is to surround the penis with an ivory, rubber, or linen yoke, secured to the pubes by means of four pieces of tape, carried around the thighs and pelvis. The catheter is fastened to the ring or yoke in the usual way. In the annexed drawing, fig. 498, the instrument is secured by a contrivance composed of bands of gum elastic. This, however, is objectionable, on account of its liability to injure the penis, in case of erection, and to slip when the organ is flaccid. A convenient way of confining the gum elastic catheter is to tie a piece of twine around the extremity of the instrument, and to secure the ends to the hair upon the pubes. To prevent undue pressure upon the mucous membrane of the bladder, the catheter, if intended to be retained, should be at least two inches shorter than one used for merely drawing off the urine. What is called a Syme’s catheter is by far the most suitable and convenient instrument for permanent retention. The winged or self-retaining gum- Fig. 498. Mode of seem- ing Catheter in the Bladder. elastic catheter of Mr. Holt’s, fig. 499, can never come into general use, on account of the irritation which it is liable to set up. The introduction of the catheter is sometimes followed by unpleas- ant effects, as partial syncope, more or less violent shock, epilepti- form convulsions, and even death. These occurrences are most com- mon in persons of a nervous, irritable temperament, and cannot always be prevented, however carefully and gently the operation may be per- formed. The best way to avoid them is to insert the instrument, properly oiled and warmed, in the recumbent posture. The effects generally pass off speedily of their own accord. The most suitable remedies, in the event of their being troublesome, are the administra- tion of hot brandy toddy, the inhalation of chloroform, and the hypo- dermic injection of morphia. It is much easier to rupture the bladder with a catheter or sound than is generally supposed. A number of cases have been recorded where, from this cause, death was produced. Velpeau states that a surgeon in one of the Parisian hospitals introduced a catheter into a man’s bladder, but, finding no urine, he thrust the instrument up with great force, and drew off a large quantity of serous fluid, which, as the dissection showed, had accumulated in the peritoneal cavity, the case having been one of ascites. TAPPING OP THE BLADDER. When the catheter, bougie, and other means have failed to procure relief, the only thing that remains to be done is to puncture the bladder. Fortunately, this operation is seldom necessary. It is only in cases of excessive enlargement of the prostate gland, attended with great tenderness and swelling of the surrounding parts, in laceration of the urethra, infiltration of urine into the scrotum, and in deep-seated, impassable stricture, that the operation should ever be seriously thought of. I have myself been obliged to perform it only twice, and then in cases not my own. There are four routes by which the organ may be approached when paracentesis be- comes necessary, the rectum, prostate gland, pubic symphysis, and the hypogastrium. Of these, the first is the one usually preferred, on account of the facility of performing the operation, and its supposed freedom from the danger of urinary infiltration. It is, of course, contraindicated when there is great enlargement of the prostate gland, or serious disease of the anus, rectum, or bas-fond of the bladder. The operation is occasionally followed by peritonitis ; and cases have been reported in which it gave rise to emphysema, extending to the upper parts of the body. 702 DISEASES OF THE URINARY ORGANS. CHAP. XVI. Fig. 499 Holt’s Catheter. Fig. 500. Rectal Tapping of the Bladder. a. Rectal Tapping—Rectal tapping is performed with a curved trocar, about four inches in length, and provided with a suitable canula. The patient’s breech is brought over the edge ot the bed, and his legs are supported by two assistants, as in the operation for stone. I he surgeon, oiling the index and middle fingers of the left hand, introduces them into the bowel, in contact with its anterior wall; he then takes the instrument in the right hand, and retracting the point of the trocar within its sheath, places it in the CHAP. XVI. TAPPING OF THE BLADDER. 703 groove formed by the junction of the two fingers. When the instrument has passed the posterior margin of the prostate gland, the handle is depressed, and the point urged on through the superimposed structures into the interior of the bladder, as shown in fig. 500. The want of resistance, and a slight escape of urine, will indicate that the instrument has reached its destination. By a sort of double movement, the trocar is now withdrawn, and the canula pushed farther on into the distended viscus. The urine being evacuated, the canula is either at once removed, or, if there is any serious obstacle along the natural passage, it is retained until this is surmounted. b. Tapping through the Prostate Gland When the bladder is chronically inflamed from enlargement of the prostate gland, tapping may be performed through this organ, as was recently suggested and successfully practised by Mr. Reginald Harrison, of Liverpool. The operation is executed with a trocar through the perineum about three-quarters of an inch above the anus, and has the great advantage not only of affording a ready outlet to the urine, but of permitting the bladder to be washed out as often as may be deemed necessary, in a way far better than through any other route. The canula should be closed with a valve, and be secured in the usual manner. My conviction is that this operation is destined to come into general use in this class of cases, of such frequent occurrence in advanced life, and a source of so much suffering. c. Interpubic Tapping Interpubic tapping of the bladder was originally proposed by Dr. J. M. Brander, of Jersey, in 1825. As the name implies, the instrument, a hydro- cele trocar of medium size, is passed through the centre of the pubic symphysis, somewhat obliquely downwards and backwards towards the sacrum, and, consequently, only a short distance from the urethra. A piece of flexible catheter is introduced through the canula, and retained in the usual manner. The operation has the advantage of facility of evacu- ation, and of freedom from infiltration. In very old subjects it might be impracticable on account of ossification of the interpubic fibro-cartilage. d. Suprapubic Tapping This operation is objectionable, because of the great danger of the escape of urine into the peritoneal cavity and the surrounding connective substance. Fig. 501. Fig. 502. Suprapubic Tapping of tbe Bladder. In executing it, the patient is placed on bis back, the skin is divested of hair, and an incision is made from below upwards, along the mid- dle line, from an inch to an inch and a half in length, according to the condition of the parts, first through the common integument, and then through the fibrous structure between the pyramidal muscles, down to the connective tissue over the distended organ. Through this opening the bladder is pierced at its lowest part, by means of a long curved trocar, fig. 501, the point of the instrument being inclined obliquely downwards and backwards in the direction of the promon- tory of the sacrum. Transfixion being completed, the trocar is with- drawn, and the canula or double silver tube, fig. 502, gently passed into the bladder, where it is retained by an appropriate bandage, until the obstruction necessitating the operation has been removed. The patient, in the mean time, lies on his side, to promote the escape of the urine. Tube to be worn after Suprapubic Tapping of the Bladder. DISEASES OF THE URINARY ORGANS. CHAP. XVI. Aspiration of the Bladder The evacuation of the bladder in retention from hyper- trophy of the prostate gland, stricture of the urethra, and other causes, may readily be effected by means of the aspirator, the trocar being introduced at the middle line about an inch and a half above the pubes. The patient, during the operation, lies upon his back, with the hips slightly elevated with a pillow. If repetition be demanded, the puncture should not be made at the same spot. The operation may be performed quite as well with an ordinary slender trocar as with the more complicated and expensive aspirator. INCONTINENCE OF URINE. Incontinence of urine, the reverse of retention, with which it is often associated, may occur at any period of life, and may be partial or complete, temporary or permanent. It may be excited by a great variety of circumstances, the most prominent of which, how- ever, are referable to external injury, or to inflammation, spasm, paralysis, or morbid sensibility of the bladder, or of this organ and of the urethra. The water may pass off as fast as it is secreted, or it may be retained for a time, and then either dribble away or be discharged in a full stream. a. The best example of incontinence from external injury is afforded in lithotomy. A kick, blow, or fall, upon the perineum is occasionally followed by a similar result. Incon- tinence from this cause often disappears spontaneously; and, on the other hand, it is occa- sionally incurable. The treatment must be conducted upon general principles. b. Incontinence from inflammation may depend upon various circumstances. The escape is usually partial, and is almost constantly associated with more or less pain and spasm. The treatment consists in removing the exciting cause, and in employing the lancet, the hip-bath, antispasmodics, and anodyne injections. The catheter often affords instant relief. c. The disease is occasionally induced by gout or rheumatism, the attack generally coming on as a secondary affection, being translated from the part originally affected to the bladder, the mucous and muscular tunics of which are rendered exquisitely sensitive, with a constant inclination to micturition. The urine is usually surcharged with lithates, and there is always marked disorder of the digestive apparatus. Relief is afforded by thorough purgation, a careful regulation of the diet, and the exhibition of colchicum and morphia, Dover’s powder, and the alkalies. If the patient is very plethoric, blood may be taken from the arm; if anemic, tonics and stimulants must be employed. d. Paralysis of the bladder, or of this viscus and of the urethra, however induced, is a frequent cause of incontinence. It is particularly liable to supervene upon injury of the brain and spinal cord. It also occasionally follows upon parturition. Owing to the fact that the sphincter muscle generally retains some contractile power, more or less of the urine accumulates in the bladder, while the rest gradually passes off, leading thus to a belief that the case is one purely of incontinence, when, in reality, it is one both of incontinence and of retention. The remedies, in the treatment of this affection, must be addressed chiefly to the invig- oration of the nervous system. For this purpose, after having cleared out the bowels and corrected the secretions, the patient is put on the use of strychnia and ergot, either alone or combined with some mild tonic, as extract of cinchona and sulphate of iron. Cantha- rides may also be advantageously given, especially if carried to the extent of slight stran- gury. The diet should be light, but nutritious. The cold shower-bath, followed by dry frictions, is often highly beneficial. Counterirritation by blisters or, what is far better, the actual cautery, is maintained in the sacrolumbar region. Occasionally prompt relief is afforded by injecting the bladder daily with a few ounces of cold water. Electricity is also worthy of trial. e. Incontinence may arise from morbid sensibility of the neck of the bladder, or of the entire organ, excited by the acid character of the urine, or by sympathy with the kidney, rectum, anus, vagina, or uterus. Masturbation and inordinate sexual indulgence may be followed by a similar result. In most of these instances, the disorder is incomplete. Maniacs are very liable to attacks of incontinence, apparently due to excessive morbid sensibility of the bladder, probably the result of self-pollution. To this variety of the affection obviously belongs that form of the disease known as puerile incontinence. Although it is most frequent in young, delicate boys, before the age of ten, it is by no means uncommon in girls. It often begins very early in life in CHAP. XVI. INCONTINENCE OF URINE. 705 both sexes, and occasionally continues long after the age of puberty, greatly to the annoy- ance, both physical and mental, of the poor sufferer. The discharge, which may take place several times during the night, is most common towards morning, and is sometimes effected under the influence of the will or of a dream, but, in general, it is strictly involun- tary. When it becomes habitual, as it usually does, it may last for years. In most cases, however, it gradually disappears on the approach of adolescence. It is promoted by the use of fluids, by exposure to cold, and by sleeping on the back, a posture favorable to the accumulation of urine in the morbidly sensitive portion of the bladder. In boys one of the most common exciting causes of this affection is masturbation, which, in confirmed cases, frequently keeps up the incontinence until a late period of life. In young children it is often produced by ill health, arising from improper feeding and want of good air and exercise, followed by disorder of the digestive organs ; by malarious dis- eases ; by worms in the alimentary canal; by the inordinate use of saccharine drinks; by the irritating properties or the excessive quantity of the urine; by stone in the bladder; by a long, tight, or adherent prepuce; and by the accumulation of irritating secretions upon the head of the penis. In all cases of incontinence in boys a careful examination should be made of the entire genito-urinary apparatus. In public institutions and asylums the affection occasionally assumes an endemic character. In the treatment of this form of incontinence, the removal of the exciting cause is a matter of paramount importance. In boys and girls, the cure may be greatly expedited by proper attention to the diet, which should always be bland and unirritating. Late suppers are avoided, and the patient must abstain entirely from drink for several hours before going to bed. During the night, he should be compelled to rise two or three times to empty his bladder, and this practice should be persisted in for weeks and even months, until the disagreeable habit is thoroughly broken up. During all this time, as well as, indeed, for a long period afterwards, the child should lie upon his side, to prevent the urine from coming in contact with and irritating the neck of the bladder. To secure this object fully a bandage with a large knot opposite the sacrum should be worn around the pelvis at night. The internal remedies from which I have derived most benefit are the bromides, in doses of five to ten grains in combination with two, three, or five grains of chloral, every night at bedtime, according to the age of the patient. Occasionally it is well to admin- ister these articles as often as three times in the twenty-four hours. Belladonna is also a very valuable medicine in nocturnal incontinence, given by itself, or in union with one of the bromides and chloral. When a tonic is required nothing answers so well as quinine and tincture of chloride of iron. A combination of ergot, belladonna, and iodide of iron also proves highly useful. Benzoic acid has been greatly extolled in this class of cases, but the trials I have made with it have disappointed my expectations. Paregoric is sometimes useful, especially when given in combination with the bromides, chloral, or belladonna. When the complaint is dependent upon chronic cystitis or great morbid sen- sibility of the bladder, balsam of copaiba, in doses of five to ten drops twice daily is sometimes beneficial; and it is in these conditions that a full anodyne at bedtime, in the form of.Dover’s powder, often exerts a very happy influence. Colchicum proves ser- viceable when the child is laboring under the rheumatic diathesis. In very obstinate cases the neck of the bladder should be cauterized with nitrate of silver. In the female the application is made to the orifice of the urethra. The cold shower-bath and change of air often do much good. Pressure applied to the urethra, gentle but steady, and gradually increased, has some- times been found beneficial in removing the complaint; and Dr. Corrigan, of Dublin, warmly recommends closing the preputial orifice with collodion, which is easily removed with the finger nail on the following morning, or whenever the child desires to pass water. In nocturnal incontinence, one of the chief duties of the practitioner is to secure the cooperation of the patient. The child must be reasoned with, and even threatened with chastisement; but he is not beaten, nor does any sensible man, at the present day, ever think of tying up the penis. Circumcision is, of course, performed when the foreskin is at fault. Some interesting facts in relation to nocturnal incontinence of urine, as it occurred, in 1857, in the Philadelphia House of Refuge, have been published by Dr. Addinell Hew- son. Of 292 boys, not less than 78 were simultaneously affected with this disorder. Of the 78, however, only 63, inclusive of 34 negroes, were under constant surveillance. The ages ranged from seven to eighteen years, the average being thirteen. Many of the 706 DISEASES OF THE URINARY ORGANS. CHAP. XVI. boys bore the marks of ill health, especially of derangement of the digestive organs; 24 suffered from ascarides; some had herpes; 20 labored under constipation ; and nearly all were suspected of masturbation, eighteen acknowledging their guilt. I lie prepuce was discolored and elongated, either from frequent scratching or pulling, in not less than 46 cases. A considerable number wet themselves both day and night. The urine deposited uric acid in nearly one-half of the cases. The use of stimulating food, and sudden atmos- pheric changes, always produced a marked increase of the disorder. The remedies which proved most efficacious were the juice of belladonna, prepared according to Bentley’s process, magnesia, the cold douche, and a reduced supper of bread, without any drink. Those who had worms were treated with turpentine and bicarbonate of sodium. Each boy was compelled to get up and micturate an hour after retiring at night. Under this treat- ment, especially the influence of a restricted diet, enjoined as a punishment, the endemic rapidly disappeared. In an endemic of incontinence of urine in the Smithfield Peniten- tiary, Ireland, the disorder was promptly and effectually arrested by a threat to whip every boy with nettles who wet his bed. Finally, when the incontinence is irremediable, a urinal should be worn, to prevent the fluid from soiling the clothes. The best contrivance for this purpose is a gum-elastic bag, shaped somewhat like a Florence flask, capable of holding about twelve ounces, and fur- nished at its inferior extremity with a screw, for the purpose of evacuating the urine after it has accumulated to some extent in the artificial reservoir. The interior should be frequently washed for the sake of cleanliness, and every patient should be provided with an extra vessel, so that he may not suffer any inconvenience in case of accident. A uri- nal now much used is a gum-elastic bag attached to the inside of the leg, and connected by a tube with the penis. It is much more convenient than the old contrivance. MORBID CONDITIONS OF THE URINE. The urine, both in disease and injury, often deviates in a remarkable degree from the normal standard. The most important alterations to which it is liable are referable, first, to its color, odor, and consistence; secondly, to its quantity and specific gravity ; thirdly, to an increase of its more important normal constituents; and, fourthly, to its admixture with various extraneous substances, as blood, fibrin, albumen, pus, and spermatic fluid. 1. Naturally the urine is of a light amber color, or of the color df pale sherry, espe- cially if water has been largely used. The fluid that is voided in the morning is gene- rally a few shades darker, and during the progress of fevers and acute affections it not unfrequently assumes a deep hue, so as fully to justify the word high-colored, then so com- monly applied to it. In certain affections of the bladder and kidneys, particularly in chronic cystitis, it is sometimes remarkably dark, either at the moment it is passed, or after it has stood a while. A whitish, milky, or lactescent appearance of the urine is usu- ally indicative of imperfect assimilation. Bile renders the fluid yellowish ; blood, smoky or reddish ; melanic acid, blackish. A bluish urine is sometimes observed, owing to the presence of uroxanthin. Various articles of diet and of medicine impart their specific hue to the renal secretion. In inflammatory affections, as the different forms of fever, gout, rheumatism, pneumo- nia, pleurisy, erysipelas, wounds, and hectic irritation, the urine is always abnormally red, or even pink, from the presence of purpurine. In nervous diseases, as hysteria, epi- lepsy, and hypochondriasis, it is remarkably clear, if not actually limpid. In diabetes, in which the fluid is often thrown oft’ in vast quantities, the color is very pale. Urine depos- iting cystine generally exhibits a peculiar yellowish tint, similar to that of honey. The odor of this fluid is naturally a little aromatic, not unlike that of healthy perspira- tion, without acidity or alkalinity. In certain diseases, it becomes remarkably fetid, occa- sionally even before it is voided, and always after it has stood for some time in the receiver. Asparagus, garlic, cubebs, turpentine, valerian, gin, and other articles invariably impart their peculiar odor to it. In diabetes it has a whey-like smell, while in the cystine dia- thesis it resembles the odor of the sweet briar. In injuries of the spine, and in diseases of the bladder, dependent upon calculus, stricture of the urethra, or enlargement of the prostate gland, it generally exhales a most offensive, ammoniacal odor. Sometimes the smell strongly resembles that of putrid cabbage, owing, probably, to the disengagement of sulphuretted hydrogen. The consistence of urine is subject to much diversity, and often affords important diag- nostic information. An aqueous state of the fluid is generally denotive of nervous disease ; CHAP. XVI. MORBID CONDITION'S OF THE URINE. 707 it is commonly associated with lightness of color, and low specific gravity. In inflamma- tory affections, whether idiopathic or traumatic, the urine is usually very thick, owing to the presence of an abnormal quantity of mucus, lithic acid, and other extraneous matter. In disease of the urinary apparatus, especially chronic cystitis, inordinate consistence is generally combined with remarkable viscidity. 2. The quantity of urine excreted by a healthy adult, in the twenty-four hours, is from 35 to 45 ounces, from which it may range from 20 ounces, as the minimum, to 55 ounces, as the maximum. In diabetes it often amounts to several gallons during this period for days together; it is also frequently very abundant in nervous diseases, particularly in hysteria. In inflammatory affections, on the other hand, the quantity is always greatly diminished, especially during the early stages of the attack. In dropsy, there is generally a remark- able deficiency of urine, the quantity being often less than one-sixth the normal standard. The density of the urine is liable to be influenced by various circumstances. On an average, it is about 1022.5 in the healthy state. It is increased by copious perspiration, active exercise, heat, dry food, and all articles containing much azote ; diminished by the liberal use of water, the lighter wines, malt liquors, vegetable food, cold, and sedentary habits. In disease, it varies from 1001, as the minimum, to 1055, as the maximum. 3. An increase or diminution of the normal constituents of this fluid is of frequent occur- rence, and, therefore, capable of affording valuable diagnostic information. The water of the urine, as it naturally exists in greater abundance than any other ingre- dient, amounting generally to about 933 parts in the 1000, is subject to remarkable changes. In nervous affections, especially in such as partake of a hysterical character, the fluid is always very copious, as well as very thin and limpid. In diabetes insipidus, it is highly aqueous, and is excreted in enormous quantities; it is destitute of urea, and deposits, on evaporation, a yellowish-brownish syrup, devoid of crystals, and possessed of a very feeble reaction. In general, comparatively little water exists in the urine in inflam- matory affections. The amount of urea voided in the twenty-four hours varies with the nature of our food, drink, exercise, and health, its excretion, according to Roberts, being at the rate of 3|- grains per pound weight of the body. A purely animal diet affords, according to Leh- mann, 821 grains, a mixed 501, a vegetable 347, and a non-nitrogenous 237. Urea is furnished very sparingly in acute and active diseases of the kidney, while its elimination is diminished in chronic diseases. In all other acute febrile and inflammatory affections the quantity is increased. Sometimes the kidneys refuse to secrete it, and then, as it is retained in the blood, it acts as a poison, causing headache, nausea, depression, and con- vulsions ; in fact, all the phenomena of uremic disturbance, speedily followed by death. The acid of the urine is most abundant for some time after the completion of digestion ; during the continuance of this process, the quantity is very slight, or the fluid may even exhibit a neutral or alkaline reaction, especially if the meal has been a vegetable one. As a general rule, it may be stated to be in an inverse ratio to the amount of gastric juice. Errors of diet, and whatever has a tendency to impair the powers of the stomach or to dry up the cutaneous perspiration, increase the acid of the urine. Hence, it is generally pre- sent in undue quantity in dyspepsia, gout, rheumatism, and in intermittent, traumatic, and other fevers. It is also very much augmented by the internal use of various kinds of acids, as sulphuric, nitric, phosphoric, and tartaric. An alkaline condition of the urine is met with in various states of the system. It is generally present, in a very high degree, in disease of the urinary apparatus, dependent upon injury of the spinal cord, or mechanical obstruction of the urethra, leading to hyper- trophy and chronic inflammation of the bladder. The pus or gelatinous mucus which is formed in such cases by the affected mucous membrane acts as a kind of ferment, causing decomposition of the animal matter, and thus completely depriving the urine of its acid. A purely vegetable diet soon renders the urine alkaline ; and a similar effect is occasioned by the exhibition of the salts of sodium and potassium. An alkaline condition of this fluid, then, is not necessarily inconsistent with health ; it is only, or chiefly, when it is associ- ated with the presence of carbonate of ammonium or the phosphates that it should be regarded as pathological. The mucus naturally existing in this fluid is greatly augmented in certain diseases. In cystorrhoea, for instance, it is so abundant as to impart to this affection its characteristic fea- ture. When this substance is thrown off in inordinate quantity, it is generally very thick and ropy, and so tenacious as to adhere more or less firmly to the bottom of the receiver. The urine with which it is associated is usually alkaline, and remarkable prone to decom- 708 DISEASES OF THE URINARY ORGANS. chap. xvi. position, even in the bladder. When the disease upon which it depends is at all severe, or of long standing, it is nearly always intermixed with pus and fibrin, lymph corpuscles, epithelium, and phosphatic matter. During health, the lining membrane of the genito-urinary organs is constantly engaged in throwing off epithelium, the quantity of which is always materially increased when there is serious disease of these structures. The cells, fig. 503, from Roberts, are of vari- able size, and of an oval, cylindrical, caudate, or irregularly angular and flattened shape, with a well-marked central nucleus ; sometimes they are broken up, and disposed in patches or lamellated plates. They frequently occur in combination with oxalate of lime, and in certain affections, especially organic disease of the kidneys, they contain oil globules. 4. Various substances find tbeir way into the urine, either through accident, injury, or disease. Of these, the most important, practically considered, are blood, fibrin, albumen, pus, and spermatic fluid. Fig. 503. Fig. 504. Epithelium from the Bladder, Ureter, and Pelvis of the Kidney. Blood Corpuscles, The presence of blood in this fluid may be due to various causes, as injury and ulcera- tion of the genito-urinary apparatus, a renal or vesical calculus, or the existence of a sarcomatous, papillary, or erectile tumor. It may generally be readily detected, espe- cially if recently effused, by the reddish color which it imparts to the urine, by its tend- ency to subside to the bottom of the receiver, and by its alkaline properties. The most infallible plan, however, is to place a little of the suspected fluid under the microscope, which, if it contain blood, will at once detect the peculiar corpuscles of that substance, as displayed in the annexed sketch, fig. 504, representing these bodies unchanged, and either single or aggregated, or shrivelled and crenated, as seen to the right of the figure, when the urine has stood for some time. Fibrin, plasma, or lymph, is nearly always present in the urine in serious disease of the kidney and bladder. It frequently occurs in distinct flakes, fragments, or little masses, of a whitish or drab-colored appearance, and, under the microscope, always ex- hibits the peculiar features of that deposit. In renal affections, fibrinous casts are often found in the urine, generally in association with pus corpuscles, blood disks, oil globules, and epithelial cells. Albumen exists in the urine in many affections, both of the kidneys and of other organs. It is often present in traumatic and idiopathic fevers, pneumonia, dropsy, phthisis, and even in prurigo. It is generally very abundant in Bright’s disease, of which it forms a characteristic feature. The urine with which it is associated is of low specific gravity, from deficiency of urea and salts, of a pale, opaline color, and readily coagulable by heat and nitric acid. What is knowrn as chylous urine is met with chiefly in the inhabitants of the tropics, and is generally of a white, opaque appearance, like milk; or if there be any admixture of blood, of a faint rose tint. Its white color is due to the presence of very delicate globules of oily or fatty matter. The fluid, on standing, coagulates spontaneously CHAP. XVI. MORBID CONDITIONS OF THE URINE. 709 into a soft tremulous mass, and similar changes are impressed upon it on the addition of heat and nitric acid. Occasionally it coagulates in the bladder. It is generally of low specific gravity; and always contains granular nucleated corpuscles, similar to those of chyle or mucus. The cause of this condition of the urine is not well understood, but I have myself no doubt that is generally dependent upon disorder of the digestive and assimilative functions. Its course is generally irregular, and its appearance and disap- pearance are often very abrupt. Sometimes the occurrence is more or less distinctly periodical. Fig. 505. Fig. 506. Pus Corpuscles. Spermatozoa. Pus is a very common ingredient of urine, and is generally denotive of serious disease of the genito-urinary apparatus. Its presence, however, may be purely accidental. The urine with which it is combined always contains albumen and mucus, is more or less tur- bid in its appearance, readily putrefies, and generally affords an alkaline reaction. After the fluid has stood for a while, the pus collects at the bottom of the receiver, as a yellow- ish, homogeneous stratum, of variable thickness. Under the microscope, it exhibits the characteristic globules, delineated in fig. 505. Seminal fluid, is, perhaps, more frequently present in the urine than is commonly sup- posed. More or less usually exists in all confirmed cases of masturbation and venereal excesses. The microscopical appearances are well shown in the accompanying sketch, fig. 506, representing spermatozoa. These bodies are not unfrequently found in the urine in health ; and they may generally be easily detected in this fluid, if it be examined soon after it has been voided, with a power of four hundred diameters. Care should be taken not to mistake for zoosperms fragments of cotton, linen, and other vegetable substances, as they sometimes assume forms very closely resembling them. Besides these ingredients, numerous others are often found in the urine, as urea, urates, uric acid, bile, sugar, oil, cystic and xanthic oxides, oxalate, and carbonate of lime, and the triple phosphates. Cases have been met with in which this fluid contained hairs, short, destitute of bulbs, commonly of a light color, and combined with an excessive secre- tion of white, chalky matter. Their source has not been determined. The probability is that they are sometimes derived from a diseased ovary. The examination of the urine with a view to the detection of its more important mor- bid changes demands skill and patience. The apparatus required for the purpose consists of a microscope, a urinometer, several test tubes, a spirit lamp, a graduated burette, a small flask, and stirring rods, with a few chemical reagents, as litmus paper, acetic acid, nitric acid, liquor potassse, strong liquor ammonias, and a prepared copper solution. Simple inspection with the unassisted eye is seldom satisfactory. The urine usually selected for investigation is that passed in the morning. Of this from four tosix ounces should be put into a conical glass, in which it should remain undis- turbed for at least two hours, in order to afford an opportunity for the separation of its constituents. A note is now made of its color, odor, and reaction, the appearance of the floating matter, and the nature of the deposit. If it be acid, it will turn blue litmus paper red, and red litmus paper blue if alkaline. A reddish brick-colored sediment indicates an excess of acid. If the alkali is fixed, the blue tint will be permanent; but if it is occa- sioned by the presence of ammonia, the test paper will resume its original hue on the application of gentle heat. Mucus, pus, and blood, especially if present in large quantity, may generally be readily detected with the naked eye; but the most satisfactory result is always furnished by the microscope, a drop of the deposit being placed upon a glass under the field of the instrument. The characteristic properties of these substances have already 710 DISEASES OF THE URINARY ORGANS. CHAP. XVI. been pointed out. The epithelium found in the urine generally proceeds from the kidney and the bladder ; in the former case the cells are small and more or less spherical, in the latter flat and scaly. Any doubt that may arise as to the source of the blood, may gene- rally be satisfactorily solved by the presence or absence of renal casts. Among the most reliable tests for albumen are heat and nitric acid, the former coagu- lating it, the latter throwing down a flocculent, white precipitate. Deception, however, may arise: thus, if phosphates exist in the fluid, heat may cause a cloudy deposit resemb- ling albumen, although this may readily be dissipated by the addition of a little nitric acid, if the turbidity is owing to the earthy salts, whereas it will be permanent if caused by animal matter. Again albumen may be present, but, the urine being alkaline, no coagu- lation may occur. When this is the case, the normal acid reaction should be restored by the addition of acetic acid before it is boiled. Finally nitric acid may produce a precipi- tate when there is no albumen, but simply an admixture of urates. The addition of heat promptly clears the urine. The carbolic acid test of Mehu is a very delicate one for the detection of albumen. It consists of one part each, by weight, of crystallized carbolic acid and of commercial acetic acid, dissolved in two parts of alcohol, 90 p. c. If 10 c. c. of this solution, which retains its properties without change for an indefinite time, be added to a mixture of two ounces of urine and 2 c. c. of commercial nitric acid, the albumen will be precipitated in the form of white flakes. If the albumen exist in large quantity, or if this substance is surcharged with salts, the addition of nitric acid will not be necessary. Urea may be detected by adding to urine, in a watch-glass, an equal bulk of colorless nitric acid. If it exist in excess, irregular hexagonal crystals of nitrate of urea, of a pearly lustre, and easily recognizable with the microscope, will speedily form, whereas, if the quantity be very small, they will not appear for some time. The presence of bile is ascertained by mixing a drop of nitric acid with a small quantity of urine on a white plate, and observing the play of color that takes place, passing more or less rapidly from green to violet, blue and red. The bile acids are easily recognized by dissolving a drop of syrup in a drachm of urine in a porcelain capsule, and then slowly adding two-thirds of its bulk of sulphuric acid. On the application of gentle heat, a cherry red color is produced, which soon passes into a deep purple. For the detection of sugar, one of the most simple tests is Boettger’s. It consists in boiling urine with one-half its bulk of the officinal solution of potassa, a small quantity of subnitrate of bismuth having previously been added to the mixture. The presence of sac- charine matter is announced by the precipitation of a dark gray or black powder, due to the conversion of the suboxide into metallic bismuth. The fermentation test is suf- ficiently accurate for ordinary purposes. It consists in mixing the suspected fluid with yeast, and keeping the mixture in a warm place for a short time, when, if sugar be pres- ent, it will evolve carbonic acid and produce alcohol. The urine which accompanies this formation is remarkably clear, aqueous, of high specific gravity, the average being 1044, and of a peculiar whey-like odor. It seldom deposits any sediments. Fatty matter exhibits, under the microscope, transparent, characteristic oil globules. Its existence may also be detected by ether, by adding an equal quantity to the suspected urine, and then gently evaporating the mixture. The residue will be greasy, immiscible with water, and pervaded by oil glob- ules. The urine, when much of this substance is present, is of an opaque, milky aspect. The specific gravity of this fluid may readily be determined with a urino- meter, sketched in fig. 507, floated in a tall, narrow cylindrical vessel, con- taining about six ounces of urine. The number on the graduated stem, on the level of the fluid, w ill, if added to 1000, express the specific gravity. A spe- cific gravity bottle will afford a still more accurate result. It should be capa- ble of holding 1000 grains of distilled water at a temperature of 60° Fahr. The vessel, being counterpoised, is filled with urine, the weight of which will represent its specific gravity. Fig. 507. TTrinometer. CHAP. XVI. URINARY DEPOSITS. 711 URINARY DEPOSITS. The only deposits in perfectly healthy urine are a slight amount of mucus and epithelial debris, which gradually subside in the form of a delicate cloud as the fluid cools; but in various abnormal conditions of this excretion, either from excess of its constituents, from a hyperacid condition, or, again, from an alkaline state, owing either to the fixed or vola- tile alkalies, other precipitates occur. The most common of these are, first, uric acid, either pure or combined with some bases; secondly, phosphoric acid, as the phosphate of lime, the phosphate of magnesium, or what is called the triple phosphate, consisting of a combination of phosphoric acid with magnesium and ammonium ; thirdly, oxalic acid, in combination with lime ; and, fourthly, cystine and xanthine. The latter two substances, however, are very uncommon. 1. Uric acid, fig. 508, appears as a deposit in crystals, under varied forms, of which the rhombic prism and its modifications are the most common. The urates occur as amorphous sediments, of which there are two, the yellow and the red. The color, in the former, is probably owing to hematine ; in the latter, to a peculiar pigment, termed pur- purine. Both uric acid and the urates are distinguished from all other deposits by their beha- vior with nitric acid, on the addition of a drop of the concentrated fluid to a small quantity of the secretion. The first perceptible effect is an effervescence, followed by solution ; and, on drying the mass carefully over a spirit lamp, a beautiful crimson tint is produced, termed alloxanthin. The color is converted into a rich purple much heightened by sub- jecting the residue to the fumes of ammonia due to the formation of murexide or purpur- ate of ammonium. The two deposits are also readily distinguished from each other on the application of heat. The crystallized sediments, red sand, or gravel, consist of lithic acid, nearly in a .pure state. They appear in the form of minute particles, resembling very much in shape, size, and color, the particles of Cayenne pepper, and are always indicative of hyperacidity of the urine. Heat does not dissolve them, as it does lithate of ammonium. Under the Fig. 508. Fig. 509. Uric Acid. Amorphous Urates. microscope they are found to consist of exceedingly delicate crystals, most of which have the appearance of rhombic prisms, which may, therefore, be presumed to be their normal form. The most perfect specimens are generally contained in the deposits of yellow sand in the urine of young infants. The crystals are sometimes nearly square; or they are very thin, and longer than broad, so as to represent square tables ; or, finally, they are so thin as to appear merely like pale, lozenge-shaped lamellae. Occasionally they lie across each other, and are firmly coherent, forming glomeruli or aigrettes. The lateritious sediment, as it is termed, is colored by the pigment of the urine, and is composed of urate of sodium, in union with a small proportion ot urate of ammonium and lime. The urates, fig. 509, appear as a colored, amorphous deposit, and are redissolved on heating the urine, which is not the case with uric acid. An excess of the yellow deposit may generally be regarded as denotive of disturbance of the digestive functions, or dis- order of the cutaneous transpiration. The urine depositing this substance is ot a pale amber tint, more or less acid, and clear when voided. Its quantity is commonly confined within the natural limits, its specific gravity ranging from 1015 to 1025. 712 DISEASES OF THE URINARY ORGANS. CHAP. XVI. The red deposits are always present in those states of the system which are attended with imperfect assimilation, or a want of proper aeration of the blood. The pink sedi- ment, described by Prout, is merely a variety of this ; it is exceedingly rare, and is gene- rally expressive of organic disease of the lungs, liver, or spleen. The crystallized sediments are generally produced under the influence of a luxurious, indolent life, attended with dyspepsia, flatulence, acidity, and constipation of the bowels, with disorder of the cutaneous secretion. In the treatment of this affection, it is important to ascertain, if possible, the causes by which it has been induced. It may be assumed, from what was previously stated, that these deposits are all dependent upon the retention in the system of nitrogenous princi- ples, which, in consequence of derangement of the cutaneous and other emunctories, are obliged to pass off by the kidneys. The causes which may conduce to this result are— 1st. Imperfect assimilative action ; 2dly. The use of unwholesome food and drink ; 3dly. Defective oxygenation of the blood from disorder of the lungs and skin ; 4thly. Conges- tion, irritation, or inflammation of the urinary apparatus. The first indication is to improve and invigorate the state of the digestive organs ; 1st, by attention to the patient’s diet, and, 2dly, by a proper regulation of his bowels. As a general rule, no articles of food should be permitted that are known to disagree. All kinds of pastry, fresh bread, and oily, fatty, and saccharine substances, should be inter- dicted. Boiled fish, raw oysters, and the white meats may be used in moderation once a day. For breakfast and supper, the latter of which should always be very light, brown bread, dry toast, or soda biscuit, with a small quantity of butter, and a cup of black tea, will generally be sufficient. At dinner, green vegetables and ripe fruits may be indulged in, provided they do not impede the digestive process, or create flatulence and acidity. They promote the peristaltic action of the bowels, and furnish the urine with alkaline matter, thus preventing the deposit of gravel or lithic acid. Beef, pork, and mutton, if used at all, should be taken very sparingly. An important rule is to masticate as thor- oughly as possible, to eat slowly, and not to overload the stomach, or overtask the powers of this organ. Coffee, beer, and alcohol should be eschewed. If the patient has been accustomed to the use of wine, he should either be obliged to discontinue it entirely, or limit himself to a little dry sherry or Madeira at dinner, although brandy and gin are far preferable. Hard water must be avoided. Some mild aperient, as blue mass and rhubarb, should occasionally be given to regulate the bowels. Active purgation is rarely required or proper. When there is much acid in the stomach and bowels, Castile soap may advantageously be united with the cathartic medicines. Exercise should be taken at stated periods, in the open air, on foot, on horseback, or in a carriage; but it should never be carried to fatigue, or be taken immediately after a meal. The skin must be habitually kept in a clean and healthy condition. In warm weather, sponging with cold water, either simple or impregnated with salt, mustard, or alcohol, and followed by dry frictions, should be used, and if there be no contraindication, the same plan may be pursued in winter. Cold ablutions are more invigorating than warm. They are, in fact, to the external surface what cold air is to the lungs. Nevertheless, a warm bath will occasionally prove highly beneficial, especially during a fit of the gravel. The body and bedclothes should be frequently changed and aired, the skin protected with flannel, and exposure to cold carefully avoided. When the lithic deposit is connected with a gouty or rheumatic diathesis, colchicum, preceded and accompanied by mercurial cathartics, will be of service. Not unfrequently it is necessary to administer mercury in alterative doses until slight ptyalism is induced. When, from any cause, the lithic deposit is unusually large, marked relief generally follows the use of bromide of lithium, given in doses of five to ten grains, in carbonic acid water. When tonics are required, the best articles are quinine, iron, and mineral acids, par- ticularly the nictric and hydrochloric. The vegetable acids are also beneficial. Both kinds may be exhibited, either alone, or in combination with some of the vegetable bitters. Bicarbonate of sodium and of potassium are useful in relieving acidity and flatulence. The best time of exhibition is about an hour after meals. Phosphate of sodium and ammonium, biborate of sodium, liquor potassae, and benzoic acid are also valuable remedies. Irritation of the urinary organs, especially if inflammatory, may be relieved by the application of leeches, cups, and blisters to the lumbar region, sacrum, or perineum. CHAP. XVI. URINARY DEPOSITS. 713 The warm bath will also be useful, and anodyne injections rarely fail to afford prompt relief. Opiates have a happy effect in controlling the excretions in question, often curing the milder, and mitigating the distress in the more severe, forms. Morphia, lupulin, and hyoscyamus are the best articles of this class. When the skin is disordered, Dover’s powder may be administered. 2. The oxalic deposit holds, in point of frequency, an intermediate rank between the lithic and phosphatic, to the former of which it is closely allied. It occurs in the form of a white, glistening powder, insoluble on the addition of heat, acetic acid, and liquor potassas, but soluble in hydro- chloric acid, which is suspended in the urine, and manifests no disposition to precipitate itself, unless it can attach itself to some substance capable of constituting a nucleus. Under the microscope, this powder is found to consist of beautiful, transparent crystals, of an octahedral figure, with sharp and well-defined edges and angles, as in fig. 510. Occasionally, but rarely, they are shaped like dumb-bells, or like two kid- neys united at their concavities, and so closely approximated as to appear almost circular. They vary much in size, but in general they are exceedingly minute. If they are sub- jected to ignition on platinum foil, the oxalic acid is decom- posed, and a small quantity of carbonate of lime is left, which is readily dissolved with effervescence on the addition of dilute nitric acid. Oxalate of lime sometimes occurs as a distinct deposit, in the form of a small concretion resembling a hemp-seed, which may be retained in the bladder, and go on gradually increasing until it constitutes a mulberry calculus. The formation of oxalic acid is favored by whatever has a tendency to impair the assimilative powrers and to exhaust the vital energies. Hence, it is most commonly in- duced by errors of diet, or the use of unwholesome food and drink, excessive mental exertion, inordinate venery, exposure to cold, long-continued suppression of the cutaneous perspiration, and injury of the spinal cord, brain, or sacrolumbar nerves. The immediate agency in its production is not yet entirely settled, but the experiments of Wohler, Liebig, and Frerichs render it more than probable that it is due to the oxidation of the uric acid. Certain articles of food, as rhubarb, sorrel, and tomato, also promote its ap- pearance in the urine, as do also the frothy and sparkling wines. The symptoms of this affection are such as generally indicate the presence of derange- ment of the digestive organs and of the nervous system. Dyspepsia often exists in a marked degree; flatulence is of common occurrence; the mind is often gloomy and de- sponding; the temper is fretful; the surface is exceedingly susceptible to external impres- sions ; the extremities are almost constantly cold; the sleep is disturbed by disagreeable dreams ; and the patient continually broods over his disease, having a thousand misgivings and the most horrible forebodings ; pain in the loins is a frequent symptom ; the sexual power is usually much impaired, and the urine is often voided with uncommon frequency, as w'ell as with more or less heat and smarting. As the disorder advances, the patient becomes excessively emaciated, and ultimately falls into a state of confirmed hypochon- driasis. Serious pulmonary suffering is sometimes present, and in many cases the skin is covered with boils and scaly eruptions. In the treatment of this disorder, the first thing to be done is to improve the general health. The diet must be regulated, and such articles as contain sugar and oxalic acid, and produce acidity and flatulence, should be carefully avoided. The body should be well protected with clothing, and the skin, washed daily with tepid salt water or some other stimxdating fluid, thoroughly rubbed with a coarse, dry towel, or a flesh brush. In warm weather cold ablutions may be used. If there is much debility, tonics are indicated, such as quinine and sulphate of iron, in combination with capsicum and hyoscyamus. Sulphate of zinc, in the dose of one grain, two or three times a day, occasionally answers an excellent purpose. The mineral acids, as the dilute nitric and nitromuriatic, also possess valuable tonic properties. 3. The phosphatic deposit is characterized by its whitish or fawn color, pulverulent arrangement, solubility in dilute acids, and insolubility in ammonia and liquor potassae. It presents itself under three distinct varieties of form, the triple, the calcareous, and Fig. 510. Oxalate of Lime. 714 DISEASES OF THE URINARY ORGANS. CHAP. XVI. a. The triple phosphate consists of phosphate of ammonium and magnesium, on which account it is generally called the ammoniaco-magnesian phosphate. It commonly occurs in minute white crystals of a beautifully brilliant aspect, transparent or opaque, and remarkable for their sharp angles and edges. In their form, these crystals exhibit great diversity, but in most cases they are right rhombic prisms, as in tig. 511. Occasionally they have a stellar, penniform, or foliaceous arrangement. They often float on the surface of the urine, especially if it is partially decomposed, and look like an iridescent film of grease. The urine which accompanies this deposit is preternatu- rally copious, pale, or whitish, of low specific gravity, ranging from 1005 to 1014, and precipitates the deposit on the application of heat. It has a faint, sickening smell, which soon becomes ammoniacal and offensive. In some instances of the affection the fluid is unnaturally dark, brownish, or greenish-brown, decidedly alkaline, and loaded with dense, ropy mucus. The triple phosphatic deposit very often alternates with the yellow litliic or calcareous. Old persons are more subject to it than children and adolescents; and it is always asso- ciated with great disorder of the digestive organs. The patient is weak, irritable, and bloodless ; the slightest exercise fatigues him, and he complains constantly of a dull, heavy, aching pain in the lumbar l’egion. Overexertion, errors of diet, dyspepsia, severe courses of mercury, and excessive venery are its most common exciting causes. b. The calcareous deposit is composed of phosphate of lime, in the form of an impal- pable powder, of a whitish, grayish, or drab color. The urine, as in the triple variety, is pale, copious, of low specific gravity, and readily decomposed by exposure to the at- mosphere. The deposit is often accompanied by an inordinate secretion of mucus. c. The mixed deposit, consisting of a combination of the two preceding, is very common. It is usually combined with mucus, which is often secreted in large quantity, and of a ropy, viscid character. The urine is fetid, pale, and abundant, depositing a thick, mortar- like sediment upon standing. The most common causes of this condition are, injury of the lower part of the spine, organic disease of the kidney and bladder, dyspepsia, long- continued bodily fatigue, mental anxiety, loss of sleep, unwholesome food, and debilitating medicines. Patients thus affected are weak, flatulent, irritable, nervous, easily influenced by cold, emaciated, and of a gloomy, desponding disposition. The urine is voided more frequently than in health, and with more or less pain and scalding along the urethra. Pain in the loins is seldom wanting. Carbonate of lime is occasionally found in small quantity in deposits of earthy phos- phates, in union with alkaline urine. It generally occurs as an amorphous powder, but now and then in dense, crystallized circular stellie. Its presence is readily detected with nitric acid, which dissolves it with effervescence. In the treatment of this diathesis, the principal indications are, first, to improve the condition of the digestive organs; secondly, to acidify the urine; and thirdly, to invigo- rate the system. To accomplish the first of these objects, it is necessary to regulate the diet, and administer mild aperients. Hard water should be avoided. Exercise should be taken daily in the open air, but it must never be carried so far as to induce fatigue. The skin should be frequently bathed. To fulfil the second indication, acids are required, of which the dilute nitric is the best. It may be administered by itself, in a large quantity of water, or, what is generally pre- ferable, in union with hyoscyamus, black drop, paregoric, or infusion of opium. Ano- dynes can rarely be dispensed with, and are often of immense benefit in allaying pain and nervous irritation. When the urine is preternaturally acid, or the patient is harassed with pyrosis, soda, or soda and potassa, along with uva ursi and hop tea, will be the most appropriate remedies. All diuretics, properly so called, are injurious. The third indication is fulfilled by the use of tonics, as quinine, bark, and iron, a plain, but generous diet, exercise in the open air, and change of residence. A sea voyage is sometimes highly beneficial. Exposure to cold, irregularities of diet, and indiscretions of every kind, should be avoided, both during the actual existence of this diathesis, and for a long time afterwards, on account of the great tendency to relapse. When the deposit depends upon lesion of the spinal cord, the internal use of strychnia, and counterirritation, in the form of blister, issue, or the hot iron, will be beneficial. Fig. 511. Triple Phosphates. CHAP. XVI. STONE IN THE BLADDER 715 If inflammation of the bladder or kidney exist, it must be combated by the ordinary means. 4. The cystine deposit, a very rare, uncommon form, presents itself as a whitish sediment, consisting of colorless, hexagonal crystals of various sizes, impregnated with fatty matter, and often serrated at the edges. It is readily dis- solved by the strong mineral acids, as well as by potassa and ammonia, and contains about 26 per cent, of sulphur. The urine which furnishes this sediment emits an odor similar to that of sweet briar, and is commonly found in connection with ill health, as dyspepsia, imperfect nutri- tion, and exhaustion of the nervous system. The fluid is sometimes acid, at other times alkaline. The quantity of urea and of uric acid is generally below the normal standard. The bladder is not irritable, nor is there much lumbar pain. Cystine forms the chief ingredient of the cystine calculus. The microscopic characters of this deposit are represented in fig. 512. The chief means for correcting the state of the system upon which this deposit depends are the mineral acids, quinine, mix vomica, gentle exercise in the open air, mental relaxation, cold ablutions, and a generous diet, with a glass of sherry, Madeira, or whiskey at dinner. STONE IN THE BLADDER. Most urinaxy calculi take their rise in the kidney, from which they descend into the bladder, where, if retained for any length of time, they gradually increase in size, and ultimately produce more or less obstruction. When they have a nucleus of uric acid or oxalate of lime, the probability is that they had a renal origin ; but vesical, if it is phos- phatic. Their progress along the ureter has already been described. The disease occurs at all ages. I have met with it in very young infants, and cases have been related which render it highly probable that it is occasionally an intrauterine affection. Thus, in an instance recorded by F. Hoffmann, a stone, the size of a peach kernel, was found after death in the bladder of a child only three weeks old. In my Treatise on the Urinary Organs are given the ages of 8574 cases of stone in the bladder, as occurring in England, France, Russia, India, and the Pennsylvania Hospital, of which 3498 were observed from the first to the tenth year, 1488 from the tenth to the twentieth, 748 from the twentieth to the thirtieth, 438 from the thirtieth to the fortieth, 588 from the fortieth to the fiftieth, 685 from the fiftieth to the sixtieth, 722 from the sixtieth to the seventieth, 338 from the seventieth to the eightieth, and 19 from the eightieth to the ninetieth. Thus, it will be seen that more cases occur prior to the age of twenty than at all other periods together. In attempting to form a correct estimate of the relative frequency of calculous com- plaints in children, adults, and old persons, we must not lose sight of the fact that many of the cases which fall into the hands of the surgeon are examples of long standing, extending, perhaps, through a period of many years. Thus, a man at forty may have contracted the disease at ten or fifteen. Moreover, it should be borne in mind that cal- culous diseases are more frequent, in certain countries, among children than among adults, and conversely. It is not satisfactorily ascertained whether this affection is ever hereditary. Cases re- lated by Civiale, Front, and others, seem to warrant such an inference; but I have myself not met with any confirmatory evidence. Stone in the bladder is very uncommon in females, owing, mainly, to their having a much shorter and more capacious urethra, which thus favors the excretion of any deposits that might otherwise form in the bladder. It has been alleged that this immunity is due to the fact that women are much less exposed to the exciting causes of the disease than men, a conclusion which is invalidated by the circumstance that at least one-third of all the cases of stone that are met with occur in boys before the tenth year, and, consequently, before they are subjected to any particular hardships. The different varieties of the negro race of this country are much less subject to calculous diseases than the whites. I have ascertained from reliable statistics, founded upon 443 cases of stone in the bladder, occurring in Kentucky, Virginia, Tennessee, Georgia, Alabama, Louisiana, and Missouri, that the latter suffer three times as frequently Fig. 512, Cystine. 716 DISEASES OF THE URINARY ORGANS. CHAP. XVI. as the former. The same fact disproves the idea, so much insisted upon by certain writers, that the use of corn bread and bacon, which constitute a large proportion of the daily food of 4he colored population, in the above regions, is favorable to the production of urinary calculi. Stone in the bladder occurs in all parts of the world, although by no means with equal frequency. In this country, it is more common in Kentucky, Virginia, Tennessee, Ohio, and Missouri, than in any other regions. New England is remarkably exempt from it. The disease is sufficiently common in France, Austria, Hungary, Russia, England, Wales, Teneriffes, Ireland, Egypt, and in certain districts of China and India. Thus, Dr. J. G. Kerr, who practised at Canton upwards of twenty years, met with nearly four hundred cases of vesical calculi during that period, very few of which came beyond one hundred miles from that city, situated in latitude on the borders of the torrid zone. Stone is very common in the Northern Provinces of India. During a period of twelve years Rai Ram Narain Dass cut 240 cases, of whom 190 were Hindoos, men who lived mainly on raw or imperfectly cooked vegetables. The inhabitants of Ireland, Spain, Portugal, Switzerland, Sweden, and Norway, on the contrary, suffer comparatively seldom from it. In Holland calculus of the bladder is much less frequent now than it was a hundred years ago. In England Norfolk and Suffolk furnish the greatest number of cases of calculous diseases. The causes of these topographical differences in regard to the occurrence of stone in the bladder have not been determined. The great prevalence of the disease in limestone regions has long been familiar to observers, but whether the use of limestone water has really any agency in its production, is still a mooted question. It is certain that it frequently occurs in freestone regions. It has long been known that calculous diseases are much more common among the poor than the rich. Upon what this difference depends is not positively ascertained; the proba- bility is, that it is mainly due to derangement of the digestive organs, engendered by the use of unwholesome food, by irregular habits, want of cleanliness, intemperance, and deficient clothing. Occupation, no doubt, exerts an important influence upon the production of this dis- order, but in what manner, or to what extent, is unknown. In Ohio, and the South- western States, especially Kentucky, Tennessee, and Alabama, the great majority of calculous subjects are common laborers, farmers, and mechanics. Seafaring people are remarkably exempt from urinary calculi, and a similar immunity seems to be enjoyed by soldiers. Climate, also, exercises no little influence in the formation of urinary concretions. Thus, it is well known that the disease is most common in those parts of the world which are subject to frequent, great, and sudden atmospheric vicissitudes. In very cold and tropical regions it is exceedingly rare. Certain kinds of food predispose to the formation of calculous disease. All articles having a tendency to create acidity and flatulence exert a deleterious influence upon the renal secretion, changing its properties, and promoting the deposition of earthy matter. Hot bread, in its various forms, frequently only half-baked, and generally very imperfectly masticated, is sufficient, if used for any length of time, to wear out the strongest stomach, and break down the most vigorous frame. A weakened digestion, with a sour and flatu- lent state of the stomach, constipation of the bowels, and an irritable condition of the brain, cannot by any possibility produce a healthy blood, any more than a morbid state of the blood can produce a healthy urine. Various kinds of drinks exert an influence favorable to the formation of stone in the bladder. It has long been remarked in England that those districts in which cider is much employed are remarkably subject to calculous disorders. On the other hand, it is alleged that the use of Rhenish wine and of gin acts as a preventive. The formation of stone in the bladder is remarkably favored by certain kinds of dis- eases, especially stricture of the urethra, chronic enlargement of the prostate gland, and organic affections of the bladder, ureters, and kidneys. Injury of the spinal cord, particu- larly when it involves the dorsolumbar portion of that structure, or the nerves detached from it, is extremely prone to be followed by phosphatic deposits; and it has long been known that gout and rheumatism are eminently conducive to the formation of uric acid calculi. Physical Properties—Most calculi have a distinct nucleus, around which the earthy matter accumulates and crystallizes. The nucleus may be formed of any substance, either solid or semisolid, whether generated in the urinary organs, or introduced from without. It generally consists of some saline matter of the urine, as uric acid, oxalate of lime, urate CHAP. XVI. STONE IN THE BLADDER. 717 of ammonium, or phosphate of lime and magnesia. Inspissated mucus, lymph, hair, or clotted blood, may serve a similar purpose. In my private collection are specimens in which the concretions were formed around the tail-bones of a squirrel, an elm bougie, a piece of lead-pencil, and a bullet, the latter having been kindly presented to me by Dr. Robinson, of Warfordsbury, Pennsylvania. A similar case recently occurred to Professor.!. C. Hughes, of Keokuk, in a man thirty-four years old, wounded four years previously. The concretion was as large as a hen’s egg, and composed of phosphate of lime. Professor Hunter McGuire, of Richmond, has reported the par- ticulars of three cases of stone in the bladder, in each of which a bullet formed the nucleus of the concretion. In a preparation in the cabinet of Dr. Sabine, of New York, the nucleus consists of a piece of cork, as seen in fig. 513. Professor Van Buren informs me that he has a stone in the centre of which is an ear of wheat; and a somewhat similar case has been observed by Dr. B. B. Leonard, of West Liberty, Ohio. Professor Billroth, of Vienna, in 1868, showed me two calculi, one removed from a man, the other from a woman, in each of which the nucleus consisted of a piece of paper. In the museum of the Royal College of Surgeons of Edinburgh is a concretion formed around a small nutshell. Professor Blackman has recorded a case in which the nucleus was an incisor tooth, evidently derived from an ovarian cyst opening into the bladder; and in one observed by Mr. Curling, it consisted of human hair derived from a dermoid cyst situated between the bladder and rectum. Finally, the nucleus varies much in size, color, shape, and consistence; and, although generally single, it is sometimes double, triple, and even quadruple, probably from the aggregation of several concretions. In India, according to Dr. Carter, of Calcutta, oxalate of lime forms the nucleus of urinary concretions twice as frequently as in England. The number of concretions is variable. In general, there is only one, but there may be several dozens, if not several hundred. The largest number I have ever found was fifty- four. Dr. B. C. Toler, of Illinois, has reported a case of one hundred and sixty-seven; and Dr. Physick, in the case of Chief Justice Marshall, removed upwards of one thousand, from the size of a partridge shot to that of a bean. The mulberry calculus is most always solitary; and the same is true, although not to the same extent, of the uric calculus. The phosphatic calculus, on the contrary, is not unfrequently multiple. When the concretions are numerous, they are generally propor- tionately small and smooth; when solitary, rough and comparatively large. The volume of urinary concretions ranges from a hemp-seed to a goose’s egg. In young subjects, and in recent cases generally, it is usually inconsiderable. The size of a urinary calculus, however, does not necessarily depend upon the period of its sojourn in the blad- der, or the age of the patient. Occasionally, it increases very rapidly, so as to attain a large bulk in a very few months; and, on the other hand, it may remain small for many years. The ammoniaco-magnesian and the fusible calculi are capable of attaining a very large size, while the uric, oxalic, cystine, xanthic, and fibrinous are almost always compara- tively small, whatever may be their age, or the age of the patient. This fact is interest- ing in a practical point of view; because, by ascertaining the calculous diathesis of the sufferer, a tolerably correct idea may be formed of the volume of the stone under which he is laboring. The weight of urinary concretions seldom exceeds a few drachms or ounces. Many examples, however, are recorded of four, six, eight, ten, twelve, fifteen, and even sixteen ounces. Cline gives one of forty-four ounces, and Deschamps one of fifty-one. In a case seen by Morand the weight is said to have been six pounds. The consistence of vesical concretions varies from that of semiconcrete mortar, chalk, or wax to that of stone. The hardest calculi are the oxalic and uric, which commoidy emit a clear sound when struck with a steel instrument, and cannot be fractured without a considerable degree of force. Calculi, on the other hand, composed of ammoniaco- magnesian phosphate and phosphate of lime, are friable, and easily reduced to powder. The cystine and fibrinous calculi are quite soft, the latter scarcely equalling that of yellow wax. In what are termed alternating calculi, one part of the stone is commonly hard and compact, while another is soft and friable, if not pulverulent. Fig. 513. Calculus with a Cork for a Nucleus. 718 DISEASES OF THE URINARY ORGANS. chap, xvi. Calculi are occasionally composed of a mixture of sabulous matter and hair. Tlieir formation is of rare occurrence, and they appear to consist, principally, of phosphate of lime and magnesium. The color of these bodies is variable. The cystine and fibrinous calculi are of a yellow hue; the phosphatic, whitish or grayish; the oxalic, dark or blackish; the uric, rose, red- dish, or brown. Vesical calculi assume a great variety of forms. The circumstances which are chiefly concerned in producing this result are the action of the bladder, the friction which the concretions, when multiple, exert upon each other, and the nature of the nucleus. It is not unlikely that the chemical constitution exerts more or less influence upon the shape of a stone. Vesical calculi are generally of an oval form, but they may be spherical, cylindrical, conical, spiculated, or even angular. Sometimes several are matted together, so as to resemble what, geologically, is termed a pudding-stone. The late Dr. Mussey showed me a very curious calculus, depicted in fig. 514, which had been removed after death from the bladder of a man who had long labored under disease of that organ. It is of a light- brownish color, and consists of a central portion and a number of distinct processes, each of which has a small cavity containing animal matter. The processes are remarkably rough, and some of them are nearly half an inch in length. Its composition is supposed to be oxalate of lime. Occasionally the concretion consists, apparently, of two parts, one corresponding with the bladder, and the other with the urethra, as in fig. 515, or one with the bladder and one with the ureters. The surface of these concretions may be smooth or rough. The oxalic calculus de- rives its common name from the irregularity of its exterior, which resembles that of a Fig. 514. Fig. 515. Thorny Calculus. Urinary Calculus ; a showing the Vesical, and b the Urethral, Portion. mulberry. The uric acid calculus is usually finely tuberculated. The surface is gene- rally smooth when more than one concretion is present. Chemical Properties The chemical constitution of urinary calculi varies very much in different localities. The oxalate of lime calculi, for example, in the Medical College at Calcutta, amount to 38.65 per cent.; in Guy’s Hospital, London, to 22.59 per cent.; in the Royal College of Surgeons, to 14.75 per cent.; and in the Norwich Hospital, to 13.27 per cent. Uric acid calculi occur in smaller proportion in India than in England ; and, as to phosphatic calculi, they reach only 3.36 per cent, in the former, while they amount to 10 per cent, in the latter. Dr. A. H. Hassall, of London, states that of 1000 calculi, the composition of which was ascertained by chemical analysis, 372 consisted of uric acid, either alone or mixed with small quantities of the urates and oxalate or phos- phate of lime; 253, chiefly fusible concretions, of the earthy phosphates; 233 of varying layers of uric acid, oxalate of lime, and earthy phosphates ; and 142 of oxalate of lime. The subjoined account includes all the varieties of concretions at present known. The uric calculus, called also the lithie calculus, the most common species of all, is of a brownish color, inclining to that of mahogany, of a flattened, oval shape, occasionally finely tuberculated on the surface, but most generally smooth, but not polished, unless there are several concretions at the same time, and from the size of a currant to that of a hen’s egg. If it be sawed, it will be found to consist of several layers arranged concen- CHAP. XVI. STONE IN THE BLADDER 719 trically around a common nucleus, the laminae being frequently distinguishable from each other by a slight difference in color, and sometimes by the interposition of other ingredients. Water has but little action upon it; it is perfectly dissolved by hydrate of potassium, and dis- appears with effervescence in hot nitric acid, the solu- tion affording, on evaporation to dryness, a bright car- mine-colored residue. Before the blowpipe it chars, emits a peculiar odor, and is gradually consumed, leaving a mere trace of ashes. Its specific gravity is about 1500. Fig. 516 shows the oval shape and finely tuberculated surface of the calculus, with its internal concentric layers. The uro-ammoniac calculus, a variety of the pre- ceding, is principally observed in children, and is ex- tremely rare. It is generally of small size, with a smooth surface, of a clay or slate color, and composed of concentric rings, which present a very fine earthy appearance when fractured. Much more soluble in water than the uric calculus, it gives out a strong ammoniacal smell when heated with hydrate of potassium, and defla- grates remarkably under the blowpipe. Its specific gravity is about 1475. The oxalic calculus, next in point of frequency to the uric calculus, is generally of a dark brown, olive green, or purplish color, rugged, spinous, or tuberculated on the surface, very hard, compact, and imperfectly laminated, seldom larger than a walnut, spherical, and always single. Under the blowpipe, it expands and effloresces into a white powder, while it dissolves slowly in nitric and hydrochloric acid, provided it be previously well broken up. In the alkalies, it is perfectly insoluble. Its fracture is splintery, and its specific gravity 1700. It is often called the mulberry calculus, from its fancied resem- blance to the fruit of the mulberry, and consists essentially of oxalate of lime. Fig. 517 shows the external appearance and internal structure of this concretion. A variety of mulberry calculus is known as the hemp-seed calculus, fig. 518, from some resemblance which it bears in color and lustre to that substance. It is always of small size, remarkably smooth, and generally multiple, often existing in considerable numbers. Fig. 516. Uric Calculus. Fig. 517. Fig. 518. Fig. 520. Hemp-shaped Calculus. Fig. 519. Oxalic Calculus. Phosphatic Calculus. Ammoniaco-magnesian Calculus. The phosphatic calculus, fig. 519, is of a pale brownish color, and of a loosely lami- nated structure, with a smooth, polished surface, like porcelain. The shape is mostly oval, and the size, although generally small, is sometimes very considerable. It whitens when exposed to the blowpipe, but does not fuse ; and readily dissolves in hydrochloric acid, without effervescence. Composed essentially of phosphate of lime, it is extremely rare, as forming entire concretions, but frequently constitutes alternate layers with other matters. It is sometimes called the bone earth calculus, and occasionally contains small quantities of carbonate of lime. The next species of calculus is the ammoniaco-magnesian, fig. 520, so called from the fact of its being composed of phosphate and ammonium and magnesium. It is of a white color, friable, and crystallized on the surface, looking a good deal like a mass of chalk, 720 DISEASES OF THE URINARY ORGANS. CHAP. XVI. as its texture is without laminae ; it easily dissolves in dilute acids, but is insoluble in hydrate of potassium ; before the blowpipe it exhales an ammoniacal odor, and at length melts into a vitreous substance. It sometimes attains an immense size. The fusible calculus is a combination of the last two. It is of a white color, ex- tremely brittle, leaves a soft dust on the fingers, is easily separated into layers, and pre- sents, when broken, a ragged, uneven surface. It is insoluble in hydrate of potassium, but gives off ammonia; and, under the blowpipe, it is readily converted into a transparent, pearly-looking glass. This concretion is very common, and sometimes attains a very large size. It is frequently met with as an incrustation of foreign bodies. Its specific gravity is about 1300. Fig. 521 exhibits the outer appearance and internal structure. The cystic calculus is very uncommon, small, tuberculated, of a waxy consistence, and of a greenish or tawny color. It consists of a confused crystallized mass, exhibiting, when fractured, a compact, radiating, lustrous structure. It burns with a faint bluish flame, exhales a strong characteristic odor of sulphuret of carbon under the blowpipe, dissolves easily in acids and alkalies, and is generally of an oblong, oval shape. Its ex- ternal and internal characters are shown in figs. 522 and 523. The xanthic calculus is also extremely rare. Its texture is compact, hard, and lamina- ted, its color cinnamon brown, its surface smooth, its volume small. In a case, however, Fig. 521. Fig. 522. Fig. 523. Fusible Calculus. Cystic Calculus. observed by Von Langenbeck, a concretion of this kind weighed nearly six drachms and a half. It dissolves very readily in acids and alkalies, and is gradually consumed before the blowpipe, emitting a peculiar fetid odor, splitting into fragments, and leaving a minute quantity of white ashes. rYi\\e. fibrinous calculus is composed principally of the fibrin of the blood, a property to which it owes its name and character. It is of small size, of a spherical or oval shape, and of a brownish color. When dried, it shrinks, and loses some of its weight. It is of very rare occurrence. Urostealith, a very uncommon form of concretion, first described by Heller, is of a rounded or oval form, soft, elastic, dark brown, and from the size of a hemp-seed to that of a hazelnut; when dried, it becomes brittle, and assumes a waxy or greenish-yellow appearance. It readily melts under heat, emitting a peculiar pungent odor, similar to that of benzoin, and is promptly dissolved by ether and solutions of hydrate of potassium, but is insoluble in boiling water. It consists essentially of fatty matter. In fig. 524, from Roberts, the concretion, a specimen in the Hunterian Museum, of London, is surrounded by phosphatie matter. Situation.—Calculi lie generally loose within the cavity of the bladder, and are, con- sequently, liable to shift their position, not only with that of the viscus in which they are contained, but also with that of the body. Hence at one moment they may be at the bas- fond of the organ, at another at the neck, at another at its superior portion, at another at its CHAP. XVI. STONE IN THE BLADDER 721 sides, and at another, perhaps, at its anterior part, just above or behind the pubes. A knowledge of this variation in the position of these foreign sub- stances is of no little importance in regard to the operation of sounding. Their most common situa- tion, undoubtedly, is the bas-fond of the bladder, from the fact that this is the most dependent por- tion of the reservoir. In old subjects, affected with enlargement of the prostate, the concretion gener- ally lies just behind this body, in a kind of pouch, hollow, or cul-de-sac. When this is the case, and the calculus is of large size, it may often be easily felt by the finger in the rectum. When the bladder is perfectly sound, the concretion, especially when the patient is in the erect posture, and the urine evacuated, rests against the neck of the organ, and sometimes even projects into the orifice of the ure- thra. Cases occur in which the concretion is alternately loose and fixed. This may be owing to the existence of an abnormal pouch. The foreign body may also be arrested in the folds of the mucous membrane, in a depression behind the prostate, in the substance of this gland, in the orifice of the ureter, or in the mouth of the urethra. Vesical calculi may become permanently adherent, attached, or fixed, as exhibited in fig. 525, from a specimen formerly in the cabinet of Dr. Peticolas, of Richmond. This Fig. 524. Urostealith Calculus. Fig. 525. Encysted Calculi. may occur in different ways, and under a variety of circumstances, of which the following may be mentioned as the most important: 1. An effusion of plastic matter. 2. ie formation of an abnormal pouch. 3. The existence of a papillary tumor or excrescence. 4. A bilobed state of the bladder. 5. The projection of the concretion into the ureter, or some other passage. 6. Its lodgment in the wall of the bladder. Finally, the calculous matter, instead of being collected into a distinct concretion, is 722 DISEASES OF THE URINARY ORGANS. CU AP. XVI . sometimes spread out in the form of a layer upon the bas-fond of the bladder. A stratum of this kind, of considerable thickness, now and then forms around a papillary, erectile, or fibrous tumor of this organ. When the calculous matter presents such an arrangement, it grates under the instrument, and may be distinctly felt through the rectum. When struck with the sound it emits a peculiar noise, not unlike that of a cracked pot. I have seen several specimens in which this lamelliform arrangement coexisted with separate calculi. Symptoms.—The symptoms of stone in the bladder may conveniently be divided into the rational and physical, or into local and general, according as they affect the urinary apparatus or the system at large. The rational symptoms are : 1. Pain in making water, especially when the last drops are being expelled, felt both in the bladder and the adjacent parts. 2. A sense of weight and uneasiness in the pelvis, anus, and perineum. 3. Frequent micturition. 4. An occa- sional interruption of the stream of the urine. 5. Pain and itching in the head of the penis, with smarting and pricking sensations in the urethra, particularly at its orifice. 6. Enlargement of the penis and elongation of the prepuce. 7. Occasional priapism, with or without sexual desire. 8. An increased secretion of mucus from the lining membrane of the bladder, not unfrequently mixed with pus. 9. A bloody state of the urine. 10. In- continence of urine. 11. Prolapse of the anus. 12. Sympathetic suffering. 13. Noise furnished by the calculi knocking against each other in the bladder. These symptoms usually come on gradually, and a considerable period often elapses before the patient is led to suspect the real nature of his condition. This is especially the case when the general health is good, and the bladder perfectly sound. An albuminous condition of the urine is a very common occurrence when the calculous affection is complicated with chronic trouble in the kidneys, and is a sign of evil import. Pain and a frequent desire to pass water are generally the earliest symptoms of stone in the bladder, and they persist with gradually increasing severity, until permanent relief is afforded. A sudden stoppage of urine, caused by the rolling of the concretion against the mouth of the urethra, before the bladder is completely emptied, is a frequent occurrence, which always greatly aggra- vates the suffering. Elderly persons laboring under an enlargement of the prostate gland experience much less inconvenience from this disease than children and young adults. The constitutional symptoms of urinary calculus are exceedingly variable. In general, however, the suffering is much less than might at first be supposed. In children, particularly, the distress is often entirely local, the system taking little, if any, cognizance of the affection. In a great majority of the children whom I have cut, upwards of seventy in number, the general health was excellent, as was proved by the state of the countenance, appetite, and bowels, and the absence of fever and disorder of the secretions. Very often, indeed, the patient is, to all appearance, perfectly well. Ilis cheeks are rosy, and he is fat and plump, as if nothing ailed him. Occasionally, however, he suffers very much, perhaps at a very early stage of the disease, and the distress goes on progressively increas- ing until the health is completely wrecked. Adults and elderly subjects are, as a general rule, much less tolerant of urinary calculi than children; the system soon gives way, the appetite and strength decline, and the features are strongly denotive of the vesical disease. Lesion of the associate organs, of course, always increases the constitutional suffering. This is particularly true of disease of the kidneys. Whenever these structures are seri- ously implicated, the general health rapidly declines, and the patient, if not timeously relieved, gradually sinks under his complicated disorders. Disease of the bladder, as ulceration, hypertrophy, or chronic inflammation, invariably aggravates the constitutional symptoms. Persons of a nervous, irritable temperament suffer more severely than the cold and phlegmatic. The nature of the concretion also exercises an important influence. Oxalic and phosphatic calculi usually cause more distress, both local and general, than any of the other varieties. Large stones, other things being equal, occasion more suffer- ing than small, rough than smooth, multiple than single. The most important general symptoms are, gradual failure of the health, disorder of the digestive organs, as flatulence, acidity, and irregularity of the bowels, derangement of the secretions, depression of spirits, loss of flesh and strength, and a remarkable susceptibility to atmospheric vicissitudes. The pulse is small, irritable, and abnormally frequent; the extremities are habitually cold ; and the skin, dry and husky, exhales a peculiar urinous odor. Now and then, without any assignable cause, or under the effects of treatment, the symptoms, both local and general, temporarily disappear, to return subsequently, perhaps in an aggravated form. Calculus of the bladder occasionally produces epilepsy, as in a case reported by Dr. John Duncan, of Scotland. The patient, a boy, five years old, had been suffering all his life CHAP. XVI. STONE IN THE BLADDER. 723 from dribbling of urine, pain in the bladder, and other symptoms of stone. For upwards of two years he had frequent attacks of epilepsy, which continued, with more or less severity, until about a fornight after he was lithotomized, when they permanently dis- appeared. Physical Sigtis—Sounding—Diagnosis When the symptoms above described are all present, or even when several of them are absent, there is a strong probability that the patient is laboring under stone of the bladder, and this probably is converted into cer- tainty when the surgeon is able to feel and hear the foreign body. Nevertheless, cases occasionally occur, in which, notwithstanding the existence of both rational and physical signs, no concretion is to be discovered. Sounding consists in introducing into the bladder an instrument shaped like a catheter, either solid or hollow, with which the cavity of the organ is explored. The instrument itself is called a sound. Sounds vary in their construction, in their size, and in the materials of wrhich they are composed. The best are solid, well polished, and made of steel, with varying degrees of curvature, as in figs. 526, 527, and 528. For an adult, the length from one extremity to Fig. 526. Ordinary Sound. the other should be about twelve inches. Children, of course, require a shorter instrument. Generally speaking, a sound of moderate diameter is preferable to one of large size, as it is more easily moved about in the bladder. The vesical extremity or beak should be rounded off, not conical or pointed, so that it may not be arrested by the irregularities of the urethra. The curved portion should not, as a general rule, exceed three inches, and form an angle of about 45° with the straight portion. The handle of an adult sound should not be less than two inches in length, by one inch and an eighth in width; it should taper somewhat towards the stem of the instrument, be about a line in thickness, rounded at the corners, and well polished. Every lithotomist should be provided with several sounds, of various sizes and curvatures. A short time before the operation, the bowels should be well cleared with castor oil, or a purgative enema, in order that there may be no obstruction in the rectum. The bladder, at the time of the exploration, should contain from three to five ounces of urine; or, if it be too irritable to retain that quantity, or if the patient has urinated inad- vertently, the requisite distension should be produced by the injection of tepid water, through a silver catheter, which may then be used as a sound, care being taken to stop up its orifice, to prevent the regurgitation of the fluid. An excellent substitute for the Fig. 527. Hollow Sound. catheter is the hollow sound, represented in fig. 527, which permits the gradual escape of the urine, thereby, in complicated cases, greatly facilitating the detection of the calculus. During sounding, which should always be performed with the greatest possible care and gentleness, the patient should lie upon his back, with his head and shoulders some- what elevated, and the lower extremities slightly flexed and separated, to relax the abdominal muscles. Adults are sometimes examined in the erect posture; children never, except under particular circumstances. The surgeon comports himself precisely as in catheterism. Frequently the sound encounters the stone the moment it enters the neck of the blad- 724 DISEASES OF THE URINARY ORGANS. CHAP. XVI. der; should this not happen, it must be passed farther in, and moved about in different directions until the object is accomplished. The pubic surface of the bladder can be reached only by an instrument with a very long curve, not unlike that of an English S. Very frequently the stone cannot be felt, in consequence of its lying in a pouch in the bas-fond of the organ, just behind the prostate. When this is the case, the index finger of the left hand, properly oiled, is introduced into Fig. 528. Abruptly-curved Sound. the rectum, and the foreign body pushed forward against the sound. When the difficulty is very great, an instrument with a short, abrupt curve, as in fig. 528, which can be moved freely in every direction, may be used. Sometimes it is necessary to change the position of the patient, making him lie on his side, sit or stand, bend forwards, or raise his buttocks. The crying and struggling of children may be quieted by the use of an anaesthetic, which I am in the habit of employing in nearly all cases of the kind, both for the purpose of preventing pain, calming the patient’s mind, and soothing the bladder. The noise and sensation communicated by sounding are peculiar. The noise is a sort of click, clink, or clear metallic resonance. It is in the highest degree valuable as a diag- nostic sign. It may often be perceived at a distance of several yards from the patient. Some surgeons, in order to render it more distinct and satisfactory, attach a flexible stethoscope, or a sounding-board of light, compact wood, to the handle of the instrument; but I have myself never found any need of such an expedient. Mr. L’Estrange, of Dublin, many years ago, devised what may be called a reverberating sound, consisting of a small circle of light wood, in the form of a little drum, mounted on a stem, which, fastened to the ordinary instrument, affords a more accurate appreciation, both by the ear and finger, of the material struck, than any other contrivance. A grating, rubbing, or friction sensa- tion is sometimes distinguished, but this is rather indicative of a fasciculated state of the bladder, a morbid growth, or an incrusted condition of the mucous membrane than of the existence of stone. As a rule, a stone readily found may be supposed to be a large one. When the stone is very small, or the feel and noise elicited are very feeble, xecourse may be had to auscultation, the stethoscope being applied either to the pubic region, to the sacrum, or to the perineum, while the sound is moved about in the bladder. Valuable information in regard to the existence or absence of stone may occasionally be obtained by the bimanual exploration, as it is termed, which consists in inserting as high as possible the index and middle fingers of the left hand into the rectum, while counter- pressure is made with the right hand or fist upon the hypogastrium immediately above the pubic symphysis, the force being directed downwards towards the perineum. To render the examination effective, the bowels should previously be well emptied and the bladder should contain hardly any water. When these conditions are observed, even a small cal- culus may sometimes be promptly and satisfactorily detected. It must not be forgotten that such a mode of exploration is not always free from danger. For measuring a stone, the instrument commonly employed is a lithotrite, furnished with a sliding scale. Other contrivances have been devised for the same purpose, but most of them are faulty, and unworthy of notice. Patients are often brought to the surgeon from a distance for operation. When this is the case, they should not be sounded until they have recovered from their fatigue ; nor should* the operation be pei'formed during or immediately after a “ fit of the stone.” The system should be prepared for the operation. Fi’om neglect of this precaution, pa- tients are often subjected to much suffering, and there is no doubt that life has been re- peatedly sacrificed in this way. I have myself in a number of instances witnessed very serious effects from this kind of indiscretion ; and Sir James Paget states that he has known death to follow the mere sounding for stone in not less than six cases. Similar examples have been recorded by Fletcher, Crosse, Coulson, and other observers. The cause of death in these cases is generally peritonitis. Sounding enables the surgeon not only to detect the presence of a stone, but frequently furnishes important data in regard to its bulk, situation, and consistence, and as to whether it is single or multiple, rough or smooth, loose or attached. Another object in sounding is to ascertain the condition of the urinary apparatus. This CHAP. XVI. STONE IN THE BLADDER. 725 can frequently be accomplished in no other manner. The capacity of the organ, and the amount of its sensibility or tolerance may thus be determined ; and a pretty accurate idea may also generally be formed of the state of its inner surface, as to whether it is smooth or rough, ulcerated or fasciculated, incrusted with lymph or sabulous matter, or studded with papillary, fibrous, or other morbid growths. The passage of the sound along the urethra enables us to judge whether this tube is healthy or diseased, contracted, changed in its direction, or obstructed by foreign matter. The condition of the prostate gland is best determined with the finger in the bowel. The anus and rectum should always be carefully examined. Although sounding is the only certain mode of detecting the presence of a stone, it is by no means free from error, as is proved by the fact that many a poor patient has been subjected to all the pains and perils of lithotomy, when the bladder was perfectly free from everything of the kind. I am cognizant of nearly a dozen cases in which this mistake was committed. The circumstances which may give rise to it differ very much in their character, some being dependent upon the bladder itself, others upon the neigh- boring parts, as the prostate gland, rectum, uterus, vagina, and pelvic bones. Mere irri- tability of the bladder, attended with a frequent desire to void the urine, may lead to the supposition of the existence of stone, and if the surgeon, anxious for the eclat of an operation, should, in such an event, strike his sound against a mass of impacted feces, a projecting sacrum, or a morbid growth in the bladder or pelvis, he might very easily de- ceive himself. The greatest possible circumspection should, therefore, always be used in sounding ; the operation being, if necessary, performed again and again, until it is per- fectly certain that there is or is not a stone. On the other hand, there may be a stone in the bladder, and yet the surgeon be unable to detect it by sounding, aided, perhaps, by all the auxiliary means at his command. This failure has frequently occurred even when the concretion was uncommonly large, and when the operation was repeated with the greatest care and skill, as well as varied in every possible manner. Want of success has sometimes attended even when the calculi were multiple. Again, it has happened that a stone has been promptly detected in a first sounding, and, perhaps, not at all, or only after much trouble, in a subsequent one. Or the reverse of this may occur, that is, the concretion may elude the instrument in a first and second sounding, but be always readily detected afterwards. It is with sounding as with everything else ; to perform it well requires great tact in the use of instruments, a perfect knowledge of the anatomy of the urinary apparatus, and a degree of experience which multiplied observations alone can supply. The want of success, however, in this operation, is not confined exclusively to the young, the ignorant, or the unskilful. Men of the most consummate dexterity have occasionally failed in detecting a stone, when a stone really existed. Of the various circumstances which may prevent the detection of urinary calculi, some relate to the stone itself, some to the bladder, and some to the neighboring and associated organs. Thus, the foreign body may be very small; or there may be too much or too little water in the bladder during sounding ; or it may be encysted, as in fig. 529, or Fig. 529. Sounding for Stone in Sacculated Bladder. lodged in a cul-de-sac, at the bas-f’ond of the bladder, just behind the prostate gland, as in fig. 530, when it will escape detection unless the beak of the sound be reversed. Some- times, again, the concretion lies in a dilated ureter, or in a pouch in the prostate gland itself. 726 DISEASES OF THE URINARY ORGANS. chap. xvi. Fig. 530. Sounding for Stone in Enlarged Prostate. Pathological Effects Although the formation of vesical calculus is the immediate re- sult of a morbid condition of the urinary secretion, the bladder and its associate organs are generally diseased, to a greater or less extent, in the progress of the affection. The primary impression is probably always made upon the viscus in which the concretion is confined ; but the irritation which its protracted presence there induces is gradually re- flected upon the other portions of the apparatus, awakening in them, in the first instance, important sympathetic actions, and, ultimately, serious structural lesions. One of the first effects to which the foreign body gives rise is inflammation of the mu- cous coat of the bladder, as indicated by a frequent desire to make water, spasmodic pains in the lower part of the pelvis, and an increased secretion of mucus. Thickening of the lining membrane with increased vascularity, and the development of granulations, is another consequence ; and, the irritation extending to the different coats of the bladder, hypertrophy of the organ may take place. A diminution in the size of the bladder is not usual even in young subjects, but is much more common in old persons, who have labored for years under the continued irritation of a calculus. Ulceration of the mucous coat sometimes occurs. It is most frequently observed at the neck and bas-fond of the organ. One of the most distressing accidents which occasionally take place, during the pro- gress of this disease, is perforation of the bladder, followed by the partial, if not the com- plete, escape of the stone, and the formation of a fistule. When it is accompanied by extravasation of urine into the surrounding connective tissue, it may terminate fatally in a few days, or lead to violent inflammation and suppuration, inducing death at a more distant period. If the patient survive any length of time, the concretion becomes grad- ually encysted, or it may even eventually be discharged externally by ulceration. The urethra rarely suffers except in its prostatic portion, which may be unnaturally red, inflamed, hypertrophied, or attenuated. The prostate gland soon becomes diseased. It gradually increases in volume and density, sometimes enlarging in every direction, imped- ing the flow of urine, augmenting the pain and spasm of the bladder, and even producing serious pressure upon the rectum. Ulceration, abscess, and sloughing may follow from the constant and excessive irritation. In some instances the prostate is greatly dimin- ished in volume, or converted into a cavity, nearly equal to that of the contracted bladder itself, and capable of lodging a calculus of considerable size. The ureters are frequently inflamed and thickened, sometimes ulcerated, and now and then enlarged, or enlarged at one place, and contracted at another. The kidneys seldom entirely escape. In the worst forms of the malady, it is not un- usual to see one of them converted into a large pouch filled with purulent matter, or turbid urine. In rare cases Bright’s disease is present. Abscesses and fistules occasionally form in the perineum. Prolapse of the anus may take place, attended with relaxation of the sphincter muscles, inflammation and thicken- ing of the mucous membrane, and hemorrhoidal tumors. The excessive straining some- times leads to the formation of hernia of the groin. The orifices of the seminal ducts are, in many cases, dilated, or otherwise affected, and the ducts themselves may be variously altered. The seminal vesicles are sometimes atro- phied, or diminished in volume and changed in structure. A calculus of the bladder has sometimes obstructed parturition, and required extraction CHAP. XVI. TREATMENT OF STONE IN THE BLADDER. 727 before the labor could be completed. In one such case the woman died undelivered be- cause the nature of the difficulty was not determined during life. Finally, when a number of calculi coexist, some of them may occasionally break spon- taneously in the bladder, by striking forcibly against each other, as when the patient is running very fast, or even, perhaps, simply from the violent contraction of the bladder upon its contents. The occurrence, which is occasionally witnessed at a very early age, as in two cases observed by Southam, of course, implies extraordinary brittleness of the concretions, which is probably due to the decomposition of their cementing mucus. The oxalic calculus is not susceptible of such a change, of which a good illustration is afforded in fig. 531, from Liston. Prognosis—The prognosis of this affec- tion is variable. The only reliable treat- ment is removal of the concretion by ope- ration. If it is permitted to remain, it generally steadily increases in bulk, and ultimately leads to serious organic disease of the bladder, prostate gland, ureters, and kidneys, which causes not only a great deal of suffering, but imperils life by its long continuance, the patient being finally worn out by hectic irritation. The period at which death occurs ranges from a few years to ten, fifteen, twenty, and even thirty years. TREATMENT OF STONE IN THE BLADDER. A small calculus is sometimes extruded spontaneously, especially when the bladder, crowded with urine, contracts upon its contents with unusual vigor. Such an event is, of course, much more likely to happen in the female than in the male, owing to the dif- ference in the length and dilatability of the urethra. Cases have occurred in which rid- dance was effected by ulceration of the bladder, the concretion passing off by the rectum, vagina, perineum, or hypogastriuin. Spontaneous fracture of a stone in the bladder is always fraught with danger, as the fragments, by their jagged edges and rough surfaces, must inevitably cause severe irrita- tion, speedily followed by violent cystitis and death. In some cases, the patient perishes from peritonitis, or, if he survive the immediate effects of the accident, the bladder may give way by ulceration, and he may lose his life from extravasation of urine. Occasion- ally a sharp, irregular fragment is impelled into the urethra, causing retention of urine, or the obstruction may be produced by the presence of coagulated blood, poured out by the vessels of the irritated bladder. When a calculus breaks spontaneously in the bladder, no time should be wasted in idle attempts at palliation ; the only effectual remedy is lithotomy, and the sooner this is per- formed the more likely will the patient be to do well. The operation should be resorted to even when there are already well-marked evidences of cystitis, although the chances of recovery will then be proportionately diminished. The treatment of stone in the bladder necessarily divides itself into medical and sur- gical, of which the former is, in general, merely palliative, although frequently of para- mount importance, whether it be considered only in reference to the temporary comfort of the sufferer, or as a means of improving his health, with a view to his relief by an operation. 1. MEDICAL MEANS. Persons affected with stone in the bladder do not always find it convenient to submit to the operation of lithotomy or lithotrity, and it, therefore, becomes a matter of great importance to render them as comfortable as their circumstances may admit of. By attention to the general health, as regulated by food, drink, and exercise, much may be done to allay local suffering, and to make the patient almost forget his disease. A con- cretion, which may have been a source of great distress for years, may, by appropriate and well-directed treatment, become a comparatively harmless tenant of the bladder, Fig. 531. Calculus Breaking Spontaneously, and Causing Death By Inflammation. 728 DISEASES OF THE URINARY ORGANS. chap. xvi. and thus convert a state of torture into one of Elysium. The improvement thus pro- duced has sometimes lasted many years, although, in general, it is comparatively short. A consideration of these circumstances has led to a belief, not altogether unfounded, that urinary concretions are sometimes dissolved in the bladder, and voided along with the urine. Hence certain remedies, supposed to be endowed with this property, have received the name of lithontriptics or solvents and disintegrators of stone. Much of what might be said under this head has been anticipated in the article on the different calculous deposits. It is hardly necessary to remark that a due regulation of the diet is of the first import- ance in the treatment of stone in the bladder. Without entering into details, it may be observed, in general terms, that the diet should be simple, easy of digestion, and yet sufficiently nutritious. Plainly roasted meats, boiled fish, mealy Irish and dry sweet potatoes, well-boiled rice and hominy, soda biscuit, and stale wheat bread, with weak tea, or milk and water, are, ordinarily, the most suitable articles. Coffee, wine, fer- mented liquors, cider, and subacid fruits, with pastry, and the coarser kinds of vege- tables, are to be eschewed. If the patient is feeble, or has been in the habit of employ- ing liquor, a little French brandy, or, what is better, Holland gin, may be allowed at dinner and after exercise. Gin has a specific tendency to the urinary organs, and its use is occasionally attended with good effects. Some persons are greatly benefited by hop tea, beer, or malt liquors. Generally speaking, however, these articles produce more harm than good. All kinds of hard water must be abstained from as common drink. The patient should be well clad, avoid exposure to wet and cold, and refrain from rough exercise. In the winter, he should keep himself well housed, or reside, if possible, in a warm and genial climate. Sexual excitement must be carefully guarded against, for any indulgence of this kind is always sure to be followed by an aggravation of the complaint. The urine must be maintained in as neutral a condition as possible. If it be acid, alkalies are indicated; if alkaline, acids. Frequent examinations of the fluid, are, therefore, necessary, in order that the remedies may be varied as the circumstances of each par- ticular case may render it proper. It is worthy of remark that some patients are most benefited by alkalies, others by acids, even when the urine and the stone are both appa- rently of the same character. In my own practice, I have generally derived most benefit from the use of alkaline remedies, whatever may have been the nature of the diathesis, or of the concretion. The best alkalies in the treatment of vesical calculi are sodium and potassium, in the form of bicarbonate, either alone, or variously combined with each other. I usually give the preference to the sodium, for the reason that it seems to me to exert a more obtunding effect upon the mucous surfaces of the urinary passages. The best form of exhibition is a solu- tion in a strong infusion of hops and uva ursi, in the proportion of thirty grains to the ounce, three or four times a day. The best period for using the medicine is about one hour after meals and at bedtime. Administered in this way it readily mixes with the ingesta, prevents the evolution of acidity and flatulence, and exerts a more controlling influence over the urinary secretion. The quantity of the salt may be gradually increased to forty, fifty, and even sixty grains, according to the tolerance of the stomach; and a good plan is to pretermit the use of it occasionally for a few days. Carbonate of potassium is sometimes employed alone, but its beneficial influence is always greatly enhanced by giving it in union with sodium. Liquor potassm now and then answers an excellent purpose in these cases, particularly in persons of a dyspeptic habit. It should be administered, largely diluted with water, in doses varying from twenty to forty drops, three times daily, or, what is better, under such circumstances, in combination with some of the simple bitters, as tincture of gentian, quassia, or cinchona. Some patients derive much relief from the free use of lime-water, castile soap, magnesia, or lye. Marked benefit, sometimes of a permanent character, arises from the long-continued use of certain mineral waters. Of the various waters, celebrated for their virtue of solving calculi and soothing the bladder, those of Vichy, in France, are the most remarkable, on account of the numerous cases that have been relieved by their employment. The Vichy waters contain a large quantity of free carbonic acid, and very nearly a drachm and a half of bicarbonate of sodium in every thousand drachms of the menstruum, upon the presence of which their good effects, no doubt, mainly depend. When the urine is decidedly alkaline, acids are indicated. Those usually employed are the nitric and hydrochloric, of which the former is preferable. The best form of CHAP. XVI. EXTRACTION OF CALCULI THROUGH URETHRA. 729 exhibition is the dilute nitric acid of the shops, in doses of fifteen to twenty drops, three times daily, in a third of a tumblerful of cold water, sweetened with sugar. Attempts have been made, from time to time, to dissolve urinary calculi in the bladder by means of injections of acid and other fluids; but the results have not been such as to encourage a repetition of the operation, now that the subject is so well understood. The same remark is true in regard to the effects of galvanic electricity, proposed by some French surgeon. 2. EXTRACTION OF CALCULI THROUGH THE URETHRA. The fact that small calculi sometimes escape during micturition was long ago noticed by practitioners, and has been turned to good account by modern surgeons. When it is known, for example, that a concretion has recently descended from the kidney, its expul- sion from the bladder may occasionally be effected by making the patient grasp the head of the penis, while he distends the urethra with urine; then, letting go his hold, he empties his bladder with all the force he can direct upon it by the action of the diaphragm and abdominal muscles. The water should be previously accumulated to the greatest possible extent, and, during its evacuation, the patient should lie upon his belly, or bend his body forward, to place the stone in the most favorable position for reaching the urethra. These attempts at extrusion are much facilitated by the prior dilatation of the tube by means of the metallic bougie. Efforts have been made, especially in recent times, to remove calculi entire from the bladder, through the urethra, by means of forceps. It was observed, long ago, that, during catheterism, small concretions became occasionally impacted in the eyelets of the instru- ment, which they followed upon its withdrawal. It was in this way that the late Mr. George Bell, of Edinburgh, had the good fortune to rid a patient of one hundred and fifty concretions. In performing such an operation, a full-sized catheter, with two large eye- lets, or Bigelow’s evacuating tube, should be selected, and the bladder should be previously distended with water, so that, as the fluid runs off, the calculi may have a better chance of being forced into the tube. Instruments have been constructed for the special purpose of seizing the stone, and removing it entire. Sanctorius, if not the first, was one of the earliest surgeons who busied themselves in this manner. He has described the operation with some minuteness, and has figured a pair of forceps which he contrived for performing it. Hales, Hunter, and others also invented instruments which have been greatly improved since by Sir Astley Cooper, and some of the French lithotomists. The forceps of the English sur- geon, which are represented in fig. 532, and with which he extracted upwards of eighty Fig. 532. Cooper’s Stone Forceps. small calculi from one individual, consist of two movable blades, shaped, when closed, like a curved catheter. They are introduced in the ordinary manner, and are used at first as a searcher. When the stone is found, the blades are gently separated and ex- panded over it, when, being again shut, the instrument is carefully withdrawn. An index upon the surface of the instrument serves to show the size of the calculus, or, what is the same thing, the possibility of removing it entire. When the concretion cannot be ex- tracted in this manner, it may, if not too hard or too large, be crushed, and disposed of piecemeal. In performing this operation, it is important that the bladder should be perfectly free from irritation, that the urethra be previously dilated with the bougie, and that the forceps do not pinch the mucous membrane. If these precautions are neglected, serious mischief may follow. At least one instance is on record where death ensued, although the operation was executed by a competent surgeon, and the forceps were introduced only twice. A small calculus has sometimes been entrapped and removed by a very simple proce- dure. Many years ago, an American practitioner, Dr. Calvin Conant, relieved a youth, fifteen years of age, by means of a silver wire, passed through a catheter, the vesical 730 DISEASES OF THE URINARY ORGANS. CHAP. XVI. extremity of which was pierced by two holes, about a line and a half apart. The wire, which was very fine, elastic, and twenty inches long, was formed, upon its arrival in the bladder, into a loop, which was then moved about until the concretion was found and ensnared; the ends were next secured to the shoulders of the catheter, when both the instrument and stone were withdrawn. 3. RAPID LITIIOTRITY. It is not my intention in this place to enter into the history of lithotrity, or an account of the different steps by which, from humble and unsatisfactory beginnings, the operation has attained its present extraordinary degree of perfection. To Civiale is undoubtedly due the credit of the invention as formerly practised, his first notice of the operation having been published in 1824. Gruithuisen, a Bavarian surgeon, had already, in 1813, proposed to seize and perforate the stone by drilling; and Elderton, of Scotland, in 1819, formally recommended, for the same purpose, the use of a curved lithotrite. Rapid lithotrity, litholapaxy, or crushing a calculus and washing out the fragments at a single sitting, owes its successful introduction, as an important modification of lithotrity, to two circumstances, which seemed, until recently, to have escaped the notice of surgeons, namely, first, that the urethra admits of great and rapid dilatation for the easy movements of large crushing and evacuating instruments, and, secondly, that the bladder, from having become inured to suffering in calculous disease, is much more tolerant that it was formerly supposed to be of protracted manipulation. In these two facts is involved the whole gist of the new departure. To Professor Bigelow is due the great credit of being the first to call the attention of the profession to an operation, which, in the course of a few years, has met with the general acceptance of surgeons, and which has already furnished results in the hands of different lithotritists of the most brilliant character. As the method has rendered crushing applicable to much larger stones than were formerly attacked, and as it may be practised in various morbid conditions of the bladder, which are intensified by the retention of the fragments when successive sittings are resorted to and the expulsion of the debris is left, to nature, I have no hesitation in giving it my unqualified approval. It should, however, be added that beginners should use the smallest instruments and con- fine their efforts to stones of moderate size, since, if they attempt the removal of a large and hard calculus at one sitting, the operation would be likely to be a failure and might be fatal to the patient. If, in such an event, clearance be not practicable, lithotomy should at once be performed. Instruments The instruments originally used have been replaced by the screw litho- trite, which combines several improvements, of which the most important are the curve, introduced by Baron Heurteloup, of Paris, the sliding movement, invented by Mr. Weiss, the celebrated London cutler, and the screw, suggested by Mr. Hodgson, of Birmingham, the action of which has been perfected by Charriere, Robert and Collin, Weiss, Coxeter, and others. The instrument, as now constructed, is remarkable for its simplicity, its strength, and its adaptation to the end proposed. It is composed, as seen in fig. 533, of Fig. 533. Weiss and Thompson’s Lithotrite. a shaft, sliding-rod, handle, and two blades, and is from twelve to fourteen inches in length. The shaft terminates at its distal extremity in the female blade, while its proxi- mal end constitutes the handle of the instrument. The sliding-rod, which moves in the longitudinal furrow of the shaft, and is provided, on its upper surface, with a scale for indicating the size of the stone, is curved at one end to form the male blade, while at the other is attached the power through which it is moved. In the instrument of Weiss, improved by Sir Henry Thompson by the addition of a fluted, cylindrical handle, thus admitting of great delicacy of manipulation, the crushing force is applied by means of a screw worked by a wheel. By sliding the button in the handle, the screw may be fixed or detached, thus converting the operation at once into the sliding movement, or the reverse. These actions are regulated in the instrument of Civiale by a movable disk, and by a trigger in that of Robert and Collin. In the instrument of Bigelow, which is CHAP. XVI. RAPID LITHOTRITY. 731 provided with an elongated vulcanite handle, shaped to fit the hand, the lock, represented closed and open in fig. 534, is readily closed by a quarter revolution of the cover held Fig. 534. between the thumb and index finger of the right hand, without compelling the operator to relax his hold upon the stone until it has been grasped by the blades. On this account the movement is far superior to that possessed by any other lithotrite as yet devised. In the construction and choice of a lithotrite, great attention must be paid to the blades, in accordance with the object it is designed to fulfil. For crushing large and very hard calculi, an instrument with a fenestrated female blade, fig. 535, may be required, while for friable stones, which do not exceed one inch in diameter, the lithotrite with plain blades, improperly termed the scoop, fig. 536, of which the male is narrower than the Bigelow’s Lithotrite. Fig. 535. Fig. 536. Fig. 537. Different Forms of Lithotrite Blades. female, may be employed ; the instrument with blades of nearly equal width, fig. 537, being reserved for pulverizing fragments and diminutive concretions. In the first class of lithotrites, the surface of the male blade is denticulated; in the others, it is simply roughened. Finally, the angle at which the shaft and blades is united should never exceed 120°, nor be less than 90°, the most efficient instrument, so far as power is concerned, being that in which it is somewhat greater than a right angle. Every operator should be provided with a number of lithotrites, of differ- ent forms and sizes, that he may be able, without difficulty, to adapt them to the varying circumstances of his patients. When the concre- tion is large, or uncommonly hard, the diameter of the shaft should equal 20 of the French catheter scale, while the combined lateral and antero-posterior diameters of the blades should measure 24, this ratio of difference in these parts being preserved as the instrument dimin- ishes in size. For soft and medium-sized stones, the shaft may range between 15 and 20. These dimensions are still preferred by Sir Henry Thompson, but the majority of Fig. 538. Blades of Bigelow’s Lithotrite. 732 DISEASES OF THE URINARY ORGANS. chap, xvi. surgeons now employ the larger and stronger instruments of Bigelow, which are adapted to the normal capacity of the urethra. For large and hard stones the caliber of the closed blades should be equal to from 26 to 30 of the French scale. The female blade, fig. 538, has a long, blunted toe to facilitate its passage through the urethra, while the male blade is deeply notched, and provided with a spur to drive out the debris and prevent impaction. In practised hands the fenestrated lithotrite, which has been improved by Bige- low by widening the female blade and sharpening its rim inside, as well as by curving the blades later- ally, fig. 539, to increase the grasp upon the stone, is a most useful instrument. In addition to lithotrites, the operator should be provided with a Bigelow’s or Thompson’s evacuator and tubes or catheters for ridding the bladder of the broken calculus. The simplified evacuator of Bigelow, represented in fig. 540, which may be used either with or without a retort stand, consists of a strong India-rubber bottle, fitted to a glass receiver, and provided with a tubular strainer through which the fragments fall into the receiver when the water is thrown into Fig. 539. Blades of Bigelow’s Fenestrated Lithotrite. Fig. 540. Fig. 541. Bigelow’s Evacuator, with Stand. Bigelow’s Evacuating Catheters. the bladder. The tubes, or catheters, fig. 541, the smallest of which is 25, and the largest 31, of the French scale, are either straight or curved, the former being preferable, and provided with a large opening, one side of which is prolonged with a view of rendering their introduction easy. Sir Henry Thompson uses smaller sizes, but a No. 30 is the one generally employed. Selection of Cases for Operation A proper selection of cases is a matter of the first importance in this operation, for it is not every calculus that admits of being crushed. The circumstances which are favorable to the procedure are chiefly a capacious urethra, a sound condition of the genito-urinary organs, the existence of a small, or medium-sized and comparatively soft, calculus, and good health. These conditions being present, lithotrity should be selected in preference to lithotomy for women and for males above the age of puberty, the latter operation being reserved for all cases below CHAP. XVI. RAPID LITHOTRITY. 733 that period. Stricture of the urethra, enlargement of the prostate gland, or disease of the bladder, ureters, and kidneys are obstacles only when they exist in an aggravated degree. A recent stricture, which may be overcome by dilatation or rupture, ceases to be a contraindication, while the operation is, of course, impracticable when the contraction is so great as to render the easy working of the lithotrite impossible. A soft, moderately and uniformly enlarged prostate is a complication which adds to the difficulty of seizing the concretion ; but ordinary hypertrophy of the gland becomes an obstacle only when an evacuating tube cannot be readily passed. Paralysis of the bladder is a decidedly favor- able condition, as the sensibility of the mucous membrane is usually obtunded, thereby permitting a free use of instruments. The operation is inadmissible in the sacculated bladder, in cystitis, acute and chronic, conjoined with a large calculus, in ulcerated con- ditions of the bladder, in excessive morbid sensibility of the urethro-vesical mucous membrane, on account of the great susceptibility to systemic disturbance from instru- mental contact, in morbid growths, in advanced organic disease of the kidneys, and, finally, in persons of feeble health, the subjects of a hard or large concretion. With regard to the stone itself, it may be said, in general terms, that when it is encysted, adherent, very hard, or too large to be grasped and broken, or when the nucleus consists of some foreign substance which is unsuited to crushing, the operation is contraindicated, and the concretion should be removed with the knife. The fragments of the largest cal- culus as yet removed by rapid lithotrity weighed 2066 grains, the operator being Mr. Walter Coulson. Preparatory Treatment Before operating, the system and the parts more immedia- tely concerned should be subjected to a proper course of treatment. If the general health is good, and the bladder is laboring merely under the mechanical inconvenience produced by the stone, little, if anything, will be required beyond a dose of aperient medicine, rest in the recumbent posture for three or four days, light diet, and the free use of diluent drinks. Should the reverse be the case, a more thorough preparation must be instituted. Under such circumstances, in addition to the ordinary means adverted to, it may be necessary to take blood from the arm, or by leeches from the perineum and the hypogas- tric region, especially if the patient is young and robust, and to employ the warm bath, bicarbonate of sodium with hop and uva ursi tea, and anodynes by the rectum along with wasliing out of the bladder, if there be much discharge of muco-pus. In this way an attempt is made to subdue undue irritability, and to restore the tonicity of the bladder, so as to enable it to retain a few ounces of urine. The next step is to dilate and subject the urethra to a course of preliminary training, to enable it to bear with impunity the necessary manipulations. This usually requires but a few days, and is best accomplished with a series of highly-polished steel bougies, used once in the twenty-four hours. If the meatus is unusually small, it should be enlarged with the bistoury. When the irritability of the urethra is so great that it is increased, instead of being obtunded, by the passage of instruments, as may happen in nervous, excitable persons, in whom such attempts are frequently followed by attacks of urethral fever, further interference in this direction should be desisted from, and the case reserved for cutting. Operation During the operation, which is performed under the influence of ether, the patient lies on a firm mattress, with the pelvis moderately elevated by a cushion, the thighs being separated, and the knees supported by pillows. The bladder should contain from four to five ounces of fluid, that quantity being insured by requesting the patient to retain his urine for two hours previously to the sitting, or, in the event of the organ being empty, by the preliminary injection of tepid water. The surgeon, standing on the right side of, and with his back towards the face of, the patient, in- troduces the warmed and well-oiled lithotrite into the meatus, the penis being supported as in the ordinary operation of catheterism, the shaft resting on, instead of being grasped by, the fingers, and lying horizontally across the groin, and permits it, as it is being carried towards the middle line of, and in close proximity to, the abdomen, while the penis is drawn forwards, to find its own way, as it does by virtue of its weight, to the opening in the triangular ligament, its arrival at this point being denoted by impediment to its onward progress. The handle is then changed to the vertical position, a man- oeuvre through which the beak engages in the orifice, traverses the membranous urethra, and glides on into the bladder through the prostatic portion, as the handle is depressed between the thighs. Force is inadmissible, the instrument, as it were, falling, rather than being passed, into the bladder. 734 The next step of the operation is to seize the stone. This may be accomplished in two ways. In the first method, originated by Heurteloup, the handle of the lithotrite is elevated, and while the male blade is withdrawn, the female blade is pushed forwards and pressed gently against the in- ferior fundus of the bladder, as represented in fig. 542, thereby making a conical depression, into which, and con- sequently into the separated blades, the tendency of the concretion is to fall. Should this fail, the operator endea- vors to dislodge the calculus and coax it between the blades, by imparting slight concussions to the bladder by tapping the instrument with the fingers, or slapping the pelvis of the patient, the male blade at the same time being pushed onwards. In the second mode, now generally practised, the contact of the instrument with the bladder is etfected in as gentle a manner as possible. Should the stone be felt on the introduction of the lithotrite, the jaws are inclined to- wards the opposite side, while the female blade is propelled forwards and the male blade withdrawn. Having been separated to the requisite extent, the blades are then turned towards the stone and closed. In this way, seizure is almost always readily accomplished. If the stone is not felt as the instrument enters, the jaws are maintained at the centre of the bladder, the male blade being drawn towards the ope- rator, and inclined, first, to the right side, and then to the left, and closed, the axis of the shaft remaining unaltered. Should the stone not be caught, the blades are raised from the floor of the bladder by slightly depressing the handle, opened, turned horizontally to the left, and closed. This failing, they are again brought to the centre of the bladder, separated, inclined as before to the right side, and closed. If these manoeuvres are pro- perly executed, few stones will escape detection and seizure. In enlargement of the prostate gland, in very corpulent persons, and in dealing with small concretions or fragments, the pelvis must be elevated from four to six inches, and lithotrites with short blades, in order that they may be used in reversed positions, be employed. Any of these conditions being present, the handle of the instrument is still farther depressed, and the blades, first brought into the horizontal position, inclined to the right, then to the left, and, lastly, completely reversed, the precaution being observed DISEASES OF THE URINARY ORGANS. CHAP. XVI. Fig. 542. Seizure of the Stone. Fig. 543. Civiale’s Method of Seizing the Stone behind the Prostate. to separate them before turning. When the concretion lies in a pouch behind the pro- state, the beak of the lithotrite must be turned towards the rectum, as in fig. 543, from Civiale, the male blade being maintained steadily at the neck of the bladder, while the female blade is propelled onwards. If the male blade be withdrawn, under these circum- stances, it will impinge against the stone, press it against the neck of the bladder, and thus defeat our object. Seizure having been effected, the next step of the operation is the crushing of the CHAP. XVI. RAPID LITHOTRITY. 735 stone, previously raised to the centre of the bladder, as shown in the annexed sketch, fig. 544, and firmly fixed by locking the screw and giving the handle a gentle turn. The power being gradually increased, the stone is broken into several fragments, when the male blade is disengaged, drawn back, and the latter successively attacked, without altering the central position of the instrument. When the stone is soft or small, it may readily be crushed by propelling the male blade onwards by the palm of the right hand, Fig. 544. Position of Stone for Crushing. the handle being steadily held in the left hand. In either mode, the operator continues his efforts for about ten minutes, or until the stone is obviously well fragmented, when he withdraws the lithotrite, and inserts an evacuating catheter, the caliber of which has been previously determined by examination of the urethra. The bladder having been distended with warm water, the evacuating bottle is attached to the catheter, and being alternately compressed and expanded by the hand of the operator, the return current brings with it the fragments, which fall into the glass reservoir. As the fragments become fewer, the position of the catheter must be changed ; and when they cease to fall into the receiver, and the clicks imparted to the instrument indicate that they are too large to pass, the catheter is removed, and the lithotrite, which may be one with plain blades, it' the stone be of moderate volume, is introduced. The operation proceeds in this way until the bladder is entirely cleared, which may be determined by the absence of clicks against the tube, and by thorough sounding for a possible last fragment. The time required for crushing the stone and emptying the bladder varies in accordance with the size and composition of the concretion and the skill of the operator. Bigelow has successfully prolonged the sitting to nearly four hours; but it may be said, in a general that an hour will suffice. At the completion of the operation, the bladder is washed clean, and left empty. After-treatment—The subsequent treatment must be conducted on general principles, the great object being to allay irritation, both local and constitutional. On no account should the patient be permitted to walk to his home, as in the event of his being an out- patient. Every man subjected to the operation should be treated either at his own house or in the wards of a hospital. Under opposite circumstances, I have known the worst consequences to ensue, although not in my own practice. After the operation the patient is to remain in bed for several days, warmly wrapped up, and kept upon light diet, using, however, large quantities of diluent drinks. If much pain or spasm ensue, with frequent desire to empty the bladder, a large anodyne is given, either hypodermically, by the mouth, or by the rectum, hot fomentations are applied to the hypogastrium and perin- eum, and an infusion of uva ursi and lupuline, with bicarbonate of sodium, or bromide of potassium, is administered internally. Retention of urine is relieved with the catheter. If peritonitis threaten, the antiphlogistic treatment, modified by the general condition of the patient, is carried to its fullest extent, aided by the liberal use of opium. Accidents and III Effects The accidents and ill effects of this operation are—1. Hem- orrhage. 2. Rigors and fever. 3. Retention of urine. 4. Contusion and laceration of the prostate and urethra. 5. Cystitis. 6. Perforation of the bladder. 7. Impaction of fragments of the stone in the urethra. 8. Peritonitis. 9. Purulent infection. 10. Atony of the bladder. 11. Renal irritation. 12. Orchitis. 13. Bending and fracture of the 736 DISEASES OF THE URINARY ORGANS. CHAP. XVI. lithotrite. Some of these accidents are unimportant, others serious, if not fatal. Hemor- rhage, rigors, retention of urine, cystitis, and prostatitis, should be treated upon general principles. Perforation of the bladder, although uncommon, has sometimes happened in the hands of the most skilful operators. The accident, which is a most serious one, may be caused either by the instrument itself, or by a fragment of the calculus, a sharp corner of which may, perhaps, be pressed into the coats of the bladder, as the lithotrite is withdrawn. How- ever induced, the lesion is generally rapidly followed by infiltration of urine and death. A fragment of the broken calculus may be arrested in the urethra, and, if sharp and angular, serious mischief may ensue. If it is situated far back, an attempt should be made to push it into the bladder, or, this failing, it should be removed by an incision ; but, if it has advanced considerably forward, it may be removed with a curette or with the forceps, delineated in the section on foreign bodies in the urethra. Purulent infection occasionally occurs, chiefly in old, enfeebled subjects. It is usually very stealthy in its character, and is nearly always fatal. Our principal reliance must be upon opium, tonics, and stimulants, with free incisions to afford vent to effused and pent- up fluids. Atony of the bladder, as an effect of lithotrity, occurs chiefly in old subjects, from rude and protracted efforts at crushing. The irritation thus occasioned rapidly extends to the muscular fibres of the organ, which, crippled, if not completely paralyzed, is unable to expel the urine, the retention of which becomes an additional source of suffering, both to the part and system, the great danger being from cystitis, accompanied with a low form of fever and excessive prostration. The proper remedy is the catheter with injections of hot water, in addition to the usual general measures. Renal irritation, followed by suppression of urine, is a rare, but commonly a fatal, acci- dent after lithotrity. It is most frequent in elderly, irritable persons, and is character- ized by pain in the back, a quick, frequent pulse, intense thirst, and other evidences of prostration, along with typhomania. The treatment must be supporting, the chief reme- dies being quinine, opium, and milk punch, with cupping of the loins, and the use of the wrarm bath. Orchitis, as a consequence of lithotrity, is uncommon : due to the extension of inflam- mation along the ejaculatory and deferent ducts, it is most liable to follow upon injury to the prostratic urethra, within a few days after the accident, and is to be treated upon ordinary antiphlogistic principles. Fracture of the lithotrite has occurred, but is scarcely possible in instruments as con- structed and tested at the present day. Should one of the blades be retained in the blad- der, an attempt should be made to extract it with the forceps; this failing, the organ should be opened through the perineum. Statistics and Residts as Compared with Lithotomy and Ordinary Lithotrity Of 312 cases of rapid lithotrity collected by Dr. S. W. Gross, including several of his own, 17, or 5.45 per cent., died, a ratio of mortality which is materially lessened in the hands of expe- rienced surgeons, since of 180 operations performed by Sir Henry Thompson, Bigelow*, Van Buren, Weir, and Stimson, only 5, or 3.33 per cent., proved fatal. Of 1470 examples of lithotrity, as formerly practised, and tabulated in my Treatise on the Urinary Organs, 159, or 10.81 per cent., died ; while of 13,570 lithotomies by all methods, inclusive of opera- tions in children, who are notoriously good subjects, 1549, or 11.40 per cent., perished, and the death-rate is nearly doubled in adults. These marked differences in the mor- tality of these three procedures admit of no doubt as to the one which should be selected for adult males. The comparison, however, is scarcely a fair one, since it does not rep- resent the actual state of affairs, the cases for lithotrity having been selected, while those for lithotomy have been taken irrespective of complications. For children and boys lithotomy should be the rule, crushing the exception. In this class of subjects the urethra is small, and the bladder very excitable, as well as, from its situation, unsuited to the operation, which is only permissible when the concretion is so small that it can be disposed of in one short sitting. Of 21 cases, in the hands of Guersant, 6 died, and 3 were subsequently cut. Of 62 operations at the Moscow Clinic, 6 died, and 54 recovered, in twenty-four of which only one sitting was required. Thus, of 83 cases, 12, or 1 in 7, perished. From infancy to sixteen years, 1028 cases of lateral lithotomy, collected by Thompson, show 68 deaths, or 1 in 15, while the median operation up to the age of twenty, according to Allarton, gives only 1 death in every 27 cases, or, according to Mr. Williams, of the Norfolk and Norwich Hospital, 1 in 20 for the same CHAP. XVI. LITHOTOMY. epochs of life. Of 72 cases of lateral lithotomy in children up to the age of puberty, I have lost only two. In estimating their comparative value, it is distinctly to be borne in mind that relapse is more frequent after ordinary lithotrity than lithotomy. In the practice of Thompson it occurred once in every eleventh case, and in that of Civiale in every tenth. In the Nor- folk and Norwich Hospital, on the other hand, stone recurred once in fifty-eight cases, and in the Luneville Hospital once in 116 cases of lithotomy. My own experience, which comprises one hundred and fifty-nine cases of the latter operation, has afforded me only one instance of recurrence. The frequent relapse after lithotrity is doubtless due to the fact that fragments of the broken stone are so liable to be left in the bladder, which thus become, often in a very short time, the nuclei of new formations. In lithotomy, on the contrary, the concretion is generally removed whole, while any pieces that may be split off are either extracted at the time, or they are washed away subsequently by the urine as it flows through the wound, the patency of which, for a certain time, greatly favors this mode of clearance. No statistics of relapse after rapid lithotrity have as yet appeared; but from the great care which is exercised in evacuating the last fragment, there is reason for believing that the rate will be far less than after the old procedure. The results of rapid lithotrity, like those of lithotomy, vary, no doubt, materially in the hands of different operators, according to the manner in which they select their subjects, the mode and skill with which they execute their manipulations, and the attention which they bestow upon the preliminary and the after-treatment. All things considered, the conclusion is inevitable that the procedure, in skilled hands, is decidedly more safe and satisfactory than lithotomy. 4. LITHOTOMY. Lithotomy may be performed at any period of life, even in early infancy. Experience, however, has shown that the greatest number of recoveries takes place in children and in elderly subjects. Young adults and middle-aged persons are more prone to suffer from inflammation of the urinary apparatus, and perhaps, also, from erysipelas of the wound, and phlebitis of the neck of the bladder and prostate gland. When a patient is about to undergo lithotomy, he should be subjected to a certain de- gree of preparatory treatment, in order to place him in the best possible condition to bear the shock and other effects of the operation. There is no doubt that much of our success depends upon the manner in which this is done. When the patient is in good health, he will seldom require anything more than a dose or two of aperient medicine, and abstinence from animal food, with rest in his room. Four or five days will, in fact, generally suffice to put him in a proper condition for the operation. But it is very different when he is in bad health ; for then a more thorough course of preparatory measures is necessary. The secretions must be rectified, the bowels opened by mercurial and other cathartics, the diet regulated, and, in a word, all sources of excitement, local and constitutional, removed. Too much preparation, however, must be avoided. All serious lesions of the heart, lungs, kidneys, ureters, bladder, prostate gland, and other of the more important viscera, forbid interference. Lateral Operation.—Of the different operations for stone, the lateral, originally devised, as is supposed, by Peter Franco, introduced into France by Frere Jacques de Beaulieu, and perfected by Cheselden in the early part of the last century, is by far the most im- portant, not only on account of its greater frequency, but also of the remarkable success which has hitherto attended it. In the description which I am about to give, I shall speak of it as I am myself in the habit of executing it, premising that this does not differ, in any essential particular, from the method devised and so happily practised by the great English lithotomist and his disciples. The design of the lateral operation is to make an opening on the left side of the peri- neum, extending from the surface of the skin through the neck of the bladder and the prostate gland, and large enough to admit of the easy extraction of the foreign body. It may be described as consisting of three steps or stages. In the first, the surgeon divides the skin, the connective tissue, and the superficial fascia ; in the second, the transverse muscle, the triangular ligament, and the membranous portion of the urethra; and, in the third and last, the prostate gland and the neck of the bladder. The wound made in the operation may be said to represent a truncated cone, the apex of which corresponds with the neck of the bladder, and the base with the surface of the 738 DISEASES OF tfHE URINARY ORGANS. CHAP. XVI. perineum. In the adult, its extent externally varies from two and a half to three inches and a half, while internally it does not, as a general rule, exceed fifteen or eighteen lines. Its superior angle is an inch and a quarter above the verge of the anus, and immediately on the left side of the raphe of the perineum ; the inferior, on the contrary, is usually about three-quarters of an inch to an inch below the anus, and a little nearer to the tuberosity of the ischium than to the outlet in question. The inner wall of the wound corresponds with the middle line of the perineum ; the external, with the ramus of the ischium and the erector muscle of the penis. The evening before the operation, a brisk purgative is administered, to clear out the alimentary canal. The article which I usually select for this purpose is castor oil; but if the secretions are disordered, as indicated by the state of the tongue and stomach, a com- bination of calomel and rhubarb, with a few grains of jalap is to be preferred. If the rec- tum has not been thoroughly evacuated, a stimulating enema, consisting of tepid salt water, is thrown up a few hours before the operation. It is of paramount importance, both as it respects the safety of the lower bowel, and the comfort of the surgeon, that this precept should be faithfully attended to. Moreover, by opening the bowels freely, im- mediately before the operation, there will generally be no necessity for any purgative medicine for some days after. The urine should be retained for several hours before the operation, as a certain degree of distension of the bladder is necessary to prevent injury of its walls, and facilitate the extraction of the foreign body. If, as in the case of a child, the patient cannot hold his water without great difficulty, a piece of tape should be tied loosely around the penis, otherwise he will be sure to disobey an injunction which every lithotomist must regard as of no little consequence. In old subjects, affected with excessive irritability of the blad- der, and with a constant desire to micturate, a full anodyne should be given several hours before the operation. If this do not suffice, a few ounces of warm water should be in- jected into the organ immediately after the patient is placed on the table. During the operation the patient lies upon his back, on a narrow table, about four feet in length, with stout, firm legs, to prevent it from shaking. It is covered with a folded blanket, over which are spread, first, a piece of soft oil-cloth, and, next, a folded sheet. Several pillow’s are required for the head and shoulders, which, however, should be but slightly raised, otherwise the abdomen will be doubled up, and thus unduly com- press the bladder. The breech is fully exposed to the operator, and is, therefore, brought well down over the edge of the table. If an anaesthetic be used, there will be no necessity for tying the hands and feet ; other- wise they should be secured by two stout worsted bands, from six to eight feet in length by tw’o inches and a half in width, with a hole in the middle to afford greater security against their slipping ; or they may be arranged as in fig. 545. As a preliminary step, the patient, stripped to his shirt, and placed upon the table, is desired to grasp his feet in such a manner as to apply his fingers to the sole and the thumb to the instep, in which position they are confined by means of the fillets, passed around them in the form of the figure 8, the ends being tied in a double knot, or fastened wdth stout pins. This duty is generally confided to the assist- ants, for which reason it is often discharged so badly as to be followed by much delay and annoyance, the patient, perhaps, becoming untied during the operation. A careful supervision should, therefore, always be exercised in this respect by the surgeon. The limbs, wdiether bound or not, are given in charge of two assist- ants, w’ho, one standing on each side of the patient, place one hand upon tlie top of the knee, and the other beneath the sole of the foot. When the operation is about to be commenced, the thighs are moder- ately separated from each other, and held nearly at a right angle with the trunk. It can easily be perceived how important it must be, as it respects the speedy and successful execution of the operation, that the patient’s limbs should be thoroughly controlled, and out of the surgeon’s way. It is usually recommended that the staff should be introduced previously to the ligation of the patient; but to such a procedure I am altogether averse, because it is productive of serious annoyance to the patient, and is almost sure to be fol- lowed by a premature escape of the urine. Besides, it is a source of inconvenience to the persons who have charge of the limbs. My rule, therefore, ahvays is to attend to these matters first, and to introduce the staff immediately afterwards, taking care to confide it to a Fig. 545. Lithotomy Bandage. CHAP. XVI . LITHOTOMY. 739 good, intelligent assistant, one who is thoroughly acquainted with the anatomy of the pelvis, and the different steps of the operation. A poor staff-holder is a great nuisance; for he often excessively embarrasses the surgeon, and makes him commit blunders which he might otherwise avoid. During the opeiation, the instrument is to be held almost perpendicu- larly, with the handle nearly at a right angle with the trunk, and inclined slightly towards the right side. The curved portion, securely lodged in the bladder, is hooked up closely against the pubic symphysis. The object of this advice is to prevent the instrument from pressing upon the rectum, which would otherwise be in danger of being wounded. By inclining the handle of the staff a little towards the right groin, the curved portion is made to bear against the left side of the perineum, with the effect of rendering it somewhat prominent and thereby facilitating the division of the membranous portion of the urethra. The assistant having charge of the instrument stands on the left side of the patient, in order that he may use his right hand, and he also holds the scrotum out of the way. The staff which I am in the habit of using, is represented in fig. 546. It is shaped like an ordinary silver catheter, and is about ten inches in length exclusive of the handle, Fig. 546. Grooved Staff. which should be at least three inches long, by two lines and a half in thickness and fifteen lines in width, with a very rough surface, that it may be the more securely held in the hand. The groove, placed a little towards the left side, and extending from near the middle of the instrument down to its beak, should be perfectly smooth, and as deep and wide as possible. The instrument, warmed and oiled previously to its introduction, should be large enough to distend the urethra to as great a degree as may be compatible with the patient’s comfort. By adopting this advice, it will be comparatively easy to find the groove of the staff, and to effect, in a safe and proper manner, the division of the neck of the bladder and the prostate gland. The surgeon, during the operation, sits upon a low, firm chair, or stool, as he may find it most convenient ; or he may place himself, as I usually do, in the half-kneeling pos- ture, resting upon the right knee. I generally prefer this posture, because it affords greater freedom to my hands and elbows. A piece of old carpet, or a sheet, is laid upon the floor, under the patient’s breech, to receive the fluids. Fig. 547. Lithotomy Knife. The knife which I have, for many years, been in the habit of using is the one sketched in fig. 547 ; it is of simple construction, very light and slender, sharp-pointed, and nearly seven inches in length, of which three are occupied by the blade, which hardly exceeds Fig. 548. Beaked Knife. two lines in width. With this instrument, the lateral operation may be safely and expe- ditiously executed in all its stages. For enlarging the opening in the prostate and neck of the bladder, after the withdrawal of the staff, I sometimes use the probe-pointed bis- 740 DISEASES OF THE URINARY ORGANS. CHAP. XVI. toury, delineated in fig. 548, although the sharp-pointed is quite as safe, provided the extremity is carefully guided along the index-finger as it lies in the bottom of the wound. Everything being thus prepared—the bowel cleared out, the instruments arranged on the tray, the limbs tied and held out of the way, the staff in the bladder and in the hand of the assistant, the breech projecting over the table, and the patient fully under the influence of an anaesthetic—the operator is ready to begin. Introducing the index- finger, well oiled, into the rectum, to induce it to contract, and to enable him to ascer- tain the position of the staff, and marking with his eye the situation of the tuberosity of the ischium he stretches the integument of the perineum with the thumb and finger of the left hand, and commences his inci- sions. The knife is entered just at the edge of the raphe, on the left side of the perin- eum, an inch and a quarter above the mar- gin of the anus, and is carried obliquely downwards and outwards, a short distance below the tuberosity of the ischium, and a little nearer to this point than to the anus, as shown in fig. 549. If the part is unusu- ally full, the instrument is plunged at the first stroke to the depth of at least one inch ; otherwise it must be used more cautiously. As the knife descends, it is gradually with- drawn from its deep position, so as to give the wound a sloping appearance. The length of the incision must be regulated by the size of the perineum and the age of the patient ; but, in the adult, it should not, in general, be less than two and a half to three inches. In the young subject, it must, of course, be proportionately smaller. Placing the point of the left index finger in the upper angle of the wound, the knife is reentered just by the side of it, and is made to divide, by repeated touches with its edge, the deep connective substance of the perineum, the transverse muscle, an.d a portion of the triangular ligament, with a few of the fibres of the elevator muscle of the anus. The membranous portion of the urethra being thus exposed, a little in front of the pro- state gland, the surgeon feels for the groove of the staff, at the bottom of the wound, and cuts into it through the denuded tube, the finger-nail serving as a guide to the point of the knife, as in fig. 550. The length of the opening in the urethra need not exceed the third of an inch. The knife, inserted into the groove of the staff, through the opening in the urethra, is now carried on into the bladder, dividing, as it proceeds, the neck of the organ and the left lobe of the prostate, in a direction obliquely downwards and outwards, which is in that of its long axis. In executing this step of the operation, the rectum is to be held out of the way, by pressing it over towards the right side with the left index-finger, which should be steadily kept in the bottom of the wound, from the moment of the first incision. Great care should also be taken not to prolong the incision in the prostate gland too far back, for fear of penetrating the reflection of the pelvic fascia and the adjacent venous plexus. As soon as the bladder has been opened, the urine generally escapes in a gush ; the knife is now removed, and the finger, lying in the bottom of the wound, is placed in contact with the staff, which is immediately withdrawn. The urine, as it passes off, commonly forces the calculus down against the artificial opening, so as to afford the surgeon an opportunity of ascertaining its form and bulk. When it fails to do so, the finger is carried into the bladder to its full length, and used as a searcher. If the stone is found to be disproportionately large, the wound must immediately be dilated, either with the finger or the bistoury, according as the resistance may seem to depend upon the prostate or the muscular structures. In elderly subjects, the instrument will generally be necessary, as the gland is not sufficiently lacerable to yield to pressure. Fig. 549. Lateral Operation for Stone. Fig. 550. The Finger and Knife in the Groove of the Staff. CHAP. XVI. LITHOTOMY. 741 1'he incisions being completed, the next step of the operation is to extract the calculus. This is done with the forceps, fig. 551, conveyed into the bladder along the upper surface Fig. 551. Lithotomy Forceps. of the index-finger, as it lies in the bottom of the wound, in contact with the foreign body. The forceps are introduced with the blades closed, and are used at first as a searcher. As soon as they are brought in contact with the concretion, the blades are expanded over it, in the direction of its long axis, with a firm grasp, as seen in fig. 5o2, to prevent the risk of slipping. Taking care that the instrument does not embrace any of the folds of the mucous membrane, the operator extracts the foreign substance by gently moving the forceps from side to side, or upwards and downwards, on the same principles as in the delivery of the child’s head. The facility with which the stone may be seized depends upon circum- stances. In general it lies in contact with the inner extremity of the wound, and may readily be caught in the embrace of the blades of the instrument. Some- times, however, as when it is lodged in the bas-fond of the organ, it refuses to come down, and may thus embarrass the operator. The difficulty, as will be particularly mentioned here- after, is easily remedied by inserting the finger into the rectum, and pushing the concre- tion forwards against the forceps. When the stone is situated in the superior fundus of the bladder, the forceps must be carried high up, in the direction of the long axis of the pelvis, where they are to be moved about as a searcher. Occasionally it lies behind the pubic symphysis, and cannot be seized until it has been dislodged by pressure upon the inferior part of the hypogastric region, aided by the finger in the bladder. Fig. 552. Mode of Introducing the Forceps and Seizing the Stone. Fig. 553. Lithotomy Scoop. If the calculus is very small, it is sometimes more easily extracted with the scoop, fig. 553, than with the forceps. The same instrument should be used when the concretion has been broken, whether accidentally or designedly, into fragments, which must then be removed piecemeal. The scoop is about ten inches in length, and is shaped, as its name indicates, at each extremity, like a spoon, or, instead of this, one end is provided with a 742 DISEASES OF THE URINARY ORGANS CHAP. XVI. suitable handle. An instrument like this may be made very serviceable in extracting an adherent, encysted, or impacted concretion. The mode of grasping and holding the stone is exhibited in fig. 554. As soon as the foreign body has been extracted, the bladder is washed out with tepid water, thrown up in a full stream from a large syringe. Any pieces or frag- ments that may have escaped the forceps or scoop are thus removed ; otherwise, there will almost certainly be a return of the calculous affection, the smallest particle frequently serving as a nucleus for a new concretion. The bladder having been washed out, a female sound is next introduced through the wound into the interior of the viscus, with a view of ascertaining whether any stones or fragments have been left behind. Should this be the case, the forceps, scoop, and syringe are again used until complete clearance is effected. In general, when the stone is rough, it is an evidence that it is solitary ; but to this rule there are occasional exceptions. The operation being finished, the patient is conveyed to his bed, a piece of soft oil-cloth and a folded sheet being placed under his breech, to absorb the urine and protect the clothing. Although the left side of the perineum is usually selected in performing this operation, circumstances may render it necessary to cut on the right side. Thus, in a case which occurred in the practice of Professor Pope, of St. Louis, a vicious projection of the thigh, caused by ankylosis of the hip-joint, offered an effectual barrier to the left lateral section ; and in an instance recorded by Zeiss, a similar course of procedure was necessitated by the occupation of the left side of the perineum by a congenitally displaced testicle. Extent of the Incision of the Prostate The wound should in no instance, however bulky the stone may be, extend entirely through the lateral lobe of the prostate, on account of the danger of urinary infiltration. When the concretion is very voluminous, it should either be broken, and extracted piecemeal, or, what is better, the opening should be enlarged by incising the opposite half of the gland. If this do not afford sufficient room, the calculus should be crushed. In ordinary cases, I incise the organ only to a very limited extent, and immediately after enlarge the opening with the finger, the pressure of which is generally amply sufficient for the purpose. When it is not, a probe-pointed bis- Fisc. 554. Scoop and Finger Grasping the Calculus Fig. 555. Left Lobe of the Prostate, as it is Divided in the Lateral Operation, a. Marks the Incision of the Membranous Portion of the Urethra and the Side of the Gland, b. The Left Lobe of the Prostate, b*. The Eight Lobe of the Organ, c. The Bulb of the Urethra. Close behind are observed Cowper’s Glands, d, d. The Crura of the Penis. e, e. The Seminal Vesicles. /,/. The Deferent Ducts, g. The Ureter of the Left Side. toury is used as a substitute. In old subjects, with induration and enlargement of the gland, the division is generally obliged to be effected with the instrument. The outer wound, on the other hand, should always be ample and dependent. The direction and extent of the incision in the prostate gland are represented in fig. 555, from Scarpa. In children from eighteen months to ten years, if, indeed, not until a considerably later period, the prostate is so small as to render the introduction of the finger and the CHAP. XVI. LITHOTOMY. 743 forceps into the bladder, and, consequently, the extraction of the calculus, however diminu- tive, impracticable without the division of the gland in its entire length. I am quite sure that this has happened in all my operations, seventy-two in number, and yet I have never met with a solitary instance in which the procedure was followed by infiltration of urine. The annexed drawings, tigs. 556 and 557, copied from personal dissections, exhibit the size and shape of the prostate at four and twelve years. Beyond the fact here mentioned, lithotomy in the child presents nothing peculiar. The operation is generally one of the most easy and simple in surgery. My practice now in- variably is to make a small external incision, and, after opening freely the membranous portion of the urethra, to divide the prostate gland and neck of the bladder in great degree with the finger. This can always be done with the greatest facility, as these structures, at this period of life, are re- markably soft and lacerable. To prevent the knife from passing into the connective substance between the bladder and the rectum, the index finger should be kept in close contact with the upper part of the wound, just below the arch of the pubes, otherwise the instrument may wander away from the staff, and thus lead to the idea that the bladder has been penetrated, when, in reality, it has not been opened at all. The staff should not be withdrawn until the surgeon is well assured that the finger is fully in the organ, or, what is still better, in con- tact with the stone. Extraction is usually easily effected, either with the forceps or the scoop. Difficulties of Extraction Difficulty frequently occurs in the extraction of the stone. This may depend, 1st, upon the stone itself; 2d, upon the bladder; 3d, upon the pelvis, and 4th, upon the use of defective instruments. 1st. The impediment may be caused by the lodgment of the stone in the bas-fond of the bladder, which, especially in elderly subjects with enlarged prostate, is sometimes con- verted into a deep cul-de-sac. The remedy is to raise the stone up, and place it within reach of the instrument, with the left index-finger, inserted in the rectum. When the stone lies above the pubes, it is to be dislodged, while compression is made upon the hypogastrium, with a strong probe, bent into a hook, or it may be drawn down with the index-finger. 2d. The stone may be entangled in the folds of the mucous membrane, or spasmodic- ally grasped by the bladder, which may thus prevent the expansion of the blades of the forceps. In the former case the scoop replaces the forceps, or, if this fail, dislodgment may be attempted by throwing cold water into the bladder, in a full stream, from a large syringe. Spasm rarely, if ever, occurs when an anaesthetic is used. 3d. The stone may be encysted. When this is the case, the finger is introduced into the bladder and the cyst ruptured with the nail, or a long knife, fashioned like a gum lancet. Embarrassment may be occasioned by the presence of a pouch between the bladder and the rectum. 4th. It may be difficult to seize the stone on account of the great depth of the perineum, which is sometimes upwards of three inches. 5th. The stone, under the grasp of the forceps, may break into numerous fragments, be reduced to a soft, pulpy mass, or be crushed into small sandy particles. Clearance is effected with the forceps, scoop, or syringe. 6th. Delay and inconvenience may arise from the presence of a considerable number of calculi, necessitating the frequent introduction of the forceps. 7th. The manner in which the stone is grasped may occasion difficulty. When there is reason to believe that it has been seized by its transverse diameter, the finger should at once be introduced into the wound to ascertain the fact, and to effect the necessary change. Before this can be done, however, the forceps must relax their hold upon the calculus, although there will be no need of withdrawing them. 8th. Embarrassment occasionally results from an inability to find the concretion. J his may depend upon some of the causes already detailed; or it may be owing to the expul- sion of the stone, especially if it is of small volume, at the moment of completing the section of the bladder and of the prostate gland. 9th. Serious impediment sometimes arises from the great bulk of the stone. When this is the case, the extraction is to be accomplished either by simply enlarging the wound, if Fig. 556. Fig. 557. Prostate at Pour Years. Prostate at Twelve Years. 744 DISEASES OF THE URINARY ORGANS. CHAP. XVI. this has not already been done, to the utmost permissible limits, with the probe-pointed bistoury; by incising the right lobe of the prostate to the same extent as the left; or, finally, by breaking the concretion, and removing it piecemeal. Crushing will generally be necessary when the stone is unusually bulky, and for this purpose I know of no better instrument than that represented in fig. 558. It is con- Fig. 558. Fig. 559. Stone-crusher. strueted upon tlie principle of an ice-masher, and does its work very effectually. The blades should be at least four inches in length. The instrument illustrated in fig. 559, combining the crusher with the drill, affords, if possible, a still more powerful means of breaking the stone; but, unfortunately, the use of all such contri- vances is generally the death-knell of the patient, whose chances of recovery are always greatly lessened when it is necessary to resort to such an expedient. The bladder is sure to be severely bruised, the bleeding is often great, and the constitution is always seriously affected. Hence the best plan is, when the stone is uncommonly large and hard, to remove it by the suprapubic opera- tion. With the view of facilitating the extraction of large concretions, Sir William Fergusson proposed to combine a semilunar external incision with lateral section of the prostate, and Mr. Henry Lee practises a superficial in- cision, which, commencing in the raphe, extends through the posterior half of the perineum to two or three lines in front of the anus, from which it is carried outwards and backwards so as to embrace one-fourth of the circumference of the bowel, the operation being completed as in the ordinary lateral method. These so-called improve- ments are, in my judgment, steps in a retrograde direction, since the free external incisions retard recovery, while they do not afford a larger opening for the passage of the stone at the points where resistance is encountered, namely, the neck of the bladder and the pros- tate gland. 10th. Extraction may be rendered difficult by the existence of a tumor of the prostate gland, especially if situated along the middle line, as has happened in two cases in my own hands. The occurrence is limited to elderly subjects, and the only thing that can be done is to pinch or twist off the offending growth with the forceps, a procedure which is nearly free from hemorrhage, and does not interfere with the patient’s recovery. 11th. Embarrassment of a very serious, if not an insurmountable, character, may arise from unusual narrowness of the pelvis. Such a defect occasionally exists in children, especially rickety ones, but is most common in elderly men, and always necessitates additional care in the use of the forceps, particularly when there is an unusually large calculus. 12th. The calculus occasionally coexists with calcareous incrustation of the surface of the bladder. The proper procedure is, first, to extract the stone in the usual manner, and then to remove the deposit with the forceps, scoop, and finger, aided with the syringe. Lastly, calculi of large size, weighing ten, twelve, and even fifteen ounces, have occasionally been successfully extracted. Most generally, however, the patient dies either from exhaustion during the operation, or a short time after from the effects of inflammation. Lithotomy Crusher and Drill for larger Calculi. CHAP. XVI. LITHOTOMY. 745 Accidents—The accidents that are most liable to occur, during and after the lateral operation, are hemorrhage, prostration, retention of urine, undue inflammation of the wound, cystitis, injury of the prostate gland, urinary infiltration, peritonitis, tetanus, lesion of the rectum, ischuria, incontinence of urine, impotence, perineal fistule, orchitis, and explosion of preexisting disease. 1. Hemorrhage—The hemorrhage after perineal lithotomy is usually very slight, not exceeding two or three ounces. It may be arterial or venous, primary or secondary. Its principal sources are the artery of the bulb and the superficial artery of the perineum. In old subjects, a copious flow of blood occasionally proceeds from the veins of the neck of the bladder and of the prostate gland. The pudic artery, in its natural course, can hardly be wounded posteriorly; anteriorly, however, it is more exposed, and, therefore, in danger of being injured. The accident is most likely to happen when the prostate is divided with the gorget, or the lithotome cache. The artery of the bulb sometimes bleeds profusely; and from its deep position, and the readiness with which it retracts, is always secured with difficulty. A case in which death resulted from its division is recorded by Dr. Kerr, in the Edinburgh Medical and Surgical Journal for July, 1847, and examples of a similar kind have been reported by other surgeons. A tremendous gush of blood sometimes proceeds from the transverse perineal artery. The bleeding generally follows the first incision, and should immediately be arrested with tbe ligature. The superficial perineal artery is seldom cut; when it is the bleeding is usually insignificant. When the affected vessel is deep-seated, the blood, instead of escaping externally, may pass into the bladder, where it is either retained, or expelled from time to time in thick clots. The organ, in the latter case, forms a hard, solid tumor, which is more or less tender on pressure, and which may mount as high up as the umbilicus. The expulsion of the clots is attended with violent spasm and tenesmus, bearing a close resemblance to labor pains. , When the bleeding vessel is accessible, tbe proper means for arresting the hemorrhage is, of course, the ligature. When it is very deep-seated, it may generally be readily seized with Physick’s artery forceps, delineated in fig. 560, the edges of the wound being Fig. 560. Physick’s Forceps. separated with retractors, the fingers, or a pair of lithotomy forceps. When the artery is situated very far back, at the neck of the bladder, or by the side of the prostate gland, it may be extremely difficult, if not impossible, to ligate it. To meet this contingency, I devised, many years ago, a pair of forceps, which, after having grasped the artery, may be permanently retained, by unscrew- ing its handle, until all danger from hemorrhage is over. The instrument is represented in fig. 561. Compression may be resorted to, when it is impossible to use the liga- ture, acupressure, or torsion. A canula, fig. 562, consisting of silver, or hard rubber, four inches and a half long by four lines in diameter, open at the vesical extremity, provided with two large eyelets, and surrounded with a chemise,is inserted into the bladder, previously emptied of clots, when the chemise, fig. 563, is tightly plugged with charpie, tow, or cotton. The instrument is then secured by means of pieces of tape to a double T-bandage, and answers the twofold purpose of conducting off the urine, and compressing the bleeding vessels. It should be retained for several Fig. 561. Arterial Compressor. Fig. 562. Canula for Plugging the Wound in Lithotomy. 746 DISEASES OF THE URINARY ORGANS. CHAP. XVI. days, or until there is reason to believe that all danger of hemorrhage is over. Professor Campbell, of Georgia, prefers a slightly curved to a straight canula, believing, from experience, that it adapts itself better to the curve behind the neck of the bladder. When no such instrument is at hand, a female catheter, a piece of reed, or the spout of a tin coffee pot, may be used as a substitute. Plugging of the wound is particularly necessary when the hemorrhage proceeds from enlarged and varicose veins at the neck of the bladder and prostate gland, or when the blood oozes from a great many small arteries, too minute to be tied. The operation, of course, always interferes with the union of the wound. Another contrivance, one which should always be at hand during this operation, is the India-rubber bag,fig. 564, introduced into practice by Mr. Buckstone Brown, of London. In- flated with air, it powerfully com- presses the bleeding vessels, and is especially serviceable in capillary oozing and in venous hemorrhage. Guyon’s canula, represented in fig. 565, also answers well. Compression may sometimes be advantageously employed by the finger in the rectum, as in an instance related by Marjolin. The patient, a child, bled obstinately after the operation, but the flow was effectually stopped by maintaining the compres- sion in this manner for three-quarters of an hour. Applying the finger directly to the bleeding vessel generally answers a much better purpose, and may readily be maintained for many successive hours by a relay of assistants. Fig. 563. Chemise. Fig. 564. Brown’s Tampon. Fig. 565. Guyon’s Tampon. Styptics are sometimes useful, especially in deep-seated venous hemorrhage, the best articles for the purpose being hot water, alum, Pagliari’s styptic, and subsulphate of iron, especially the latter, which, in fact, is the only reliable one. In cutting, not long ago, a man, sixty-four years of age, with great enlargement of the prostate gland, the blood oozed from numerous points more freely than I had ever witnessed before, but was instantane- ously checked upon the introduction into the wound of a soft sponge wet with a saturated solution of Monsel’s salt. The plug was removed three days afterwards, without any recurrence of the bleeding, or material interference with the healing process. The actual cautery can seldom be required. Occasionally the hemorrhage is promptly arrested by directing a concentrated stream of cold water from a syringe upon the bleeding spot. Exposure of the wound to the cold air, and keeping it free from clots, is also sometimes highly beneficial. Secondary hemorrhage generally takes place as soon as reaction is established, or the patient has recovered from the shock of the operation. The means already pointed out will usually be sufficient to arrest it. 2. Sinking.—Few patients, at the present day, suffer seriously from shock in this operation. Should such an event arise, as it may when there is great debility, or rough CHAP. XVI. LITHOTOMY. 747 and prolonged manipulation, especially in very young children and elderly subjects, stimulants must be employed, with the precaution of preventing overexcitement during reaction. 3. Retention of Urine—This may be caused by inordinate tumefaction of the wound, and spasm of the urethra; or, as more frequently happens, by closure of these passages by coagulated blood. In the former case relief is afforded by the catheter; in the latter, by clearing away the blood, and preventing further hemorrhage. 4. Inflammation of the Wound—It is seldom that the wound takes on undue inflam- matory action after such an operation. The occurrence will be most likely to supervene within the first forty-eight hours. The action is sometimes erysipelatous, and is then apt to spread. The treatment must be strictly antiphlogistic, combined with gently supporting measures, if there be any tendency to prostration. 5. Phlebitis—This disease occasionally occurs after this operation. It is most fre- quently met with in elderly subjects. The treatment, although antiphlogistic, is conducted cautiously, and with a due regard to the state of the system. When the phlebitis attacks the extremities, the most appropriate local remedies are leeches, fomentations, iodine, and blisters, followed by free incisions to afford vent to effused and pent-up fluids. The system must be supported by anodynes and stimulants. Venesection is inadmissible; and mercury, except in so far as it may tend to correct the secretions, is of no use. After the violence of the inflammation has subsided, the limb should be bandaged; and, as soon as the patient can move about, change of air should be advised. 6. Cystitis.—Slight cystitis is by no means uncommon after this operation, setting in within the first few days, and manifesting itself by a frequent desire to urinate, with more or less spasm, a sense of weight, and bearing-down pains. The most suitable remedies are hot applications to the perineum and hypogastrium, diluent drinks, and liberal doses of morphia. When the inflammation is urgent, local and general bleeding may be required. In some cases the inflammation, instead of attacking the bladder, invades the connective tissue between this organ and the rectum, and soon terminates in extensive suppuration, or the formation of abscesses. This occurrence is usually associated with serious renal disease, and generally ends fatally in from three to four weeks after the operation. 7. Lesion of the Prostate Gland This gland may be gravely injured in this operation, either by the forceps, or by the calculus. The most common occurrences are laceration and contusion, which may be so great as to be followed by severe inflammation, if not by gangrene. When the stone is very large, rough, or angular, such accidents are not always avoidable, although they are certainly infrequent in the hands of skilful lithotomists. The treatment must be conducted upon general antiphlogistic principles. 8. Perforation of the Bladder.—Perforation of the bladder by the staff during the per- formance of this operation has been noticed as an occasional occurrence, due, as is supposed, to the great softening which the coats of this organ sometimes undergo in cases of great and protracted suffering, reducing them almost to the consistence of wet paper. Of 78 cases of lateral lithotomy in the hands of Sir Henry Thompson, reported to 1878, this accident took place in 2. 9. Urinary Infiltration One of the most dangerous effects of lithotomy, but, fortu- nately, one of the most infrequent, is an escape of urine into the connective tissue of the perineum, or of the perineum and the parts immediately around the neck of the bladder. Its occurrence is favored by too extensive a division of the prostate gland; by the small size of the wound, or by its being too conical and sloping; by the early and inordinate tumefaction of the cut surfaces ; and, above all, by the perforation of the reflected portion of the pelvic fascia. The attack usually comes on within a short time after the operation, and often runs its course with frightful rapidity. Little can be done to arrest the progress of this affection when once established. De- pletion by the lancet and by purgatives is wholly inadmissible. The system is to be sustained by such remedies as carbonate of ammonium, quinine, iron, camphor, and capsicum, in combination with the liberal use of brandy and opium. The best topical means are saturnine and anodyne fomentations, medicated cataplasms, injections of a weak solution of nitric acid or chlorinated sodium, and touching the whole track of the wound as early as possible with nitrate of silver, or tincture of iodine. When the infiltration is caused by the small size, ill shape, or improper direction of the wound, the defect must be remedied with the knife, to afford a free outlet for the urine. Leeches and hot fomentations may be applied to the hypogastric region. 748 DISEASES OF THE URINARY ORGANS. CHAP. XVI. 10. Peritonitis Peritonitis seldom follows the lateral operation, but is occasionally observed as a consequence of the high. Sir Henry Thompson asserts that this occurrence is much more frequent in children than in adults, and that, in them, it constitutes one of the chief sources of danger. As for myself, I have not noticed anything of the kind; indeed, I have met with peritonitis only in a single instance, after the lateral operation in 159 cases. Much of the danger of peritonitis will, it may be presumed, depend upon the manner in which the operation is performed. The treatment must be prompt and vigorous. Blood should be taken by the lancet, or, if this be inadmissible, by leeches from the hypogastrium, succeeded by anodyne fomenta- tions. The bowels are thoroughly confined with opium, and the pulse is kept down with aconite and other depressants. 11. Pyemia Pyemia is probably of more frequent occurrence after this operation than is generally supposed. In 186 cases of lithotomy, analyzed by Mr. Smith, of Leeds, 4 perished from this cause. I have myself met with pyemia only once in all of my cases. The patient was a boy, three years old, who, although everything went on most favorably for the first week, died on the twenty-eighth day from numei’ous little abscesses in the left kidney. The wound itself was nearly healed. Pyemia, as an effect of lithotomy, is most liable to occur in broken-down persons, especially if the stone is of great size, or if the operation is unusually protracted, painful, or bloody. The disease, generally announced by more or less violent rigors, followed by copious sweats and rapid prostration, may set in within the first twenty-four hours, although seldom so early, and usually ends fatally in less than a week. The structures which are most liable to suffer from abscesses are the kidneys, lungs, liver, joints, and connective tissue. The treatment, which is seldom of any avail, is supporting, milk punch, quinine, and anodynes being the chief means. 12. Tetanus This occurs very rarely. The proper remedies are anodynes and anti- spasmodics, aided, if there is unusual debility, by quinine and alcoholic stimulants. Chloro- form is a valuable adjuvant, when there is much suffering in controlling muscular action. 13. Wound of the Rectum Such an accident may happen in the hands of the most skilful surgeon, but will not be likely to do so if the proper precautions are taken in per- forming the operation. The opening, which is generally situated immediately in front of the neck of the bladder, soon begins to diminish, and usually closes in a few weeks. Some surgeons seem to regard this accident as of little moment. Several years ago a gentleman, who then stood high in the profession, said, in my presence, in conversing upon the subject, that he had opened the bowel not less than three or four times in twenty operations without any serious consequences. Sir William Fergusson, in 1865, publicly stated that the accident had happened to him repeatedly, and that he considered it of no particular importance as it respects the final result of the case. Cheselden wounded the rectum twice, and Deschamps four times. The accident also occasionally occurred to Frere Come. Sir Henry Thompson, in 1878, frankly asserted that he had wounded the rectum in 4 out of 78 cases. Now, although a wound of the rectum does not endanger life, or, perhaps, even materially interfere with recovery from the immediate effects of the operation, yet such an occur- ence is not only “ a blot in the operation which should be avoided,” but it may render the patient miserable for life by entailing upon him a permanently incurable rectovesical fistule, as I have had occasion to witness in not less than five cases in the hands of other surgeons. The treatment consists in preventing the bowels from acting, except every third or fourth day, by means of anodynes, in washing out the rectum frequent!}' with warm or cold water, as may be most grateful, in permitting none but the most bland and simple food, in enjoining strict recumbency, in the constant retention of the catheter, and in touching the edges of the wound every third or fourth day very gently with solid nitrate of silver, or a weak solution of acid nitrate of mercury. Chronic cases should be managed upon the same principles as harelip, that is, the edges of the fistule should be refreshed with the knife, and carefully united with wire sutures. When access to the bowel is ren- dered difficult, the best plan is to divide the sphincter muscles of the anus, immediately in front of the coccyx. Sometimes a cure may be effected by means of the actual cautery. When the fissure is situated at the neck of the bladder, or at the junction of the bladder and urethra, it may be necessary to lay these parts and the bowel freely open with the knife, as in the common operation for anal fistule. 14. Sloughing of the Rectum—This is most likely to take place in weakly, dilapidated subjects. The immediate cause of the occurrence is probably slight infiltration of urine, CHAP. XVI. LITHOTOMY. 749 in consequence of the great and unnecessary depth of the wound, or of injury done to the rectovesical septum during the extraction of the calculus. No definite rules can be laid down respecting the treatment, which must he regulated by the circumstances of each individual case. In general, it will be necessary to support the strength by proper diet and by tonics, especially quinine, wine, and brandy. 15. Lithotomists speak of a wound of the posterior wall of the bladder as an occa- sional occurrence. Such an accident, which is more common in children than in adults, would be most liable to arise when the bladder is not sufficiently distended with water, and the knife, as it is pushed along, forsakes the staff, wandering about at random, as it were. Only an unskilful operator would be likely to commit such a blunder. In the event of a free opening, more or less urine would be sure to escape into the peritoneal cavity. Erichsen refers to a case in which the operator, miscalculating the depth of the perineum, thrust the knife so low down that it penetrated the bladder behind the prostate gland without having touched the urethra, the patient dying from the effects of cellulitis and urinary infiltration. 16. Ischuria—Suppression of urine cannot be said to be peculiar to the lateral method, for it has occasionally been witnessed after the suprapubic, and even after the recto- vesical operation. The affection, which is extremely uncommon, generally comes on suddenly within the first forty-eight hours after the patient is placed in bed, and is nearly always promptly fatal, from uremic poisoning. The most prominent symptoms are, ex- cessive prostration, gastric irritability, intense thirst, copious sweats, and great stupor, with more or less delirium. The treatment principally consists in the exhibition of diuretics with quinine and strychnia, and the application of sinapisms, veratria ointment, and stimulating liniments to the dorsolumbar region. 17. Incontinence of Urine Incontinence of urine, consequent upon perineal lithotomy, is happily infrequent. It is not always easy to determine how this accident is produced. Most commonly, however, it arises from injury inflicted upon the neck of the bladder during the extraction of a large and very rough calculus, although I have known it to occur when the stone was unusually small. When there is a probability that incontinence of urine will take place, every effort should be made to prevent it. The patient should be strictly confined to his bed, a warm bath should be administered once a day, for twenty-five or thirty minutes at a time, cold water should frequently be thrown into the rectum, and free use should be made of diluent drinks. When the affection is fully established, it will be necessary to leech the perineum occa- sionally, and to apply gentle but steady pressure upon it with the pad of a X-truss. In obstinate cases, cauterization of the neck of the bladder and of the commencement of the urethra may be tried. 18. Impotence and Sterility These occurrences, which are very uncommon after perineal lithotomy, doubtless depend upon injury inflicted upon the ejaculatory ducts by the knife in making the deep incisions, and are, of course, irremediable. The two effects are not always associated. Thus, for example, a man may be able to copulate but not procreate, while another may be both impotent and sterile, as in a singular case commu- nicated to me by Professor McGuire, of Richmond, Virginia, of a man, thirty-one years of age, who has had no erections, seminal emissions, or sexual desire since he was cut for stone nearly twro years ago, notwithstanding he is very strong and healthy, and perfectly free from vesical trouble. When only one ejaculatory duct is obliterated, the other re- maining sound, the faculty of procreation would probably be little, if at all, impaired. 19. Perineal Fistule The wound made in lithotomy generally heals in from three to four weeks ; but sometimes it remains open much longer, and occasionally it does not close at all, but degenerates into a fistule, the existence of which is determined by the appearance of urine at the external opening, and by an examination with the probe. The treatment consists in retaining a catheter constantly in the urethra, and in cauter- izing, every fourth or fifth day, the neck of the bladder with nitrate of silver. The patient should be confined to his back, with the nates elevated. When the track is un- usually small, or the perineum uncommonly thin, relief may sometimes be afforded by the occasional introduction of a heated probe, wire, or knitting needle. In intractable cases, it may be necessary to incise the parts, and pare the edges of the wound. 20. Orchitis Acute swelling of the testicle occasionally follows this operation. I have seen only two cases of it in my own practice ; a circumstance which leads me to suppose that it is infrequent. It seldom comes on before the end of the second or third week, and is no doubt due to injury inflicted upon the ejaculatory ducts in the division 750 DISEASES OF THE URINARY ORGANS. CHAP. xvi. of the prostate gland or during the extraction of the calculus. It generally involves only one organ. The treatment is the same as in ordinary orchitis, the disease usually yield- ing in a few days. 21. Explosion of Preexisting Disease -Stone, as is well known, frequently coexists with other diseases, which, whether latent or open, often acquire new intensity on the removal of the vesical irritation. The organs most likely to suffer in this manner are the kidneys, bowels, brain, heart, and lungs. In old subjects death occasionally occurs, during the progress of the cure, from apoplexy. A patient of mine, a man, seventy-one years of age, perished from an attack of this kind six weeks after the operation, from the immediate effects of which he had thoroughly recovered at the time of his seizure. After-treatment As soon as the stone has been extracted, the bladder washed out, and the bleeding arrested, the patient is carried to his bed, always properly arranged beforehand. It should be provided with slats, and a cotton, moss, or hair mattress, cov- ered with a sheet, over which is spread a large piece of soft oil-cloth. Another sheet, called the draw-sheet, folded several times, and arranged so as to make the middle of it correspond with the buttocks, is placed upon the top of the oil-cloth, and serves to ward off pressure, as well as to receive the secretions as they flow from the wound. The head and shoulders should be slightly elevated by a pillow. It matters little, if any, according to my experience, what posture the patient assumes after he has been put to bed. I usually, however, request him to lie on his right side for the first five or six hours, to afford the lips of the wound an opportunity of becoming glazed with lymph before he is obliged to urinate. At the end of this period, and, indeed, often much earlier, I permit him to rest upon his back, or upon either side, as may be most agreeable. Young subjects, unless incessantly watched, seldom remain in the same posture beyond a few minutes, and I have never seen a case in which any detriment re- sulted from this source. It is equally unnecessary, in my judgment, to tie the patient’s knees together after the operation ; or to introduce a tube into the bladder by the wound, to conduct off the urine, with a view, as is alleged, of preventing infiltration of the surrounding connective tissue. The expedient can never be required except in those cases in which the incisions are unusually extensive. The urine sometimes begins to flow by the wound in a few minutes after the opera- tion ; but, in general, very little, if any, passes for the first three or four hours. It then usually comes away in a gush, attended with pain and spasm of the neck of the bladder. By the end of the first day, the edges of the wound are commonly so much swollen as to compel the urine to pass mainly by the urethra. This, however, rarely continues beyond twenty-four or thirty-six hours, when the tumefaction has generally so far subsided as to allow the fluid to resume its original course. The period at which it begins to pass off permanently by the urethra varies from ten to fourteen days. The change in the direction of the fluid is always attended with more or less pain at the neck of the bladder, and a scalding, smarting, or burning sensation in the urethra and head of the penis. The treatment after the operation must be strictly antiphlogistic. The patient is kept quietly in the recumbent posture, and all excitement, both bodily and mental, is sedu- lously guarded against. The pain consequent upon the operation is often extremely severe. It generally makes its appearance as soon as the patient wakes from the effects of the anaesthetic, and should be promptly met by a full dose of morphia, introduced, if possible, hypodermically. Demulcent drinks should be used freely throughout the treatment, especially in the earlier stages. They serve both to allay thirst and to dilute the urine. They may be simple, or combined with nitrate of potassium, bicarbonate of sodium, or dilute nitric acid, according to the particular indications of the case. The diet must be light, unirritant, and of the most simple kind. For the first few days the patient should take little else than panada, gruel, animal broth, or milk and bread. After that he may use rice, toast and tea, crackers, or mush and milk. No meat or vege- tables should be permitted under five or six days, unless there is marked evidence of de- bility. My invariable rule after this operation is to lock up the bowels for the first three days with a full anodyne, administered as soon as the patient has sufficiently recovered from the effects of the anaesthetic. At the end of this time a dose of castor oil or Rochelle salt is ordered, assisted, if necessary, by an enema. Every possible attention should be paid to the cleanliness and comfort of the patient. CHAP. XVI. LITHOTOMY. 751 Excoriation should be guarded against and the scrotum kept out of the way of the wound by a suspensory bandage. The smarting, burning, or scalding sensation of the skin from the contact of acrid urine is always promptly relieved by covering the affected surface several times a day with benzoated zinc ointment. The free use of nitrate and acetate of potassium will tend to render the fluid less irritating. When, as occasionally happens, the edges of the wound become covered with earthy phosphates, the best remedy will be the nitric acid lotion, in the proportion of about four drops of acid to the ounce of water, applied by means of a folded cloth. When the incrus- tation extends far back, the fluid may be daily injected into the bladder. In most cases the local application should be aided by the internal exhibition of the remedy. When the wound is tardy in healing, or has contracted to a mere orifice, indisposed to close, a catheter ought to be permanently retained in the bladder, to conduct off' the urine through the natural channel. Although the wound made in this operation occasionally unites by the first intention, such an event is extremely uncommon. I do not recollect a solitary example among my own cases, in which the parts were seriously bruised in the extraction of the calculus, or unduly divided in making the deep incisions, and yet I have never had an instance of union by the first intention, properly so called. Statistics.—Of 11,987 cases of the lateral operation of lithotomy with the knife, of which 10,150 are tabulated in my treatise on the urinary organs, 10,709 recovered and 1278, or about 1 in 9.38 died. Sir Henry Thompson, in 1879, reported 78 cases with a loss of 29, or 37.18 per cent., a frightful mortality which can be explained only by sup- posing that most of the cases were bad cases, rendered so by ill health and more or less severe diseases of the urinary organs. My own practice, embracing 159 cases, shows 14 deaths, or 1 in 111. Of 72 children, all, except 2, recovered, while of 87 operations in adults and old persons, 12, or 1 in every 6.50, died. Guersant, at the Hopital des Enfans, Paris, cut 60 children with a loss of 9. Pouteau operated with the single lithotome upon 120 cases with a loss only of 3; Crichton saved 186 out of 200, cut partly with the knife and partly with the gorget; and Dudley, who operated exclusively with the gorget, had 207 cases with a loss of 6. Watt- mann, of Vienna, who always employed a large knife, shaped somewhat like a gorget, lithotomized 180 cases, of which 146 recovered, and 34 died. Of 426 cases of the opera- tion with the gorget in the practice, chiefly private, of American surgeons, the mortality was 1 in 23T7?. The results of lateral lithotomy in hospital practice are not so encouraging as those in private. Thus, of 5149 cases 4461 recovered, and 688 perished, the ratio of deaths being I in 7\. The mortality is greatly influenced by the weight of the calculus and the age of the patient. Thus, of 1327 cases, analyzed by Mr. Crosse and Dr. Garden, the death- rate was 9 per cent, when the stone weighed an ounce and under, while it was 23.74 per cent, when the weight was above an ounce. The experience of twenty surgeons in the Punjaub and Northwest Provinces of India, collected by Dr. Greenhow, furnishes 1718 cases of lithotomy, the majority of which were by the lateral method, of which 259 proved fatal, or 1 in 6.63. When, however, the weight of the stone was under one ounce, there was only 1 death in every 17, the mortality increasing in proportion to the weight. The influence of age upon the result is well shown by 1827 cases, of which 229 died, derived from hospital practice, and tabulated by Sir Henry Thompson. The mortality from 1 to II years was 5.7 per cent., from 12 to 16, 10.6 per cent., from 17 to 29, 13.5 per cent., from 30 to 48, 13.7 per cent., from 49 to 70, 24.2 per cent., and from 71 to 81, 31.5 per cent. Of 133 cases of lithotomy performed at the Pennsylvania Hospital from October, 1756, to October, 1878, 19, or 14.28 per cent, terminated fatally. Dr. John Kerr, in January, 1882, sent me the statistics of 437 cases of lithotomy, all of which, excepting 36, were performed by himself at the Missionary’s Society’s Hospital, at Canton, between 1856 and 1881 inclusive. His best success was obtained under the age of 20 years, comprising 185 cases with the unparalleled loss of only 8. There were 9 deaths in 84 cases under 38 years, 8 in 88 cases under 40, 2 in 42 cases under 50, 9 in 30 under 60, 2 in 7 under 70, and 1 in 1 under 80. The larger stone weighed seven ounces and a half. It will thus be seen that the total number of deaths was 41, or a fraction a little over 1 in 10. The success of Rai Ram Narain Dass Baliadoor, of Calcutta, is one of the most wonder- ful on record. Of 248 cases of lateral lithotomy, performed in the Northwestern Pro- vinces of India during a period of twelve years, only 17, or 1 in died. The death- rate from two to ten years was 1 in 28, and from ten to twenty 1 in From twenty 752 DISEASES OF THE URINARY ORGANS. CHAP. XVI. to thirty, none died; but after this period the mortality greatly increased, being 1 in from thirty to forty, 1 in 7 from forty to fifty, and 1 in from fifty to sixty. The circumstances which tend to influence the result of the lateral, as, indeed, of every other, operation of lithotomy are exceedingly numerous and diversified in their character, and are worthy of profound consideration. The most important of these circumstances are referable, 1st, to the skill of the surgeon; 2dly, the preparation, age, and health of the patient; 3dly, the nature, volume, and situation of the concretion; and, 4thly, the selec- tion of our cases. Nearly one-half of the patients that I have cut were under twelve years of age, and of these all, except two, promptly recovered. The youngest was a child of twenty months. My two oldest subjects were, respectively, seventy-three and seventy-seven. Both re- covered. The late Dr. Gilbert, of this city, performed the lateral operation six times, all his patients being over fifty years of age. The three oldest were, respectively, seventy- four, seventy-eight, and eighty-one, and they all recovered without any untoward symptom. The condition of the patient’s health must necessarily influence the result of the opera- tion. The more perfect this is at the time he is cut, the more likely, other things being equal, will he be to recover, and conversely. The operation, as already pointed out, seldom terminates favorably when the stone is unusually large, as when it weighs five, six, or eight ounces, owing to the injury that must necessarily be inflicted upon the bladder, prostate gland, and other structures, often followed by infiltration of urine, erysipelas, phlebitis, or pyemia. A patient worn out by physical suffering, or intercurrent disease, as diarrhoea, chronic dysentery, measles, or scarlatina, is a bad subject lor an operation, and will be likely to perish from its effects. Examples of the extraction of large calculi followed by recovery have been recorded by different authors. Thus, Dickinson had one of eleven ounces, Cheselden of twelve, Klein of thirteen, Mayo of fourteen, and Hamer of fifteen. In a case communicated to me by Dr. A. Dunlap, of Springfield, Ohio, he successfully extracted a stone weighing twenty ounces from a man sixty-six years of age, not, however, without breaking it into numer- ous fragments, as was easily done, as it was composed mainly of phosphatic matter. The patient survived the operation nearly three years. Relapse When it is considered that most vesical concretions have their origin in the kidneys, or, at all events, that these organs are often contemporaneously affected, it is not surprising that the disease should occasionally return after operation. What number of cases relapse after being lithotomized, is a point for the determination of which there are no positive data. There is no doubt that it is generally influenced by the nature of the calculous diathesis, and I think it is safe to affirm that persons affected with phosphatic calculi are more prone to suffer a second, and even a third time, than those affected with lit hie concretions, or concretions composed of urate of ammonium. Diseases of the urinary organs, or of the digestive apparatus, may be mentioned as predisposing causes of relapse. Indeed, whatever has a tendency to disorder the general health, will be likely to promote the recurrence of the malady. Injuries of the spine, unless promptly relieved, are almost sure to be succeeded by relapse. The period at which relapse occurs depends upon various circumstances. Occasionally, it is very short; and, on the other hand, a number of months, and even years, may inter vene. As a general rule, the phosphatic and ammoniaco-magnesian calculi are more rapidly reproduced than the litliic and oxalic. Organic disease of the kidneys, urinary bladder, and prostate gland may be mentioned as among the more powerful predisposing causes. Relapse, no doubt, is often pi’oduced by the imperfect clearance of the bladder during operations, the smallest fragment serving as a nucleus for a new stone. When the operation requires to be repeated it should be performed upon the same principles as in the first instance, and at the same place. 1 have myself never been obliged to cut the same patient twice, and in but one instance, so far as I recollect, has there been a return of the disease in any of my cases. Professor Hughes, of Iowa, lias reported an instance in which he lithotomized the same individual, a man aged sixty-two, successfully four times in five years. Clever de Maldigny, a surgeon, was cut successfully six times, and Grangeret seven times. Varieties in the Lateral Operation—The operation described in the preceding pages is, as has been seen, executed with the knife, and nothing could possibly be more simple. It is the very perfection of lithotomy. Nevertheless, there are some surgeons who prefer the use of the gorget, the lithotome cache, or the beaked knife. The operation with the gorget does not differ, in its early stages, from that with the CHAP. XVI. LITHOTOMY. 753 knife. The period for using the instrument is immediately after the incision of the mem- branous portion of the urethra. The surgeon then exchanges the scalpel for the gorget, the beak of which is placed in the groove of the staff, guided by the point of the left index- finger. After assuring himself, by drawing the instrument slightly backwards and for- wards, that it is in no danger of slipping, he takes hold of the handle of the staff’, and by a simultaneous movement of his hands, he lowers the instrument and the gorget nearly to a level with the abdomen, pushing at the same time the latter onward into the bladder. In excuting this part of the operation, care should be taken not only that the gorget does not slip out of its place, and thus pass between the rectum and the bladder, but that it is properly lateralized, otherwise there will be great risk of injury to the rectum and the pudic artery. The annexed engraving, fig. 566, exhibits the gorget as modified and im- proved by Physick and Gibson. Fig. 566. Pliysick’s Gorget. Professor N. R. Smith, struck with the difficulty which litliotomists so frequently expe- rience in hitting the staff as the operation for stone is usually performed, devised, early in his professional life, an ingenious contri- vance which, along with a gorget, he ever afterwards employed in his practice, having found it to answer most admirably the object for which it was designed. The instrument, as the annexed cut, fig. 5G7, shows, consists of a rectangular staff, with the angle well rounded off, deeply grooved in its horizontal portion, and provided with an arm-piece, or indicator, attached by means of a hinge to the body of the staff a short distance below the handle. The indicator, the length of which varies from two to three inches, is also of a rectangular form, and terminates in a sharp, lancet-shaped blade, called the cutting director, between which and the straight por- tion there is a deep groove for the guidance and secure movement of the gorget. Three sizes of the instrument are required to meet the various contingencies arising from the dimensions of the perineum in different per- sons, and at different periods of life. In some of the modifications of the instrument the conductor is secured to a movable l’od in the handle, so that by sliding it up or down it can readily be adapted to any form or depth of perineum. The indicator being drawn out at a right angle, the staff is introduced in the usual manner, and confided to an assistant. The cutting director is then brought down in con- tact with the raphe of the perineum, through the entire thickness of which it is pushed until its edge is securely lodged in the groove of the staff. The indicator being held in posi- tion by the operator with his left hand, the gorget is passed along the groove in its under surface until it also is lodged in the groove of the staff. The instrument is then with- drawn, making, as this is being done, an incision downwards and outwards to a point mid- way between the anus and the tuberosity of the ischium, as in the ordinary procedure. The gorget being again introduced in the same cautious manner as before, the operation is completed by pushing it on into the bladder, its beak, all the while, being engaged in Fig. 567. N. E. Smith’s Lithotomy Instruments. 754 DISEASES OF THE UKINARY ORGANS. es ap. x vi. the cup-shaped extremity of the indicator, which is necessarily carried on in advance of it. Instead of the gorget, which was, however, Dr. Smith’s favorite instrument, as it also is of his son, Dr. Alan P. Smith, a probe-pointed bistoury may be used. The use of the instruments of Dr. Smith has hitherto been confined chiefly to the Balti- more surgeons. Professor Christopher Johnston has frequently employed them, and Dr. Alan P. Smith, writing to me in April, 1882, states that he had operated with them sixty- three times, and six times with the ordinary staff and knife, with a loss of only two, the first being his fifty-fourth case, and the second the sixty-seventh. Such a result is creditable alike to the lithotomist, and to his method. Dr. N. R. Smith’s success was very remark- able, the mortality of his operations, upwards of two hundred, not exceeding six per cent. Dr. Alan P. Smith informs me that he has never had any troublesome hemorrhage in any of his cases. The largest stone removed by him was a mulberry one, weighing upwards of two ounces, and measuring nearly six inches in circumference. Instead of the gorget, some lithotomists employ a beaked knife, or a probe-pointed bis- toury, for dividing the neck of the bladder and prostate gland. The instrument may be either straight, or somewhat concave on its cutting edge. The one which I generally use, if I use any of the kind at all, is represented at p. 739. The single lithotome, invented, I believe, by Frere Come, is now seldom employed. The annexed cut, fig. 568, represents the instrument, as modified and improved by Char- Fig. 568. Single Lithotome. riere. It will be observed that it has a single blade, moved by a spring, and concealed in a rod, fixed in a stout handle, and surmounted by a beak, to enable it to slide the more easily and securely in the groove of the staff. The extent to which the blade may be opened is regulated by means of a screw attached to the spring. The external incisions having been made in the ordinary manner, and the membra- nous portion of the urethra being fully exposed, the beak of the lithotome is inserted into the groove of the staff, and passed on into the bladder. The blade is then expanded to the requisite degree, and the division of the deep structures effected in withdrawing the instrument, its edge being directed obliquely downwards and outwards, in the long axis of the prostate gland. Bilateral Operation The merit of devising this operation is usually ascribed to Cel- sus, although it more probably belongs to Le Dran. Its advantages have been promi- nently set forth in modern times by Chaussier, Beclard, and Dupuytren, the latter of whom, having first performed it in 1824, may be said to have regularized and perfected it. If the bilateral section possesses any advantages over the ordinary method, it must be on the ground of its affording a larger opening for the passage of the foreign body, and Fig. 569. Double Lithotome. that it is attended with less danger to the rectum and the seminal ducts. But even of these the former is, in great degree, counterbalanced by the modern method of dividing the right lobe of the prostate, if the wound in the left be found insufficient for the extrac- tion of the calculus. The operation has sometimes been performed instead of the lateral, on account of difficulty occasioned by malposition of the thigh. It requires the same preliminary measures as the other method. The incisions through the perineum, as far as the groove of the staff, are executed with an ordinary scalpel, and the prostate is divided with a double lithotome cache, seen in tig. 5G9, a narrow knife, or a probe-pointed bis- toury, according to the fancy of the surgeon. CHAP. XVI. LITHOTOMY. 755 The operation consists in making a semilunar incision across the perineum, beginning on the right side, midway between the tuberosity of the ischium and the margin of the anus, but a little nearer to the former than to the latter, and terminating at the corresponding point of the opposite side, as seen in fig. 570. The concavity of the cut is directed down- Fig. 570. Fig. 571. Line of Incision in the Prostate in Bi- lateral Lithotomy, showing its relation to the Bulb and the Internal Pudi,c Artery. Bilateral Operation. wards, and its centre, situated at the raphe of the perineum, is about nine lines above the anus. In this direction are successively divided the skin, connective tissue, and super- ficial fascia, together with a few of the anterior fibres of the external sphincter muscle. The end of the left fore-finger is now placed in the bottom of the wound, as in the ordi- nary procedure, the staff sought, and the membranous portion of the ure- thra laid open, by an incision not exceeding four lines. The nail of the finger is then applied to the staff, to serve as a guide to the lithotome, the beak of which is next inserted into the groove of the instrument, with its concavity upwards. Taking care, by moving the lithotome several times forwards and backwards, that it is securely lodged in the groove, the sur- geon seizes the handle of the staff, and depresses it nearly to a level with the abdomen, at the same time that he lowers the lithotome, and pushes it on- ward into the bladder. As soon as the instrument has reached the viscus it is turned round with its concavity towards the rectum, and while it is in this position it is withdrawn, its blades being expanded by pressing their springs. In this manner it cuts its way out, slowly and steadily, dividing in its retro- grade course the sides of the prostate, in a direction obliquely downwards and outwards, as in the ordinary section. The finger now takes the place of the instrument, the situation of the stone is ascertained, the forceps are in- troduced, and extraction is effected in the usual manner. Fig. 571, from Erichsen, shows the line of incision in the prostate gland, and its relation to the bulb and the internal pudic artery. Various modifications of the bilateral operation have been proposed, but it is questionable whether they possess any advantages over the original pro- cedure. The first, practised by Civiale from 1829 to the date of his death, consists in opening the membranous urethra as in the ordinary median opera- tion, and incising botli lobes of the prostate in a transverse direction with a straight double lithotome, the width of the superficial and deep incisions being less than in Dupuytren’s procedure. The second modification is the prerectal operation devised by Nelaton and also adopted by Richet. The crescentic incisions are carried close to the rectum, with the view of avoiding the bulb of the urethra; the bowel being depressed, the operation is finished with the double lithotome. The procedure possesses no merit, and subjects the patient to longer confinement and the liability to the occurrence of urinary fistule. The late Dr. James R. Wood, in performing the bilateral operation, in which he obtained great success, used an instrument devised by him and known as the bisector, fig. 572. In Fig. 572. James R. Wood’s Bilat- ei'al Gorget. 756 this way he secured an opening in the prostate gland in the adult from an inch and a half to an inch and three-quarters in width, through which even a large stone was generally readily extracted without laceration or contusion of the neck of the bladder. No statistics have yet been furnished, on an enlarged scale, of the results of the bilateral operation. In the posthumous work of Dupuytren, who introduced this method into France, and who imparted to it much of its present perfection, is a table comprising 85 cases, of which 19 terminated fatally, making an average mortality of 1 in Professor Briggs, up to March, 1882, had had 48 cases of bilateral lithotomy, of which 6, or 1 in 8, proved fatal. If to these are added 429 cases, collected from different sources, of which 22 died, we shall have an aggregate of 514 cases, with 41 deaths, or a loss of 1 in 12.53. Median Operation Perineal lithotomy is occasionally combined with dilatation, a process constituting what may be denominated lithectasy, the object being to make a small opening in the first instance, which may afterwards, if necessary, be increased by pressure. The operation was originally suggested by Manzoni, of Verona, early in the present century, and has since been warmly advocated by Dr. de Borsa, who gives it the preference over every other expedient, on the ground of its freedom from hemorrhage and urinary infiltration, as well as the rapidity with which it may be executed, a single minute usually sufficing for its completion. The only instruments required are a staff, a bistoury, and a pair of forceps. Having made an incision through the raphe of the peri- neum, de Borsa opens the whole of the membranous portion of the urethra, so as to ex- pose the staff to the extent of about ten lines; when, laying aside his knife, he at once passes the left index-finger into the bladder, along the right side of the instrument, and then, by a semirotatory movement of the member, gently and cautiously conducted, he dilates the prostatic portion of the tube and the neck of the bladder sufficiently to enable him to introduce the forceps and extract the calculus. The operation is, of course, appli- cable only to small calculi. A modification of this operation was devised by the late Mr. George Allarton, of South Molton, England, who published an account of it in 1855. It consists in making an inci- sion, with a long, straight bistoury, directly through the raphe of the perineum, about six lines above the verge of the anus, down upon a curved staff with a central groove, the instrument being previously hooked against the pubic symphysis, and well steadied by the left index-finger in the rectum. The knife, after having reached the staff, is carried a little towards the blad- der, but not into it, when it is with- drawn, enlarging, as it retraces its steps, the external opening towards the scrotum, so as to make it altogether from an inch to an inch and a half in length. The operator then, inserting into the bladder a probe surmounted with a bulb, removes the staff, and expands the wound with the forefinger of the right hand. If the stone is small, it will now probably fall into the wound, and be forced down by the patient as he strains. If this fail, the finger is again used, its size being increased by the addition of an India-rubber stall, until the dilatation has been carried to the required ex- tent. If the calculus is rather large, it may be crushed ; or, in- stead of this, the prostate may be divided, as in the lateral section, a procedure, however, seldom necessary. The annexed cut, fig. 573, represents the director of Professor J. L. Little, of New York, intended as a substitute for Mr. Allarton’s probe, for guiding the finger and forceps DISEASES OF THE URINARY ORGANS. CHAP. XVI. Fig. 573. Little’s Director. Fig. 574. Mode of Guiding the Finger into the Bladder to Dilate the Wound. CHAP. XVI. LITHOTOMY . 757 into the bladder. It has a flat, tapering groove, with a blunt extremity, and is about six inches in length, exclusive of the handle, which forms an angle with the blade of about 45°. The operation may be performed with an ordinary staff, or with the staff devised by Dr. Markoe, the groove of which is very wide, shallow, and continuous to the end of the instrument so as to afford a larger surface to the knife, and facilitate the passage of the director into the bladder without obstruction. Fig. 574 shows Little’s mode of dilating the neck of the bladder. The advantages claimed for this operation are, 1st, that, as there are no large vessels encountered, there is less risk of hemorrhage than in the lateral section; 2dly, that no in- jury is inflicted upon the prostate gland and seminal vesicles; 3dly, that, as the deep per- ineal fascia is not invaded, there is no danger of urinary infiltration ; 4thly, that it is more easy to maintain cleanliness during the after-treatment; and, othly, that the wound closes more rapidly than in the lateral operation. The disadvantages are, that the operation is more difficult of execution than the ordinary lateral one; that there is greater risk of wounding the rectum ; and that it is not adapted to the removal of large calculi. Of 350 cases tabulated in my Treatise on the Urinary Organs, including 205 from the practice of American surgeons, 318 recovered and 32, or 1 in 10.93, died. Dr. Little, in May, 1882, informed me that he had, up to that time, performed this operation 33 times with only two deaths. Medio-Lateral Process—Professor Buchanan, of Glasgow, in 1847, devised what he terms the medio-lateral operation, in which a rectangular staff with a wide groove on the left side, and a straight, narrow knife, with a long edge, are used. The staff being inserted into the bladder, the surgeon moves it backwards and forwards, over the left index-finger in the rectum, until the prominent angle is distinctly perceived in the perineum, at the anterior verge of the anus, or at the portion of the raphe where the skin and mucous membrane are insensibly blended with each other. The instrument is now con- fided to an assistant, who maintains it firmly in its position, with the handle inclined towards the abdomen. The surgeon,holding the knife horizontally with the edge towards the left side, as in fig. 575, penetrates the tis- sues of the perineum until the point is in the groove of the staff, when he conducts it directly onwards until it reaches the bladder, as indicated by the escape of a few drops of urine. Withdrawing the knife from this position, he now carries it obliquely down- wards and outwards, for three-quarters of an inch, in the direction of the forepart of the tubei'osity of the ischium, and then finishes by cutting, for three-eighths of an inch, almost vertically downwards. If the wound is not sufficiently spacious to admit of the easy extraction of the calculus, it may afterwards be enlarged to any desired extent. The advantages claimed for this procedure are, 1st, that it is more easily and rapidly executed than the ordinary lateral one ; 2dly, that it is less severe, because of the less ex- tensive division of the parts; and, 3dly, that it is not attended with so much risk of hem- orrhage, of injury to the rectum, and of urinary infiltration. Of 52 operations for stone, performed according to this method, by Dr. Buchanan and Dr. Lawrie, in the Glasgow Infirmary, 47 recovered, and 5 died, thus showing a mortality in the proportion of 1 to 10.4. Medio-Bilateral Operation This procedure, introduced to the notice of the profession by Civiale in 1829, never, until recently, attracted much attention, although it yielded good results in the hands of its celebrated inventor. In this country its great champion is Professor W. T. Briggs, of Nashville, who performed it for the first time in 1868, and who has devised an ingenious instrument called a cystotome for dividing the deeper structures of the perineum. The patient being placed in the usual position, and a Markoe staff being introduced into the bladder, the surgeon with the left fore-finger in the rectum, pulls that tube directly backwards, and with a narrow, sharp-pointed knife makes a per- pendicular incision along the raphe of the perineum, commencing an inch and a half above the anus and terminating about three lines from its margin, dividing the structures down Fig. 575. Lithotomy with the Rectangular Staff. 758 DISEASES OF THE URINARY ORGANS. c H A P. XVI. to the groove of the staff, into which the cystotome is next inserted, and pushed on into the bladder, the blades, expanded to the extent of half an inch, enlarging the wound on each side about three lines during the withdrawal of the instrument. The wound is then, to use the language of Dr. Briggs, slowly and gently, but freely dilated with the finger, and the stone extracted with a light pair of forceps. Little bleeding follows the operation, as no structures of importance are divided, and the track made by the knife affords a con- Fig. 576. Brigg’s Cystotome. venient route to the bladder. If the stone is too large for easy extraction, it can be readily crushed through the wound. Of 74 cases of this operation, reported to me by Professor Briggs, in March, 1882, as having been performed by himself, 2 only perished, or 1 in 37. This is certainly a marvellous result; but, what is still more remarkable, is the fact that 70 of the cases were successively successful, a result alike creditable to the medio-bilateral method and to the skill of the operator. Rectovesical Operation The rectovesical operation, proposed by Vegetius, in the sixteenth century, and first practised in 1816 by Sanson, of Paris, has long been obsolete. It consists, as the name implies, in cutting into the bladder through the rectum, perineum, and prostate gland. It has been abandoned on account, chiefly, of its liability to be fol- lowed by extensive suppuration of the connective tissue within the pelvis, injury of the ejaculatory ducts and seminal vesicles, and, lastly, although not least, stercoraceous fis- tule, difficult, if not impossible, of cure. Of 83 cases of rectal lithotomy, analyzed by Konig, 16, or 1 in 5.18, perished. Eleven patients recovered with fistules. A modification of this operation was successfully performed upon a man, twenty-six years of age, in 1859, by Dr. Louis Bauer, by opening the rectum just above the prostate gland, the canal having previously been expanded with a duck-bill speculum. The calculus, weighing an ounce and a half, was extracted with some difficulty. The wound was accu- rately closed with five silver sutures, which were removed on the eighth day, the union being perfect. In a case operated upon, in 1860, by Dr. Noyes, the wound, made through the central portion of the prostate, and enlarged bilaterally, was closed with six metallic sutures, supported by a leaden button. The apparatus was removed on the twelfth day, the parts being entirely healed, except at one little point, which afterwards cicatrized under the application of nitrate of silver. Suprapubic Operation In the suprapubic, hypogastric, or high operation, first prac- tised by Pierre Franco, about the middle of the sixteenth century, and revived by Frere Come, the bladder is opened above the pubes, in the direction of the linea alba. Its chief advantages are, that it is free from hemorrhage; that it does not expose the patient to injury of the rectum and the ejaculatory ducts ; that there is no risk from inflammation of the neck of the bladder ; that it may be performed where the lateral section is imprac- ticable ; and, lastly, that it admits of the more easy removal of a large, attached, or encysted calculus. As an offset to these advantages, it is to be remarked that the proce- dure is liable to be followed by injury of the peritoneum, and by urinary infiltration, not to say anything of the difficulty of executing it when the abdomen is loaded with fat, or the bladder does not ascend any distance above the pubes. The latter of these dangers may, however, generally be avoided by premising a perineal puncture, to serve as an outlet to the urine, which thus drains off as fast as it reaches the neck of the bladder. The former, too, may usually be guarded against, if the precaution be used, first, to distend the bladder thoroughly before the operation, and, secondly, to push the peritoneum gently before the knife, after cutting through the inferior part of the linea alba. In performing the operation, the patient is placed recumbent upon a narrow table, with CHAP. XVI . LITHOTOMY. 759 the legs hanging loosely over its lower edge, and the feet resting upon a high chair. The head and shoulders are somewhat elevated, to relax the abdominal muscles. The bladder, previously freed of its contents, and well cleansed with some antiseptic fluid, is filled with tepid water until it rises a considerable distance above the pubes. The surgeon, standing on the left side of the patient, makes an incision from three and a half to four inches in length, commencing at the pubic symphysis, and extending upwards towards the umbilicus, in the direction of the linea alba. It should pass through the skin and cellulo-adipose substance, down to the aponeurosis of the abdominal muscles. These structures, being thus exposed, are next cautiously divided to the same extent, any bleeding vessels being at once secured. The bladder will be found at the bottom of the wound, forming a large, fluctuating tumor, invested mei-ely by a thin layer of connective tissue. To divide this, a few gentle touches of the knife are sufficient; or, what is better and more safe, the dissection may be effected with the steel end of the handle of the instrument. If the bladder is not suffi- ciently prominent, it should be rendered so by the introduction of a sound through the urethra. In either case, the organ must be firmly secured with a tenaculum before it is incised, in order to prevent it from collapsing, and so sinking down behind the pubic bones; an occurrence which could not fail greatly to embarrass the subsequent steps of the operation. A puncture is next made into the anterior surface of the viscus, on a level with the pubic symphysis, large enough to admit the index-finger of the left hand, which is at once inserted, and used as a searcher, to ascertain the situation and volume of the stone. The opening is afterwards enlarged, with a probe-pointed bistoury, to any extent that may be required, and the stone is extracted either with the finger, scoop, or forceps, as may be found most convenient. The wound in the bladder is united with interrupted, carbolized catgut sutures, passed through all the coats of the organ, from two to three lines apart, the ends being tied with three knots, and cut off close. The abdominal wound is treated in a similar manner, except the lower extremity, which should be left open for the observation and removal of any morbid products that may form. Antiseptic dressings are applied, and every pre- caution taken to prevent putrefactive changes. The urine should be drawn off frequently during the first three or four days, with a very soft, gum-elastic catheter, and the opera- tion should subsequently be repeated at longer intervals, until the end of the week, when the patient may relieve himself by his own efforts. The after-treatment, aside from this, demands nothing peculiar. Both wounds usually heal rapidly. Professor Bruns, of Tubingen, was, I believe, the first to sew up the vesical one, a great improvement over the original procedure, in which a tube was left in both wounds. The suprapubic operation has recently attracted renewed attention, chiefly through the writings of Dr. Charles W. Dulles, of this city, who is one of its most enthusiastic advo- cates, and to whom I am indebted for the subjoined tables, kindly furnished me last July. Sex. Cases. Recovered. Died. Death ratio. Males ....... 517 366 151 1 3.5 Females ...... 105 88 17 1 6.2 622 454 168 1 3.7 Add fatal double operations 14 14 Total .... 636 454 182 1 3.5 Analysis of 636 Gases of Suprapubic Lithotomy. Seventy of these operations were done by American surgeons. It is well known that the suprapubic operation has usually been reserved for stones of large size, but the following table shows that the death ratio for small calculi is about as good as that of lateral lithotomy. The statistics of the lateral operation are taken from Keith’s paper, originally published in the British Medical Journal, March 20, 1869. 760 DISEASES OF THE URINARY ORGANS. CHAP. XVI. Comparison of Results with Stones of Like Weight. Lateral Operation. Suprapubic Operation. Weight. Recovered Died. Death Cases. Recovered Died. Death ratio. ratio. Under . . . . 529 482 47 1 : 11.25 97 88 9 1 : 10.77 §1 to fij . . . . 119 101 18 1 : 6.61 66 51 15 1 : 4.40 |ij to |iij .... 35 19 16 1 : 2.18 55 41 14 1 : 3.93 §iij to |iv .... 11 4 7 1 : 1.57 22 15 7 1 : 3.14 §iv to r . . . . 5 2 3 1 : 1.60 21 11 10 1 : 2.10 §v to §vj .... 2 2 . , 0 : 2. 11 7 4 1 : 2.75 5v.i to 3v'i.i • • • 2 2 1 : 1. 3 1 2 1 : 1.50 §vij to§xxxvj . . •• •• 20 9 11 1 : 1.82 703 610 93 1 : 7.56 295 223 72 1 : 4.20 Out of 295 cases where the weight is recorded, or can be estimated, in 198 it was over 3j, in 132 over §ij, in 77 over £iij, in 55 over giv, in 34 over and in 23 from §vj to 3xxxvj. The smallest stone removed was in a case of Guido Bell, a child of years, and weighed only 16 grains; the largest was the famous one of Uytterlioeven, of Brussels, weighing 36 ounces, its length being nearly seven inches, its breadth four inches, and its thickness nearly two inches and a half. It was of a gourd-like figure, rough, and accu- rately moulded to the shape of the bladder, which was greatly indurated and hypertro- phied. The patient, a man thirty-nine years old, died of inflammation, on the eighth day. In only 19 cases is there a record of injury to the peritoneum, and of these 11 recovered. The deaths attributed to urinary infiltration have been but 17, and those set down to peritonitis only 16. Most of the deaths seem to have been due to conditions incident to large stones and their removal by any method. The late Mr. George Bell, of Edinburgh, met with a remarkable, if not unique case, in which he successfully extracted several large calculi through a puncture above the pubes made originally for the relief of retention of urine caused by a greatly enlarged prostate gland. He dilated the track of the canula with sponge tents of gradually increasing size, and thus with a little patience and perseverance effected his purpose. The first suprapubic operation occurred in the hands of Pierre Franco, who performed it successfully, in 1560, upon a child two years old. In England, it was first performed by John Douglass, in 1711. His principal followers in London were Paul, Smith, Dobyns, Chesel- den, and Thornhill. Cheselden had 10 cases, of which 9 recovered, and Thornhill 16, with 3 deaths. Sermes cut 16 patients, with 5 deaths; Frere Come 100, with 19 deaths ; and Souberbielle 115, with 37 deaths, nearly all of his cases having been men of advanced age. Of Dupuytren’s 4 cases 3 perished. Amussat lost 4 cases of 14, Civiale 1 of 4, Nelaton 3 of 5, Bruns 2 of 6. Van Goudoever had 1 death in 15 operations, and Jacobi 2 in 7. Betz and Guido Bell had each 4 cases, and Gunther 8 cases, without any mishaps. Professor Yon Langenbeck, in 1868, informed me that he had performed suprapubic lithotomy upwards of 30 times, but that, having lost all his adult cases, at periods varying from eight to twelve weeks, from pyemia or exhaustion, he had abandoned it, except in children. In this country the operation has never been popular; and I should myself certainly never employ it, except in cases of encysted calculi or calculi of unusually large size not admitting of crush- ing, or of removal by the lateral method, in all respects, except those here specified, so superior. Professor William Gibson was the first lithotomist among us to perform this operation ; his patient was an old man, who died in a few days, from the effects of urinary infiltration. Dr. Carpenter, of Lancaster, repeated the operation soon afterwards with a favorable result. Professor George McClellan had altogether 5 cases, the first of which terminated fatally. Professor Willard Parker, in 1855, reported to me 3 cases, all in women, and all successful. Professor Eve, in 1855, had two cases; one fatal from peri- tonitis, the stone weighing upwards of four ounces. Inguinal, Scrotal, and Labial Lithotomy A urinary calculus is occasionally situated on the outside of the pelvis in a prolapsed bladder. The affection is most common in the groin, but instances have occurred in which the concretion descended into the scrotum, the sciatic notch, the labium, or even the perineum, as in the remarkable case related by Hartmann. The tumor which is thus formed may be of considerable bulk, especially when it is complicated with hernia of the bowel, and is either of very firm consistence, CHAP. XVI. DIFFERENT METHODS OF LITHOTOMY. 761 or soft at one point, and hard at another. Sometimes the stone is lodged partly within the pelvis, and partly on the outside. A calculus may originate in the bladder or in one of the ureters, and descend thence into the perineum, by a fistulous route, or it may be developed in such a track, the result of a urinary abscess, itself. In either event, it may gradually work its way out, or the parts will have to be relieved with the knife. The symptoms of extrapelvic calculus do not differ materially from those which attend ordinary vesical calculus. The urine is voided with great difficulty, more or less pain is experienced, and little satisfaction is afforded by sounding. In general, the foreign body may readily be detected with the finger; when a number of concretions exist, a distinct crackling noise may occasionally be elicited by rubbing them against each other. The proper treatment in these different forms of calculous affections consists in cutting down upon the foreign substance, through the coats of the prolapsed bladder, as it lies in its abnormal situation, in effecting extraction with the finger, scoop, or forceps, in sew- ing up the wound with the catgut ligature, and in retaining a soft catheter in the bladder until the wound is nearly healed, lest urinary infiltration should occur. When the con- cretion projects by its large extremity into the pelvis, it may be necessary to perform the lateral or suprapubic operation, as riddance by direct incision will then probably be impracticable. Perineal Lithotrity This operation, suggested by Malgaigne, advocated by different surgeons, and systematized by Dolbeau, consists in making an incision through the raphe of the perineum, into the membranous portion of the urethra, upon a grooved staff'; in gradually dilating the neck of the bladder with a special instrument known as a six- Fig. 577. Dolbeau’s Perineal Lithotrity ; Introduction of the Dilator. bladed dilator ; in breaking and comminuting the concretion with a pair of strong forceps, called a lithoclast; and in extracting the fragments with the scoop and other instruments. It lias been asserted that this procedure is especially adapted to those cases of lithotrity in which a stone, after having been partially crushed, cannot be extracted, and when, if left in the bladder, it would be productive of severe cystitis and other bad consequences. It certainly can have no other applicability, and even here a much better and sater plan would be to lay open the bladder freely and effect removal without further crushing; an operation, which always, as is well known, greatly enhances the dangers ot lithotomy. The annexed engraving, fig. 577, conveys a good idea of the manner of performing what may be regarded as a useless, if not a decidedly bad operation. 762 DISEASES OF THE URINARY ORGANS. CHAP. XVI . GENERAL RESULTS OF THE DIFFERENT METHODS OF LITHOTOMY. The following table presents the general results of the more important operations described in the preceding pages. Methods. Cases. Cures. Deaths. Ratio of deaths. Lateral operation ..... 11,987 10,709 1278 1 in 9.38 Bilateral “ . 514 473 41 1 in 12.53 Median “ . 350 318 32 1 in 10.93 Rectovesical “ 83 67 16 1 in 5.18 Suprapubic “..... 636 454 182 1 in 3.5 Total .... 13,570 12,021 1549 1 in 8.76 STONE IN TIIE BLADDER OF THE FEMALE. Women are much less liable to urinary calculi than men. The period of life at which they are most prone to suffer is from the twentieth to the fiftieth year. The symptoms which attend the affection, and the effects occasioned by it, are similar to those which characterize it in the other sex. Stone in the female forms more frequently than in the male upon foreign bodies, either developed in the bladder there or introduced from without. Dr. James Morton, of Scot- land, has published the particulars of a case in which he removed, by the lateral operation, from a woman, forty-seven years of age, three calculi and a bone, evidently the sequel of an extrauterine conception. Similar instances have been recorded by Blackman, Humphry, and others. A stone is occasionally found after the operation for vesico-vaginal fistule, imperfect closure of the wound, or a piece of wire serving as a nucleus. A stone in the bladder may be so large as to interfere with parturition by pre- venting the descent of the child's head. The complication thus produced may prove serious, as in the interesting case related by Mr. Thralfall, of Liverpool, where, from the true cause of the obstruction not being detected, the woman was permitted to die undelivered. In sounding, the patient is placed upon her back, on the edge of the bed ; and the instrument, a short, steel rod, slightly curved at the extremity, is carried about through the interior of the bladder, so as to explore, if necessary, every recess of this organ. In young children, the finger may, if deemed advisable, be inserted into the rectum ; but in grown subjects it is always best to intro- duce it into the vagina. Cases of the spontaneous expulsion of stones from the female bladder, weighing from two to twelve ounces, have been recorded by Callot, Molyneux, Yelloby, Middleton, Klauder, Botti, and others, The extrusion, when the concretion is small or of moderate size, is sometimes effected suddenly, but generally it occurs slowly, and with more or less pain and difficulty in voiding the urine. The spontaneous expulsion of large stones is always preceded by ulceration of the vesico- vaginal septum, or of the bladder and the urethra. The common plans of operation, for the removal of stone from the female bladder, are dilatation of the urethra, crushing, and incision. The method by rapid dilatation is more particularly adapted to small concretions, un- accompanied by any serious disease of the urethra and the neck of the bladder, although calculi two inches in diameter have been re- Fig. 578. Author’s Urethral Dilator. CHAP. XVI. STONE IN THE BLADDER OF THE FEMALE. 763 moved, and even spontaneously expelled without any resulting inconvenience. The dilatation is best effected rapidly, by means of instruments especially contrived for the purpose, as the one sketched at 578. When the stone is small, the necessary dilatation may be effected in a few moments with the ordinary polyp-forceps and the finger. Crushing may be employed when the stone is comparatively soft, and yet so large as to render it impossible to extract it without undue dilatation of the urethra. The object is best effected with a lithotrite at one sitting, preferably with Bigelow’s instruments. The operation of lithotomy is easy of execution, perfectly free from danger of hemor- rhage, and not liable, when properly performed, to be followed by incontinence of urine. The only instruments that are required for its performance are a straight staff, five inches in length, and a straight probe-pointed bistoury. The staff, fig. 579, being introduced, Fig. 579. an incision is made directly upwards towards the pubic symphysis, extending through the urethra and the neck of the bladder, in their entire length. The opening may afterwards, if necessary, be dilated with the finger to almost any extent that may be required for the safe and easy extraction of the calculus. When the concretion, however, is of unusual magnitude, and cannot thus be removed, the incision may be extended downwards and outwards towards the tuberosity of the ischium. A modification of the above operation, consisting of dilatation and incision, may some- times be advantageously employed. After dilatation has been practised to a sufficient extent to admit the index-finger, the tube is divided in one-half of its length, either anteriorly or posteriorly, according to the judgment of the surgeon. The great object of this procedure is to prevent incontinence of urine. A stone has sometimes been extracted through an incision in the anterior wall of the vagina, constituting what is called vaginal lithotomy. The operation, originally per- formed by Rousset, is extremely easy of execution, but, inasmuch as it is liable to be followed by fistule, it cannot be too pointedly condemned. Should the necessities of the case render such interference indispensable on account of the large size of the calculus, or a calculus that cannot be crushed, disease of the vulva, or obstruction to the passage of the child’s head in parturition, the edges of the wound should be immediately approxi- mated with w’ire sutures. The operation is easily performed by making an incision, of suitable length, directly along the middle line, the vagina being previously well expanded with the duckbill speculum, and a large staff firmly held in the bladder. Some surgeons make a transverse instead of a longitudinal incision, but were I obliged to perform such an operation, I should certainly give the preference to the latter, as less likely to become fistulous. Vidal, it is said, performed vaginal lithotomy thirty times without a single death. Of 35 cases collected by Aveling, only one proved fatal, while of 43 in the hands of American sur- geons, all were successful. Dr. T. A. Emmet, of New York, who is a warm advocate of vaginal lithotomy, declares that the wound in the vesico-vaginal septum always heals very readily and cer- tainly, without the risk of a fistulous opening, if proper care be bestowed upon the case during its subsequent management. He insists in particular upon the importance of fre- quent irrigation to prevent the deposit of phosphatic matter. The use of tepid water slightly impregnated with nitric acid, as two or three drops to the ounce of fluid, will also further this end. When the stone is of unusual magnitude, epicystotomy may have to be resorted to. The operation is more favorable than in males, only 10 of the 82 cases tabulated by Dr. Dulles having perished. The greatest attention must be paid during the after-treatment in lithotomy in the female. No matter how simple the operation may be, the strictest recumbency should be observed, not only until the parts are perfectly healed, but until they have, in great degree, regained their natural tone. When this matter is properly attended to, there will be little, if any, danger of incontinence of urine. Even a stone of immense size may, with such precautions; be occasionally removed with perfect safety as it respects this un- Female Staff. 764 DISEASES OF THE URINARY ORGANS. CHAP. xvi. pleasant occurrence, as is shown in the remarkable case of the late Dr. J. Kearney Rodgers, of New York, in which the calculus, weighing upwards of nine ounces, was nearly ten inches in circumference, and yet no ill effects whatever ensued. FOREIGN BODIES IN THE BLADDER. Various foreign bodies, such as balls, pins, needles, fragments of bone, pieces of straw, or other vegetable substances, and bits of catheters and bougies may find their way into the bladder, either accidentally or designedly, with the hope of relieving pain, or for the purpose of gratifying the venereal appetite. However this may be, the effects upon the foreign substance and the bladder are generally similar, or, if they differ at all, they differ only in a very slight degree. The extraneous body is usually very speedily incrusted with earthy matter, sometimes attaining a large bulk in a few months. Occasionally it perforates the bladder, and, escaping into the peritoneal cavity, excites fatal inflammation. The likelihood of such an occurrence will, of course, be greatly influenced by the form and consistence of the foreign substance. The extraneous body, if small, may be expelled spontaneously; but, generally, it will be necessary to extract it, either with or without the aid of the knife. A bullet of ordi- nary size might be removed simply by dilating the urethra; or, this failing, with Cooper’s forceps. When the foreign body refuses to come away of its own accord, or the forceps are unavailing, relief must be attempted by the median or lateral operation. The records of surgery abound in instances in which bits of gum-elastic catheters and bougies were extracted from the bladder by means of short-bladed lithotrites, or forceps, an excellent pair of which is represented in fig. 580. When the prostate gland is much Fig. 580. Forceps for Extracting Foreign Bodies from the Bladder. enlarged and the bladder greatly dilated, removal by the natural channel is sometimes very difficult. In a case of this nature, in a man, sixty-three years of age, failing to effect riddance with the lithotrite, I finally succeeded, after a preliminary median incision, in extracting, with a long brass bullet probe, bent at nearly a right angle, a No. 12 coni- cal bougie, which lay in a pouch behind and to the left of the prostate. Fig. 581 affords a good illustration of the form which such a body is capable of assuming in this organ. When the foreign body is a pin or needle, it may sometimes be entrapped in the eye of a catheter, as in the memorable case of La Motte. Dr. H. L. W. Burritt re- cently reported a case in which a piece of bougie, three inches in length, was expelled from the bladder, after pre- vious dilatation of the urethra, under the influence of a full stream of urine, retained only for four hours. In gunshot wounds of the bladder the ball, if retained, generally becomes speedily incrusted with sabulous matter, and produces all the symptoms of ordinary calculus. The only remedy is excision, an operation first performed by the celebrated lithotomist, Frere Jacques, in 1G98. Ballingall has collected nineteen examples of this kind. Of thirteen analyzed by Dixon, ten recovered, and three died. During our late war there were twenty-one examples of lithotomy for the removal of concre- tions consequent upon wounds of the bladder. Of these, seventeen recovered, three were fatal, and in one the result is not known. In a person operated upon by the lateral section, in 1871, by Professor McGuire, of Richmond, the foreign mass weighed upwards of one ounce; it was composed of triple phosphates, and had undergone spontaneous fracture. Foreign bodies in the bladder of the female generally admit of much more easy removal than in the other sex, owing to the greater brevity and dilatability of the urethra. The best plan is to effect rapid dilatation with the bougie and finger, while the patient is under Fig. 581. Contorted Bougie in the Bladder. CHAP. XVI. DISEASES AND INJURIES OF THE URETHRA. 765 the influence of an anaesthetic, and then to seize the extraneous substance with a pair of delicate lithotomy forceps. When the ends are very sharp, or infixed in the wall of the bladder, the procedure must be conducted with unusual care, otherwise the organ may be seriously lacerated. Under such circumstances it is sometimes best to combine dilata- tion with incision. Cases in which pessaries were introduced into the bladder, either by mistake or design, have been reported by H. I?. Storer, Byford, Edwards, Woolen, and others. Removal should, if possible, be effected through the urethra, the foreign body being crushed, if necessary, to promote its passage. If the attempt fail, the dilatation of the urethra should be combined with incision, as in lithotomy. Extraction through the vagina is objectionable, as it is liable to be followed by obstinate, if not incurable, fistule. Should this procedure, however, be deemed indispensable, then the proper plan certainly would be to close the wound immediately with wire sutures, as in the ordinary operation for vesico-vaginal fistule. Of 22 lithotomies in the female for foreign bodies collected by Denunce, 2 out of 15 urethral or vaginal operations, and 5 out of 7 hypogastric, were fatal. SECT. Ill DISEASES AND INJURIES OF THE URETHRA. MALFORMATIONS. The urethra is liable to a variety of malformations, which, although, exceedingly rare, ought, nevertheless, to be well understood, on account of their great practical import- ance, and the sad effects which they exert upon the happiness of the poor sufferer. The most frequent diseases and accidents of this canal are inflammation, common and specific, wounds and lacerations, hemorrhage and foreign bodies, hypersesthesia, neuralgia, morbid growths, strictures, spasmodic and organic, fistules, and false passages. Gonorrhoea is described in a subsequent section, and of common inflammation of this canal nothing need be said here, as the treatment is conducted upon the same principles as in the specific disease. The most common congenital vices of the urethra are, first, closure or contraction of the meatus; and, secondly, absence, contraction, and change of form of the canal. CONGENITAL MALFORMATIONS. The external orifice of the urethra occasionally deviates from its normal situation, lying much higher up or lower down than usual; and cases occur where it is either ex- tremely small, or altogether occluded, thus interfering more or less completely with the passage of the urine, and becoming a source of vesical disease, as cystitis, irritability, and urinary calculus, or symptoms simulative of stone and other functional disturbance, as reflex paralysis, and reflex influence of the genital irritation upon the brain. I have met with a number of instances of double meatus, in none of which, however, more than one opened into the urethra, the other ending in a blind pouch. The urethra may be absent, as is exemplified in exstrophy of the bladder, in which both the urine and semen are discharged above the pubes. Authors have described what is called a double urethra, but of such a malformation no well-authenticated case has ever been reported. Sometimes the canal is bifid or cleft, forming a kind of gutter, running along the dorsal surface of the penis, and constituting what is denominated epispadias, as seen in fig. 582. Occasionally, again, it is deficient in front, but well formed behind, termi- nating, however, always in a narrow orifice, admitting of an imperfect discharge of the urine. It is to this variety of malformation that the term hypospadias is applied. Some of these defects are, of course, irremediable ; others, however, admit of relief, although generally not without great difficulty. Occlusion of the external meatus always demands prompt interference. When it is caused simply by a duplicature of the lining membrane, forming a sort of hymen, a vertical incision is generally all that is required, the edges of the wound being kept asunder by means of a tent or bougie. When the imperforation depends upon the presence of fibrous tissue, and reaches a considerable distance back, the opera- Fig. 582 Epispadias, 766 tion will be more serious, as it will require to be performed with a trocar. A narrow* meatus is easily relieved by a free incision in the direction of the frenum. Hypospadias and epispadias are defects- of a serious character, which, besides greatly inconveniencing their unhappy subjects, often serve as causes of impotence and sterility. Hypospadias occurs under three varieties of form, of which the most common, as well as the most simple, is the one in which the urethra opens immediately behind the frenum ; in the second, the tube opens at some point immediately between the first and the scro- tum ; and in the third, the urethra terminates at the latter organ, which is cleft at the middle line. The malformation, like harelip and analogous affections, is sometimes heredi- tary, and in a number of instances it has been observed in several members of the same family. In a case reported by Frank it occurred in a series of three generations. In the more simple variety of hypospadias, a cure may be attempted by paring the edges of the fissure and uniting them by means of interrupted sutures over a catheter introduced into the bladder. Any part that may remain unclosed may be touched with nitrate of silver. The same mode of proceeding is adopted when the fissure exists farther back, only that it will be necessary, in addition, to establish an artificial urethra by means of a trocar, pushed in the direction of the natural channel. The canal is kept pervious by a catheter, until it has received a mucous lining, after which the instrument should be worn for a few hours every day for a number of months. A perineal opening will expedite the cure. The treatment for the relief of epispadias is conducted upon the same principle as in hypospadias. In a case reported by Liston, in which nearly four inches of the urethra were exposed, a complete cure was effected in a few days. The operation consisted in paring the edges of the cleft thoroughly, and drawing them together over a catheter, by means of many points of the twisted suture. Union by the first intention took place in the entire track, except near the pubes, where a very minute fistulous opening remained, through which not more than a drop of urine oozed during micturition. This was afterwards closed with a heated needle. The organ was, in all respects, and for all purposes, as perfect as could be desired. A far better procedure for closing the urethra is that of Nelaton, w hich consists in making a longitu- dinal incision on each side, at the junction of the skin and mucous membrane, and refreshing the edges so as to make raw' surfaces, nearly an eighth of an inch in width, to which are attached the sides of a flap turned down from the hypogastric region. To main- tain this flap in position and prevent its retraction during the closure of the abdominal wound, it is covered by a crescentic flap taken from the scrotum, through which the penis is slipped, so that its raw surface lies in contact with the raw surface of the first flap, to which it is fastened by twisted sutures, as represented in fig. 583, from Richard. Whatever operation be selected, it is important to make a peri- neal outlet for the urine, through which its contact with the edges of the wmund is effectually prevented. WOUNDS AND LACERATIONS. Wounds of the urethra may be incised, punctured, lacerated, contused, or gunshot, as in other parts of the body, and they are either serious or otherwise, according to their extent and the absence or presence of complications. The treatment must be conducted upon general principles, accurate apposition of the edges being effected, if possible, by suture and collodion, and the escape of urine prevented by the use of the catheter per- manently retained, or, what is preferable, inserted several times in the twenty-four hours. Gunshot wounds of the urethra are always dangerous, inasmuch as they are very liable to be followed by urinary infiltration and permanent fistules. The tube may be ruptured by causes acting either from without, or from within. Under the first head may be comprised falls, blows, and kicks upon the perineum, or the perineum and penis; under the second, injury done by the lodgment of a calculus, the violent straining which attends micturition in stricture, and the rude, forcible, or injudi- cious use of catheters, bougies, and sounds. DISEASES OF THE URINARY ORGANS. CHAP. XVI. Fig. 583. Nelaton’s Operation for Epispadias. CHAP. XVI. HEMORRHAGE — FOREIGN BODIES. 767 Laceration of this canal occasionally occurs under a violent erection, especially if the penis, while in this condition, be struck accidentally against a hard, resisting body. The accident has also been known to happen during coition and during convalescence, after attacks of fever. The rent may be limited to the mucous membrane, or it may involve along with it all the tissues which intervene between the canal and the external surface. The symptoms are generally sufficiently characteristic. The most prominent are, pain in the affected part, hemorrhage, inability to void the urine, or the discharge of this fluid in a small and imperfect manner, discoloration of the perineum, or of the perineum, scrotum, and penis, and great difficulty, if not impossibility, of introducing the catheter. The patient is weak and faint, perhaps sick at the stomach, and labors under all the effects of severe shock. The treatment must be prompt and decisive, as there will be great danger of infiltration of the connective tissue of the perineum and scrotum, from the escape of urine. If the rent be small, the first thing to be done is to pass a catheter into the bladder, one being selected that is rather over than under the ordinary size. If, on the contrary, the injury is very extensive, or if some hours have elapsed since its occurrence, and the symptoms indicate urinary infiltration, numerous and deep incisions should at once be made into the affected parts. In conjunction with this treatment, local bleeding, purgatives, the warm bath, anodynes, fomentations, and poultices may advantageously be employed. HEMORRHAGE. Hemorrhage of the urethra occurs under two varieties of form, the spontaneous and traumatic, of which the latter is the more frequent. The spontaneous form is met with chiefly in elderly and middle-aged persons, of irregular, dissolute habits. It occasionally occurs during a violent erection of the penis. Traumatic hemorrhage, on the contrary, usually depends upon direct violence, as the passage of a urinary concretion, the introduction of instruments, or attempts to force a stricture. It is a very common consequence of injury of the perineum. The bleeding, however induced, is seldom copious. Hemorrhage of the urethra rarely requires surgical interference ; in most cases it either ceases spontaneously, or it is easily arrested by repose in the horizontal posture upon a hair mattress, by iced drinks, and by pressure, for a few minutes, upon the perineum, directly opposite to the part from which the blood proceeds. A cold enema sometimes puts a sudden stop to it. Ice applied to the perineum, and cold and astringent injections into the urethra, thrown high up, are very beneficial. When the case is obstinate, compression may be made by means of a large catheter, introduced into the bladder, and supported with a bandage, a finger, or adhesive strips. The most efficient internal remedies are gallic acid, ergot, and subacetate of lead, in combination with opium. Alum, given in large doses, is also useful. In very obstinate cases, recourse may be had to spirit of turpentine and tincture of the chloride of iron, in doses of ten drops each, repeated every hour. FOREIGN BODIES. Foreign bodies in the urethra may be arranged under two heads: 1st, those which descend from the urinary bladder, or which are developed in the canal itself; and, 2dly, substances forced into the urethra through its natural orifice. 1. Foreign Bodies which descend from the Bladder, or are developed in the Urethra.— Most of the substances which descend into the urethra from the bladder are simply earthy concretions, which are developed either in the latter organ, in the prostate gland, or in the kidneys. Sometimes, however, they consist of articles which were originally admitted through the urethra, and which have afterwards, in consequences of the force impressed upon them by the bladder in micturition, taken a retrograde course. The concretion may be developed in the urethra itself, but this is rare. Urethral calculi are very common in China. During a period of twenty-five years —from 1856 to 1881—not less than 85 cases occurred at the Missionary Society’s Hospital at Canton, in charge of Dr. J. G. Kerr. One of the concretions, weighing two ounces, was contained in a pouch of the urethra anterior to the scrotum. In one of the cases a cavity under the penis, communicating with this canal, an inch behind the meatus, was occupied by 291 calculi. 768 DISEASES OF THE URINARY ORGANS. CHAP. xvx. The passage of a calculus from the bladder along the urethra is frequently productive of great inconvenience and distress. The intromission is generally sudden and unexpected, taking place while the patient is engaged in micturition. It is instantly followed by an interruption of the stream of urine, an urgent desire to empty the bladder, severe straining, more or less pain, and a sense of burning or tearing in the urethra. If the substance is small, it may be expelled in a few minutes; if, on the contrary, it is disproportionately bulky, it may be permanently arrested, and give rise to severe suffering, from organic changes in the urethra accompanied by difficulty in micturition, painful erections, and slight hemorrhage. The symptoms attending the passage of a calculus along the urethra may be simulated by other affections ; therefore, to establish the diagnosis it is necessary to institute a care- ful examination with the finger and the catheter. When the substance is situated far back, as in the membranous or prostatic portion of the canal, the finger must be inserted into the rectum. In using the catheter, care should be taken that the substance be not pushed into the bladder. It is worthy of remark that, when the calculus has escaped from the urethra and lodged in the subjacent structures, the instrument may fail to detect it, even wdien it is of considerable size. A calculus, after having remained in the urethra for an indefinite period, sometimes effects its own expulsion by exciting absorption, and, finally, ulceration of the surrounding tissues. When the foreign body is lodged in the posterior portion of the tube, and obstructs the flow of urine, the safest plan is to push it back into the bladder; whereas, if it is com- paratively small, or unusually rough, it should be removed. Before doing this, however, an attempt should be made to favor its expulsion by dilating the urethra. Occasionally extrusion may be effected by injections of sweet oil, or by closing the prepuce, and hold- ing it tightly while the patient is making a powerful effort at micturition, at the same time that pressure is applied along the under surface of the urethra, to urge on the foreign body. When the calculus occupies the spongy portion of the tube, it ought to be extracted, whatever may be its size or form, provided it cannot be extruded during micturition. When it is situated near the orifice of the urethra, it may readily be removed with a pair of narrow-bladed dissecting forceps, but if it be far back in the canal, a wire-loop, as orignally suggested by Marini, may be used. The only objection to this instrument is the difficulty of passing it behind the concretion, which, when large enough to lodge, usually fills up the entire passage. The late Professor Ilodgen, of St. Louis, published, in 18G8, the particulars of two cases, in which he promptly effected riddance of the foreign substance with a contrivance of a similar kind. When these simple means fail, recourse must be had to the urethral forceps, of which there is a great variety. The one to which I give the preference is the articulated scoop, fig. 584, of Bonnet, of Lyons, but it is applicable only to small substances. It is armed Fig. 584. Bonnet’s Articulated Scoop. with a stylet, and is furnished with a head for seizing and fixing the foreign body. The instrument, well oiled, is brought in contact with the concretion, when its blades are ex- panded over it, and extraction efFected in the most slow and gentle manner, to prevent injury of the mucous membrane. Fig. 585 represents Hunter’s forceps, as improved by modern surgeons, for removing urethral calculi. Fig. 585. Hunter’s Forceps. Crushing is applicable only when the calculus is soft and friable ; but as this can hardly ever be known beforehand, it is rarely available. The operation, moreover, is seldom safe. CHAP. XVI. MORBID SENSIBILITY. 769 Excision, which becomes necessary when extraction fails, varies according to the situation of the foreign body. When the concretion is lodged in the prostatic or membranous portion of the canal, it is performed very much after the manner of Celsus, in cutting on the gripe, the left index finger being inserted into the rectum, to protect the tube from harm, and a small incision being made in the direction of the raphe of the perineum. When the calculus is impacted in the navicular fossa, or even farther back, its extrac- tion may generally be easily effected with the forceps represented in fig. 586. Or, this failing, an incision may be made over it, along the floor of the urethra, opposite the head of the penis. Fig. 586. Forceps for Extracting Foreign Bodies from the Urethra. When the foreign body lies in the scrotal portion of the urethra, incision must be prac- tised with great caution, lest it be followed by infiltration of urine, and all the bad conse- quences of such an accident. In such a case, it would be advisable to cauterize the wound immediately with nitrate of silver, to favor the deposit of lymph, and to abstain from micturition until the parts are thoroughly consolidated. Or, instead of this, an incision might be made through the skin and connective tissue over the tumor, and the wound stuffed with lint. The requisite amount of inflammation having been excited, the operation is completed by dividing the parietes of the urethra in the usual manner. 2. Foreign Bodies introduced from without Of foreign bodies introduced into the urethra from without, the number and variety are very considerable. The occurrence is sometimes fortuitous, but more frequently it takes place through design. Bits of cathe- ters, bougies, quills, pipe-stems, wood, straw, and other substances, have been accidentally lodged in the urethra, by persons in their endeavor to draw off the urine, relieve a stric- ture, or provoke seminal emissions. Foreign bodies, introduced into the urethra from without, have a great tendency to pass into the bladder, owing to the suction power of this organ. Very frequently, how- ever, they become impacted in the tube, and they may then, unless they are situated very far back, be usually readily extracted with a pair of delicate forceps, such, for instance, as those represented in fig. 586. MORBID SENSIBILITY. This affection consists mainly, if not exclusively, in an exaltation of the natural sensi- bility of the mucous membrane of the urethra. It is very frequent in both sexes, but much more so in men than in women, and is caused by a great variety of circumstances, not always easy of recognition. In the male it is often dependent upon the effects of gonorrhoea and gleet, stricture of the urethra, and enlargement of the prostate gland ; and, in both sexes, upon disorder of the bladder, kidneys, ureters, anus, and rectum. It sometimes attends inflammation, ulceration, and other derangement of the uterus, vagina, and vulva. A morbid state of the urine may not only induce but maintain it for an indefi- nite period. Of all the causes, however, masturbation and inordinate sexual indulgence are probably the most common. The symptoms are subject to great diversity, both as it respects their nature and de- gree. In the more simple forms of the disease, there is merely an exaltation of the nor- mal sensibility of the mucous membrane. When the affection is more fully developed, the local distress is not only more severe but it often extends to the surrounding parts, as the perineum, groin, anus, pubes, and genital organs. The bladder also suffers, some- times sympathetically, and at other times from actual extension of the disease. Occa- sionally the symptoms simulate those of stone in the bladder. When the disease exists in this aggravated form, there is always marked disorder of the general health. When 770 DISEASES OF THE URINAKY ORGANS. CHAP. XVI. the posterior portion of the tube is involved, seminal emissions are apt to take place. The urine is variously altered in its properties; in general, it contains an undue quantity of mucus, and not unfrequently it exhibits, under the microscope, different deposits, espe- cially oxalate of lime and phosphates. The best mode of determining the precise nature of this disorder is the introduction of the conical steel bougie, which is passed with the greatest care and gentleness. By this means we are able to ascertain the extent and degree of the sensibility, and also whether there is stricture of the urethra, enlargement of the prostate gland, or disease of the blad- der. It should be remembered that the healthy urethra is often so extremely sensitive on the first introduction of a catheter as to cause severe shock, if not actual syncope. The pathology of this disease is not accurately ascertained. It is no doubt occasionally caused by inflammation, either subacute or chronic ; but very frequently it consists merely in an exaltation of the normal sensibility of the mucous membrane. In the treatment of this affection, one of the first objects should be to ascertain and remove the exciting cause. Marked relief commonly follows the use of bicarbonate of sodium, either alone or in union with uva ursi and hop tea, mild laxatives, and anodyne injections, with the addition of a small quantity of Goulard’s extract. The general health must be attended to. The introduction of a full-sized steel bougie, at first once and after- wards twice a day, is sometimes productive of the best results. In this way, moreover, the affected surface may be directly medicated ; the dilute ointments of nitrate of mer- cury and belladonna are, especially if used in combination, entitled to the first rank in the list of this class of remedies. When there are involuntary seminal emissions, hardly anything short of cauterization of the prostatic and membranous portions of the urethra will be likely to succeed. Whatever mode of treatment be adopted, the patient should refrain from sexual indulgence and exercise on horseback. Opiate suppositories often afford great relief. The best internal remedy, when there is no appreciable local cause for the disease, is, on the whole, the bromide of potassium, given in doses of twenty to thirty grains three times a day, either alone or in combination with chloral and belladonna. It seems to act as a sedative, by making a direct impression upon the affected parts. NEURALGIA. Neuralgia of the urethra is most common soon after the age of puberty, in persons of a nervous, excitable temperament. It is much more frequent in males than in females. Its origin is generally obscure. External injury, masturbation, and venereal excesses are among the most common exciting causes. It is sometimes dependent upon a miasmatic condition of the system. The pain is of a sharp, pricking character, darting about in different directions with the rapidity of lightning; it often remits or intermits for a short time, and then recurs with its former violence ; it is generally attended with considerable soreness of the urethra and penis, a frequent desire to micturate, and scalding in voiding urine. In some cases the disease is periodical. The treatment is to be conducted in the same manner as in neuralgia in other parts of the body. The cause is, of course, if possible, removed, after which recourse is had to quinine, arsenic, strychnia, and aconite. When the affection is of a purely miasmatic origin, no other treatment is generally required. In the milder forms of the disease, qui- nine alone will often speedily effect a cure. In obstinate cases, valerianate of iron some- times succeeds when all other remedies fail. Little is necessary in the way of local treatment. During the paroxysm, the penis may be immersed in warm water, or fomented with hot cloths impregnated with laudanum. An ointment of veratria and belladonna, and the use of a thick flannel stall to protect the penis from atmospheric vicissitudes, are occasionally of service. It need scarcely be added that all sexual excitement should be avoided. FIBROUS TUMORS. These tumors, which may be polypoid or papillary, occur in both sexes, and in different portions of the urethra. In the male, the most common site is the anterior part of the tube, just behind the meatus. In women they are generally situated superficially, some- times projecting beyond the external orifice of the urethra. In the male, polypoid growths are usually small, their volume rarely exceeding that of an apple-seed. They are of a soft, spongy consistence, of a red color, and of a pyriform, CHAP. XVI. SPASMODIC STRICTURE. 771 conical, or spherical shape, their attachment being usually by a small pedicle. In general, they are solitary, but I recollect one instance in which there were not less than three situated close together. Their surface is sometimes perfectly smooth, at other times slightly granular, rough, or studded with papilla;. In regard to their structure, they con- sist of succulent, delicate fibrous tissue, invested by a prolongation of the lining membrane of the urethra. A good idea of this variety of morbid growth is afforded by fig. 587, from Thompson. These polypoid tumors are generally free from pain, in which respect they differ re- markably from the vascular papillary growths in and around the female urethra. They are usually attended by a thin, gleety discharge, but they seldom materially obstruct micturition. Their development is tardy and insidious, and they do not often manifest any disposition to reappear after ex- tirpation. When deep seated they may exist for years without the possibility of detection. The removal of these excrescences is best effected by excision with the knife or scissors. The surface should always be touched immediately after with Fig. 587. Fig. 588. Polypoid Fibroma of the Urethra, Papilloma of Urethra. nitrate of silver or sulphate of copper. When situated low down in the urethra, they may sometimes be caught in the loop of a silver wire, especially if they have a very narrow pedicle. A papillary fibroma, villous fibroma, or papilloma, occasionally occurs in the male urethra as a result of inflammation of its mucous membrane. It is usually multiple, and presents itself as a congeries of long, filamentous, dendritic villi, or as a lobular mass resembling a cauliflower, as in fig. 588, from Lambl. The symptoms and treatment of this form of fibrous growth do not differ from those of polypoid fibroma. SPASMODIC STRICTURE. Stricture of the urethra occurs under two very distinct forms, the spasmodic and organic, or the transient and permanent. What has been called the inflammatory stricture, an affection still recognized by some authors, is simply an impediment to the flow of the urine, caused by a congested and irritated condition of the canal, attended, in rare cases, by cellular proliferation upon the free surface of the mucous membrane, such, for ex- ample, as occasionally happens in a severe attack of gonorrhma. It is not, strictly con- sidered, a stricture, although it is liable to be attended with spasmodic action. A conges- tive stricture has been described, dependent, as has been alleged, upon an engorged con- dition of the capillary vessels of the lining membrane and connective tissue, thereby leading to a diminution of the urethra with consequent difficulty of micturition. The possibility of the occurrence of a spasmodic stricture of the urethra has been denied by many able writers and practitioners. A recent English author, in speaking of it, says: “ I will tell you what a spasmodic stricture is. It is exceedingly useful as an excuse for the failure of instruments. It is a refuge for incompetence.” Others, on the contrary, strenuously insist upon the reality of such a stricture; and, considering how frequently it is met with, it is only surprising that there should be any difference of opinion respecting it. Other mucous canals are liable to this form of stricture, and there is no reason, ana- tomical or physiological, why the urethra should be exempt. Spasmodic stricture of the 772 DISEASES OF THE URINARY ORGANS. chap, xvi. (esophagus is of frequent occurrence, especially in nervous, irritable females ; vaginismus, so well described by Dr. J. Marion Sims, is a spasmodic contraction of the vagina, inter- fering with copulation ; and in fissure of the anus one of the most distressing symptoms is spasmodic stricture of the sphincter muscles. Spasmodic stricture of the larynx often causes instantaneous suffocation. It is not surprising that the urethra should be subject to this form of stricture when it is remembered that it is completely encircled, from one ex- tremity to the other, by muscular fibres, not to insist upon the fact that, in certain condi- tions of the genito-urinary apparatus, it must be influenced, in a greater or less degree, by the action of the accelerator muscles and by the muscles of Wilson and of Guthrie, which so closely embrace the posterior portion of the canal. Every surgeon knows how firmly a bougie is sometimes grasped by the urethra, and how easily a spasmodic stricture is gener- ally overcome by the mere contact of the catheter in retention of urine, the fluid often beginning to flow long before the instrument has reached the bladder. The causes of spasmodic stricture of the urethra are of a very diversified nature. Among the more prominent are, sudden suppx-ession of the cutaneous perspiration, espe- cially in persons of a rheumatic, gouty, neuralgic, or scrofulous predisposition ; venereal excesses and self-abuse; disease of the urethra, bladder, prostate gland, ureters, and kid- neys ; calculous affections; vitiated renal secretions; the lithic, oxalic, or phosphatic diathesis; reflected irritation from the anus and rectum, as in hemorrhoids, fissure, and fistule ; disorder of the digestive apparatus ; spinal irritation ; mental excitement from an overworked brain ; and intemperance in eating and drinking. One of the worst cases of spasmodic stricture of the urethra that I have ever met with occuri'ed in a young man, the subject in eaidy life of coxalgia, from drinking a glass of champagne, the attack being sure to recur whenever he indulged in that way. Similar effects occasionally follow the use of red wine, punch, malt liquors, and high-seasoned food. A long residence in a tropical climate conjoined with free living exerts a powerful pi'edisposition to the complaint. The more severe forms of organic stricture of the urethra are almost invariably attended by spasmodic sti'icture of this canal. In the female the affection is frequently produced by reflex iri’itation from the utenxs, in dysmenoi'rhcea, malpositions, and carcinomatous dis- ease of that organ. The pathology of this variety of stricture is not easily determined. The probability, however, is that it genei*ally depends upon mei*e ix*ritation of the muscular fibres of the urethra, attended, perhaps, by tempoi’ary congestion of its various component stiaxctures. In the so-called inflammatox-y strictui'e the vascular engorgement is doubtless more per- sistent, and often associated with inflammatory deposits. The spasmodic stricture is essentially characterized by anarrowingof the ui'ethra, attended with painful and difficult micturition. The contraction is commonly limited to some par- ticular portion of the canal, and the membranous is the one which is most liable to suffer, probably because it is naturally the narrowest, and because it is embraced by voluntary as well as involuntary muscular fibres. Cases, however, occur, although they are l’are, in which the contraction apparently pervades the entire tube. The attack usually comes on suddenly, generally from exposure to cold, in which the surface of the body has been severely chilled, the inordinate use of wine, stimulating food, or excessive sexual indul- gence, especially if the genito-urinary oigans have already been in an irritated condition. The patient, on attempting to empty his bladder, finds that he can void only a few drops of urine at a time, or that the fluid passes off in small, feeble jets, without affording him any decided relief. The effort is attended with great straining and tenesmus, along with a feeling of weight and uneasiness in the perineum and anus, and there is moi’e or less scalding along the neck of the bladder and the whole length of the urethra, often so great as almost to convulse the system. As soon as the bladder is completely emptied, the con- traction generally subsides, to recur, perhaps, with its former, if not inci’eased, violence, the moment almost that the urine begins to I'eaccumulate ; and thus the attack may con- tinue for hours and even days, with occasional complete intermissions of suffering. When the stricture is very severe, and prompt relief is not obtained, symptomatic fever arises, the skin becomes hot and dry, the pulse is excited, and there is more or less thirst, with disorder of the secretions, restlessness, and loss of sleep. The urethra is generally entirely free from discharge, except in cases complicated with, or directly dependent upon, inflam- mation, when there may be moi’e or less purulent secretion, accompanied with swelling and discoloration of the edges of the meatus. Occasionally painful and annoying erections are present. The treatment is palliative and radical. The first thing generally to be done is to relieve the bladder, the spasm usually subsiding the moment the organ is completely CHAP. XVI. ORGANIC STRICTURE. 773 emptied. The most efficient remedies are anodynes, the warm bath, and hot applications to the hypogastrium, perineum, and genitals. A hypodermic injection of morphia gene- rally affords the most speedy relief. Dover’s powder and laudanum enemas are highly beneficial. Sometimes nothing answers so well as the passage of a catheter, well warmed and oiled, and carefully introduced as far as the seat of the obstruction, which often yields the moment the contact is effected, the urine flowing in a full stream, followed by instan- taneous relaxation of the parts. The radical treatment is based upon the removal of the exciting causes of the com- plaint, and the improvement of the general health, by a proper regulation of the diet, attention to the bowels and secretions, suitable clothing, and exercise in the open air, aided, if there be an anemic condition of the system, dyspepsia, or general debility, by a course of chalybeate tonics, cold bathing, and frictions with the flesh-brush. All stimu- lating food and drink, and all kinds of excesses must be carefully avoided, as they are so many exciting causes of the disorder. ORGANIC STRICTURE. Organic stricture is a permanent obstruction, depending upon the formation of new tissue elements in the component structures of the urethra, where they give rise to a dense, resisting, cicatricial substance, which, encroaching more or less seriously upon the caliber of the passage, thus cause a corresponding obstacle to the evacuation of the urine and the introduction of instruments. Organic stricture presents itself in various forms and degrees. Thus, it may be simple or complicated, common or traumatic, partial or complete, soft or callous, dilatable or un- dilatable, permeable or impermeable, recent or old; terms which sufficiently explain themselves. Much diversity prevails in relation to its seat, number, shape, consistence, and extent. No part of the urethra, except, perhaps, the prostatic, is entirely exempt from this disease. My experience is that the affection is most common, first, in that portion of the urethra which is comprised between the scrotum and the head of the penis; secondly, at the membranous part of the tube, or at the junction of this and the bulbous part; and, lastly, at the anterior extremity within a few lines of the meatus. Stricture at the pros- tatic portion of the canal has been found only in a very few instances. The anterior orifice suffers occasionally, as a result of chancre, gonorrhoea, or masturbation. The seat of this disease has been very carefully examined by Mr. Henry Smith and Sir Henry Thompson. According to the former, it is most common in the bulb, or just in front of it, and about equally frequent in the membranous and spongy portions, and very rare at the meatus. The number of specimens inspected by the latter observer was 270, embracing 320 distinct strictures. Of these, 215, or 67 per cent, of the entire number, were situated at the junction of the membranous and spongy portions and its vicinity; 51, or 16 per cent., in the centre of the spongy portion; and 54, or 17 per cent., at the ex- ternal orifice, and within two inches and a half behind this point. In 226 cases, the stricture was single, and in 185 of these it was situated at the first locality, and in 24, in the anterior part of the spongy portion. In most cases, there is only one stricture; frequently, however, I have seen two, and occasionally, but very rarely, three, and even four. Hunter met with an instance of six, Lallemand of seven, Colot of eight, Leroy and S. W. Gross of eleven, and Otis of thirteen. Stricture is met with under several varieties of form. One of the most common is the linear, fig. 589, from Thompson, in which the urethra exhibits the appearance of being constricted by a thread. The annular stricture, fig. 590, is usually from one-fourth to one-third of an inch in extent, and involves the tissues to a greater depth than the preceding form. When indurated, the new tissue replaces nearly all, if not all, of the tissues of the urethra. Stricture of the meatus, of a very tight, callous character, is said to be very common among Jews. Dr. C. H. Mas- tin, of Mobile, whose opportunities for investigating this subject have been unusually great, declares that 95 per cent, of the young Israelities of Southern Alabama, are Fig. 589. Linear Stricture of the Urethra. 774 DISEASES OF THE URINARY ORGANS. CHAP. XVI. affected in this manner, and he ascribes the occurrence to the influence of the long-con- tinued friction experienced by the head of the penis after the removal of the prepuce, causing irritation in the mucous membrane of' the anterior extremity of the urethra, attended with a deposit of plasma, and the transformation of this substance into fibrous tissue. A very rare obstruction, called the bridle stricture, fig. 591, is occasionally met with. It consists of a small, narrow band stretched across the urethra from one side to the other, and is probably nothing more than a short false passage, or a portion of partially detached mucous membrane. Sometimes it is arranged so as to divide the canal into two parts. The contracted portion may be soft and elastic, or hard and firm, according to the duration of the disease, and the degree of transformation of the new tissue, upon the presence of which it essentially depends. Fig. 590. Fig. 591. Annular Stricture of the Urethra. Are strictures of the urethra ever impermeable? Much has been said and written upon this subject, especially ot late, and it is, therefore, very important that the meaning of the term should be clearly defined, and accurately understood. As long as a stricture admits of the discharge of urine, it cannot, in the true sense of the term, be considered as impermeable, although it may be impassable by the bougie, sound, or catheter. A stricture that is impermeable to urine is very uncommon; never- theless, it occasionally occurs, both in the male and female. It has been asserted that there is no stricture that is impermeable to an instrument of some kind or other; that whenever there is room enough tor the passage of urine, there is space enough for the introduction ot a bougie or probe; and that, when the surgeon fails to accomplish his object, his want ot success is attributable rather to his own awkwardness than to the nature of the obstruction. I he fact that this kind of stricture is ignored by certain pathologists, by no means proves its non-existence. I he urethra, for example, may be very tortuous, crooked, or zigzag, or there may be a multiplicity of coarctations, so seriously changing the natural relations of the tube as to offer an insurmountable obstacle to the passage of the smallest instrument in the hands of the most adroit and accomplished operator; but I go farther, and assert, upon the testimony of personal experience, that there is a class of cases, the result of ordinary causes, which, while they admit of the flow of urine, slowly and imper- fectly it may be, do not permit the introduction of any instrument, however small, into the bladder. 1 he symptoms of stricture, considered generally, are, a diminution of the stream of urine, which is usually spiral, forked, or dribbling, with temporary retention of the last few drops; frequent, slow, and difficult micturition, often preceded, accompanied, or fol- lowed by a sense of scalding; a discharge of thin, gleety matter from the urethra; uneasi- ness about the loins, perineum, and anus; pain in coition ; nocturnal emissions; elongation and thickening of the penis; and hardness at the seat of the obstruction, detectable by the finger. During the progress of the disease, the patient is liable to be troubled with swelling of the testicle, chordee, hemorrhoids, hernia, and retention or incontinence of urine. The general health is variously affected, and the slightest exposure, fatigue, in- Bridle Stricture of the Urethra. CHAP. XVI . ORGANIC STRICTURE. 775 temperance, or irregularity in eating, is sure to be followed by an exacerbation of the local suffering. Persons affected with stricture are generally excessively irritable, and remarkably sus- ceptible to atmospheric vicissitudes. They are often, so to speak, perfect barometers. The digestive organs are always more or less affected; the alimentary canal is the seat of annoying flatulence; there are frequent acid eructations; the bowels are costive; the tongue is coated, especially in the morning; the head is distressed with dull, aching sen- sations; the sleep is disturbed by unpleasant dreams; pain and soreness are felt in the sacrolumbar region, perineum, groins, and pelvis; and the urine, scanty and high-colored, is loaded with urates and an inordinate quantity of mucus. Reflex sciatica, lumbago, and partial paralysis are occasional occurrences, especially in persons of a very nervous temperament. The sexual powers are generally more or less impaired, and, in the more severe forms of the affection, the individual is nearly always impotent. If relief be not obtained, the case gradually proceeds from bad to worse; the strength steadily declines; the flesh wastes; and the sufferer at length expires in a state of complete exhaustion, often preceded by pyelitis, or Bright’s disease. Although the above symptoms are, in general, sufficiently denotive of the actual nature of the disease, they can, nevertheless, not be regarded as pathognomonic. To establish an unequivocal diagnosis, the urethra must be explored with some instrument. The one which I usually select for the purpose is a common silver catheter, of moderate size, and a little conical at the extremity, which is passed down the tube, first to the obstruction, then into it, and, lastly, if possible, beyond it. In this manner, an idea is easily obtained of the seat and extent of the stricture, as well as of its consistence. When greater accuracy is required, I use a bulbous or acorn-shaped bougie, represented in fig. 592, carried slowly Fig. 592. Bulbous Bougie. down to the obstruction, upon reaching which a mark is made upon it with the thumb-nail immediately in front of the head of the penis. This will indicate the precise distance of the stricture from the external orifice of the urethra. By slow and cautious manipula- tions, the bulb of the instrument may be insinuated through the stricture, a second mark indicating the extent of the latter when the shoulder of the bulb meets with resistance during its withdrawal. It will also be found to be highly useful when there is more than one coarctation, as the stem, which is several sizes smaller than the bulb, permits it to move freely in the first, which cannot happen with the ordinary silver catheter. The bougie, of which there should always be several sizes at hand, as it passes through the stricture, usually causes considerable uneasiness, and more or less pus or muco-pus almost invariably collects around its neck, thereby affording valuable diagnostic aid. All examinations of this kind should be conducted with the utmost gentleness. A tolerably correct idea of the nature, seat, and extent of a stricture may sometimes be acquired by the application of the thumb and finger along the under surface of the penis. These remarks are, of course, chiefly applicable to coarctations of the spongy portion of the urethra. The pathological effects of stricture deserve particular study. The affection seldom exists for any length of time, without giving rise to disease more or less serious, in the adjoining and associated parts. The organs which, besides the urethra, are most liable to suffer, are the prostate gland, bladder, ureters, and kidneys. The testes, penis, seminal vesicles, perineum, and rectum, also, not unfrequently, participate in the evils consequent upon the malady. An occasional, as well as a most serious, effect of stricture is a dilatation of the urethra behind the seat of the obstruction, as represented in fig. 593. This is evidently owing to the manner in which the urine is habitually impelled against the stricture. The canal in front of the obstruction is either normal, diminished, or dilated. When the obstruc- tion is seated in the posterior part of the urethra, the orifices of the prostatic ducts are sometimes so much enlarged as to offer a serious impediment to the passage of conical in- struments. This effect is well shown in fig. 594, from Thompson, the peculiar retiform appearance being due to the interlacement of the septa which intervene between the dilated openings. Another consequence of stricture is the development of fistule in the perineum, caused 776 DISEASES OF THE URINARY ORGANS. by ulceration or rupture of the mucous membrane behind the seat of the obstruction, and the escape of a small quantity of urine into the subjacent tissues. CHAP. XVI. Fig. 593. Fig. 594. Stricture of the Urethra, with Dilatation of the Tube behind the Obstruction. Stricture of Urethra, with Dilated Prostatic Ducts. The most common lesion of the prostate gland, in tight, callous, and protracted stricture, is inflammation of the substance of the organ, eventuating occasionally in the development of an abscess, calculous concretions, or great atrophy. Sometimes the gland is converted into a membranous pouch. The bladder, in confirmed cases, soon becomes hypertrophied, and finally sacculated. There is also not unfrequently a remarkable proneness to the development of urinary calculi, and the lining membrane is in a constant state of inflammation, attended with an inordinate deposit of mucus, or even of muco-purulent, fluid. 1 he most common lesions of the ureters are inflammation of their lining membrane, suppuration, deposits of lymph, and irregular dilatation of their caliber. Their parietes are often greatly thickened. I he kidneys are variously affected. Inflammation frequently occurs at an early period, and gradually progresses until it ends in serious mischief, if not in total ruin, of the affected structures. I he adjoining sketch, fig. 595, strikingly illustrates the effects of Fig. 595. Disease of the Kidney, Bladder, Ureter, and Prostate Gland, from Stricture of the Urethra. stricture of the urethra upon the rest of the urinary organs. The prostate gland is com- pletely destroyed, the mucous membrane of the bladder is removed by ulceration, the ureter is immensely enlarged, and the kidney is converted into a mere shell, tilled at the CHAP. XVI. ORGANIC STRICTURE. 777 time of the dissection with purulent matter. The drawing is from a specimen in the pa- thological collection of the New York Hospital. The causes of stricture may be conveniently arranged under two heads, the traumatic and the pathological. Of these, the latter are by far the more common. The particular kind of injury giving rise to the disease is generally a blow, fall, or kick upon the perine- um, eventuating in a contusion or laceration of the lining membrane, or of this mem- brane and the subjacent tissues. A bad stricture occasionally results from the maladroit use of a catheter or a bougie, and from the cicatrice left after lithotomy. Of the pathological causes of stricture by far the most frequent are gonorrhoea and masturbation. Judging from my own experience I am inclined to believe that these causes are operative in a nearly equal degree. A protracted attack of gonorrhoea, especially if badly treated, as when very severe, or irritating injections are used, is almost sure to eventuate in the formation of stricture ; and the inflammation set up in the mucous and submucous tissues of the urethra by long-continued, or frequently repeated, masturbation is hardly less certain to be a cause of this disorder, often of the very worst kind. Young men, who so commonly indulge in this vice, are especially prone to suffer in this manner, not unfrequently followed by sexual debility and various reflex complaints as distressing to the patient as they are annoying to the surgeon, from the difficulty which he experi- ences in removing them. A severe form of stricture is occasionally met with at, or immediately behind, the meatus, as an effect of chancre ; and Mr. Henry Lee, of London, has adduced facts going to show, very conclusively, that this disease is, at times, a result of tertiary syphilis. The prognosis is variable. Stricture, if early attended to, or before it has become hard or firm, or while it is still recent, and before it has occasioned any serious lesion of the urinary apparatus, is commonly neither dangerous nor difficult of cure. When, however, it has made considerable progress, offers much resistance to the passage of the urine, and has excited inflammation in the neighboring organs, it may be considered as a very seri- ous affection, liable, if permitted to proceed, to be followed by the worst consequences. It may be stated, as a rule, that a recent stricture is much more easy of cure than an old'; a small, than a large; a soft, than a callous ; a pathological, than a traumatic. Furthermore, a stricture of the membranous portion of the urethra is usually more diffi- cult to manage than one of the spongy. An obstruction in this situation is also more liable to awaken serious disease of the prostate gland, bladder, ureters, and kidneys. When a stricture is old and callous it is not only irradicable, that is, hopelessly incura- ble, but it may gradually so far undermine the general health as to cause death. Some- times the brain sympathizes with the urinary troubles, and a slow, subacute inflammation, attended with coma, is set up in this organ and in the arachnoid membrane, eventuating at length in fatal serous effusion. The worst forms of stricture, especially if unusually protracted, are almost invariably followed by pyelitis, suppuration, abscess, or albuminuria. Finally, a hard, tight stricture may be a cause of sterility, by interfering with the ejaculation of the semen, the fluid, instead of passing off in the usual manner, being forced into the bladder, where, mingling with the urine, it is speedily devitalized. Treatment Different methods are employed for effecting the permanent cure of stric- ture. Of these the most important are dilatation, rupture, incision, and external divis- ion, each of which has been more or less modified, according to the prejudice, whim, or caprice of practitioners. Before resorting, however, to any of these expedients, it is a matter of the first moment to subdue local inflammation, attend to the general health, and ascertain the normal calibre of the urethra. Too much stress cannot be laid upon the first of these injunctions. A week, ten days, or even a fortnight may sometimes be advantageously spent in this manner. Even in very simple strictures the parts are occasionally wonderfully sensitive and intolerant of operative interference; but there is a class of cases in which the morbid sensibility is so excessive as to be entitled to be designated by the phrase, “ noli me tangere,” where, if the parts and the system be not properly prepared, the most serious, if not fatal, consequences will be sure to arise. I have seen a number of such examples, and the occurrence must be familiar to every surgeon of any experience in the treatment of genito-urinary diseases. Such patients are as sensitive as sensitive plants. The slightest touch knocks them over ; the system is overwhelmed by shock ; a severe chill or rigor generally follows; all the secretions are speedily disordered; nausea and vomiting are often present in a high de- gree, and delirium is seldom entirely absent. Severe hiccough is sometimes a distressing and obstinate symptom. In a word, the case not unfrequently assumes a most alarming aspect within a few hours after the interference, and the patient is fortunate if he escapes with his life. 778 DISEASES OF THE URINARY ORGANS. CHAP. XVI. In such cases as these, which must be coaxed, not forced, the only safe plan, especially when the stricture is very tight, is either to perform the perineal section or to accustom the urethra gradually to the use of the bougie, inserted gently, as far as the seat of the stricture, until the mucous membrane is deprived of its morbid sensibility. With the same view injections of acetate of lead and opium may be employed ; and much benefit often accrues from an anodyne suppository. Great advantage may be derived, especially it the part be studded with granulations, from cauterization with nitrate of silver, performed Fig. 596. with the porte-caustique, fig. 596, an instrument which I devised many years ago, and which is far superior, in point of safety, to that of Lallemand, still so much used in this country. It is shaped like a catheter, and is closed at the vesical extremity, near which, at the convex surface, there is an elongated aperture, through which, by means of a cup in the stylet, partially filled with fused nitrate of silver, the cauterization is effected by a rotatory movement of the tube, the operation being repeated once every five or six days. The application usually causes some pain and scalding, for the relief of which an anodyne is sometimes required. The system is not neglected ; the diet is properly regulated ; disordered secretion is rectified, and the bow- els are maintained in an open condition. Rest in recumbency is of para- mount importance. When the way has been thus paved, the particular kind of treatment is to be determined by a careful consideration of the na- ture, seat, and extent of the obstruction, the idiosyncrasy of the patient, and every other circumstance likely to influence the result. The object being the restoration of the normal calibre of the urethra, no measure will be successful unless the size of the canal be ascertained in each individual case, and the contracted part brought up to that standard. Hence, a careful exploration should be made with the urethrometer of Otis, represented in fig. 597. Being inserted in its closed state, the bulb is expanded to the point of filling the urethra comfortably, when the index on the dial indicates in millimetres the normal distensibility of the canal. Other measures for determining this fact cannot be relied upon. 1. Dilatation—Dilatation is mainly applicable to the milder forms ot stricture, and may be performed either gradually or continuously, the choice of the procedure depending upon the exigencies of the particular case. Whatever method be adopted, the instrument should always be well warmed and oiled, and in the more callous forms of stricture it is a good plan to throw a little oil into the urethra as a preliminary step, inasmuch as it materially facilitates the passage of the bougie. d. In gradual dilatation the object is to proceed as cautiously and gently as possible, so as to avoid all risk of irritation, commencing with an instru- ment that will readily pass the obstruction, and using afterwards a series of steadily increasing sizes until the cure is perfected. The instruments usu- ally employed for effecting gradual dilatation are the flexible French gum- elastic bougies, the vesical extremities of which may be olive-shaped, coni- cal, or fusiform, as in figs. 598, 599, 600, 601, the first being the one gene- rally preferred, as, from its peculiar conformation, it most readily surmounts the usual impediments to introduction. The length of the instrument varies from a few inches to that of an ordinary catheter. When the ob- struction is seated near the anterior orifice of the urethra, a short bougie is generally more convenient than a long one. When the stricture is unsually tight, a solid and resisting instrument is required, and this may be either an ordinary silver catheter, or, what I decidedly prefer, a nickel-plated steel bougie, fig. 604, furnished with a heavy handle, its vesical extremity having a short curve and terminating in a somewhat conical point. The great advantage of this instrument is its weight, which, provided it is properly Porte-caustique. Fig. 597. Otis’s Urethro- ttle ter. CHAP. X VI . ORGANIC STRICTURE. 779 guided,materially facilitates its passage through the obstruc- tion without the risk ot‘ making a false passage. Whatever form of bougie be selected, its size is gradually increased, and the introduction is repeated, at first, every second or third day, and subsequently, when the canal has become more tolerant of the operation, once every four-and-twenty hours, the retention at each sitting lasting from five to fifteen minutes. When the dilatation is considerably ad vanced, the cure will be materially expedited if a small instrument, one that readily enters the stricture, be occa- sionally inserted, followed immediately by a larger one, carried into the bladder, and almost at once withdrawn. The treatment by gradual dilatation is always tedious, and, in the end, very frequently unsatisfactory, relapses being the rule, and complete cures the exception. Its success is based upon the action of the absorbent vessels, stimulated by the contact of the instrument to the removal of the new tissue, upon the presence of which the obstruc- tion depends. It is, therefore, applicable only to cases of recent origin, or to very soft strictures, and I am decidedly of opinion that it should, as a rule, give way to divulsion or internal incision. In the management of very tight or tortuous strictures, and strictures complicated by great induration of the perineum, it is sometimes impossible to overcome the ob- stacle with the ordinary instruments, when the olivary, filiform whalebone bougies, fig. 602, will prove invalua- ble. Those with spiral points, or bent at an angle near their extremities, are especially serviceable, when the opening of the obstruction is eccentric. Their passage is facilitated by previously injecting the urethra with oil, and imparting to them a rotatory movement. If much dif- ficulty has been experienced in the introduction of one of these contrivances, it should be tied in, and another passed by its side on the following day, their insertion being continued in this way until the stricture is sufficiently dilated to admit the ordinary instruments. jS. When a stricture is so tight as to give rise to con- siderable difficulty in its penetration, the more especially if it be very sensitive, or of a contractile nature, the treat- ment may be greatly expedited by substituting for the slow method of gradual dilatation that of conthiuous or permanent dilatation. With this object in view, the pliant, elastic catheter, which adapts itself to the natural curves of the urethra, without being productive of the irritation so liable to follow the use of the silver instrument, is passed, if necessary, upon a curved steel stylet, through the ob- struction, and retained until it becomes loosened, which usually happens within the first forty-eight hours. It is then replaced by a larger instru- ment, and the treatment is thus continued until a No. 10 or 12 catheter can easily be introduced, when ordinary dilatation is resorted to. By this method I have frequently succeeded in restoring the urethra to its natural size in a few days, even when the disease was very obstinate. 2. Rupture—In rupture, divulsion, laceration, or forcible dilatation, as this process is variously termed, the object is to lacerate the contracted part up to the full caliber of the normal urethra as ascertained by previous measurement, through which a splice, if the expression may be used, is inserted into the passage. The instrument with which it is performed is some one of the improvements upon the original dilator of Perreve, of which the best are those of Voillemier, Holt, and Richardson, to which Van Buren, Bumstead, Gouley, and other surgeons have adapted various contrivances for conducting them safely through narrow coarctations into the bladder. Of these, probably the most perfect is the instrument of Dr. Richardson, of Dublin, sketched at fig. 608. Having been passed into Fig. 602. Fig. 598. Fig. 599. Fig. 600. Fig. 601. French Flexible Bougies. Filiform Bougies. 780 DISEASES OF THE URINARY ORGANS. CHAP. XVI. the bladder closed, a large, dove-tailed wedge, or plunger, which, with the expanded blades, equals 18 of the American, or 30 of the French scale, is rapidly forced onwards Fig. 603. Ricliardson’s Tunnelled-handled Dilator. between the blades, when the instrument is rotated so as to separate still farther the rent, and withdrawn. The bladder having been evacuated with a catheter, a full anodyne is administered, and the patient kept in bed for twenty-four hours. Instead of lacerating the tissues with the ordinary form of dilator, I formerly employed the heavy, conical, nickel-plated steel bougie, fig. 604, which from its point to its shaft Fig. 604. Conical Steel Bougie. represents three sizes of the American scale, the largest running from 16 at the extremity to 18 at the shaft. Six of these bougies are generally put up in a case, and, while they effect the desired object equally as well as the dilator, by being rapidly inserted one after another, they are, according to my experience, far superior to it, especially when the stricture is seated in the membranous portion of the urethra, when, unless very great care is taken, there is always danger, especially in untrained hands, of the dilator slipping out of the natural channel. For the past few years I have preferred the urethral dilator of Dr. S. W. Gross, represented in fig. 605, which, as it measures only 16 of the French scale in the shaft, dispenses with previous division of the meatus. The joined Fig. 605. S. W. Gross’s Dilator. blades, which are nicely bevelled to prevent seizure of the mucous membrane, are capa- ble of being expanded to 40 millimetres by revolving the wheel below the handle. The operation of rupture with any of these instruments should always be performed under an anaesthetic. It is seldom followed by any hemorrhage, and what bleeding there is usu- ally promptly ceases spontaneously. I have never known it to give rise to any untoward symptoms; it fulfils the same indications as internal urethrotomy; is applicable to all forms of permeable stricture; and is more expeditious than, at the same time that it is as safe as, the apparently simpler procedures. For these reasons I do not hesitate to give it my unqualified approbation. It should, however, be remembered that the bands may resist the action of thedivulsor, so that a full-sized bulbous bougie should be inserted with a view of exploring the urethra, and the completion of the operation with the urethrotome if undivided bands be detected. The after-treatment of rupture is conducted upon general principles. As soon as the immediate effects of the operation have passed off, as they generally do in forty-eight hours, a full-sized steel bougie is inserted, and pressed for a few moments against the seat CHAP. XVI. ORGANIC STRICTURE. 781 of laceration, with a view of stretching the newly formed cicatricial tissue, and thereby preventing recontraction. The introduction of the instrument is subsequently repeated every second, third, or fourth day until the completion of the cure. But, when this has been attained, there is one important point which cannot be too forcibly impressed upon the surgeon’s attention, namely, the occasional passage of the bougie during the remainder of the patient’s life, at first, and for a long time, once a week, and then regularly once a fortnight. If this precaution be disregarded, relapse will be inevitable, such is the inva- riable tendency to recontraction in the cicatricial tissue at the seat of the stricture. 3. Internal Urethrotomy.—All permeable strictures, whatever their situation or nature, unless they are complicated by great thickening of the periurethral tissues, are best treated by internal incision, which possesses the advantage over divulsion of neatly and accurately dividing all resisting bands, while, in the absence of disease of other portions of the urinary organs, it is an equally safe procedure. When the coarctation is seated at the orifice of the urethra, or just behind it, a bistoury will answer every purpose ; but for strictures in the remainder of the canal, special instru- ments, which cut from behind forwards or from before backwards, are required. In the former procedure, which is the safer and more reliable, the coarctation must previously be sufficiently dilated to admit of the passage of an instru- ment provided wfth a bulb, through which, on its withdrawal, the location of the stricture is defined, and its ac- curate division insured. To fulfil these indications the most simple and perfect urethrotome with which I am ac- quainted is that devised by Dr. S. W. Gross, fig. 606, which is modelled after the bulbous bougie, the conoidal bulb carrying a concealed blade which is protruded by pressure upon the round plate above the handle. The bulb having been passed through the ob- struction and then advanced, in order that its shoulder may define the coarc- tation, it is next carried towards the bladder, the object being to divide not only the stricture, but the sound tissues for half an inch behind and anterior to it, the blade projected, and the parts severed. A steel bougie, of a size adapted to restoring the urethra to its normal calibre at the affected part, is then passed, and its curve firmly pressed against the incision with the view of widely separating its sides. In the instrument of Otis, fig. 607, the stric- ture is first overstretched by the sepa- ration of the blades, and next divided by retracting the guarded knife which runs in a groove along the upper blade, thereby effecting the same object as the urethrotome of Gross and the bougie. The instrument, however, is open to the serious objection that the situation of the stricture has to be ascertained by previous measurement, which is a most uncertain guide. Incision from before backwards may be effected with an instrument com- posed of a grooved canula, containing Fig. 606. Fig. 607. Fig. 608. S. W. Gross’s Urethrotome. Otis’s Divulsing Urethro- tome. Author’s Urethrotome. 782 DISEASES OF THE URINARY ORGANS. a stylet, armed with a little blade, which is made to project at will. The extremity of the canula, which is intended to lie within the stricture during its division, is of a conical shape, quite narrow, and about three-quarters of an inch long. The instrument which I have for many years been in the habit of employing in permeable strictures, is exhibited in fig. 608, with the stylet and blade retracted. In whatever manner the operation is performed, the moment it is over a gum-elastic catheter is passed into the bladder, and retained for twenty-four hours, the subsequent treatment being the same as that after rupture. The retention of the catheter, although not indispensably necessary, and strongly objected to by many surgeons, is of decided benefit, inasmuch as it serves to prevent the urine from coming in contact with the raw surface after the operation, and thus lessen the danger of the occurrence of urethral fever. When the stricture is very large, or hard and tortuous, more than one operation may be necessary to effect its division ; but, as a rule, it is best to do all that is necessary at one time. 4. External Urethrotomy.—The division of the stricture from the perineum includes two distinct operations, that of external incision, conducted upon a guide, first performed, in the latter half of the seventeenth century, by Folet, extensively practised by Desault in the eighteenth, and popularized by Mr. Syme in the present, and the perineal section, or external urethrotomy, without a guide, first performed, in 1652, by Molins, an English surgeon. The former procedure is adapted to permeable stricture ; the latter to stricture impassable by an instrument. a. In performing external* urethotomy on a guide, the anaesthetized patient is placed in the lithotomy position, and a Syme’s staff, fig. 609, is passed into the bladder, and intrusted to an assistant who holds the shoulder against the face of the stricture. The parts being shaved, the nates are brought to the edge of the table, and the surgeon, sitting on a low chair, or resting upon one knee, makes his incisions exactly in the middle line of the perineum, the raphe serv- ing as a guide to the instrument. Having divided the superficial structures, he feels for the shoulder of the staff, and, plunging his knife into its groove, he cuts the indurated and contracted tissues through their entire extent, thus laying the surface completely open, precisely as in the operation for anal fistule. The whole wound, which includes half an inch of the sound urethra in front of and behind the stricture, does not exceed an inch and a half, and occasionally it need not even be so large. The deep fascia of the perineum is not interfered with, lest ex- travasation of urine should take place. As soon as the stricture has been thoroughly opened, a medium-sized elastic catheter may be carried into the bladder, where it is retained by suitable apparatus for at least forty-eight hours, when it is removed, to be used afterwards a few hours a day until the wound is healed. The outcry that has been uttered agaist the retention of the catheter after this operation is, in great degree, baseless. The inflexible staff of Syme, Avhich, particu- larly in unskilled hands, may make a false pas- sage, or enter a preexisting false route, may be replaced by a filiform whalebone bougie, over which Gouley’s grooved and tunnelled catheter staff, fig. 610, is guided down to the stricture, the urethra being opened on the bridged portion of the instrument, and the coarctation divided with a small probe-pointed bistoury carried along chap, xvi. Fig. 609. Fig. 610. Symes’s Staff. Gouley’s Grooved and Tunnelled Catheter Staff. the side of the guide. The operation is completed by introducing the staff, still sup- ported by the guide, into the bladder. The results of this operation, as far as they are known, are eminently encouraging. Thus, of 108 cases in the hands of Mr. Syme, up to 1863, only 2 had ended fatally ; and of 219 cases collected by Sir Henry Thompson, there was a mortality of 15, so that the death-rate may be placed at 5.16 per cent. The most fruitful source of death is pyemia. b. In external urethrotomy, without a guide, or the button-hole operation, as the conductor is not passed into the bladder but only down to the seat of the obstruction, the amount of skill required is much greater than in the ordinary procedure. Indeed, it should never be undertaken unless the surgeon is thoroughly acquainted with the anatomy of the parts, is perfectly self-possessed, and knows how to use a knife. A grooved staff having been passed down to the stricture, the urethra is opened by a free incision in the middle line, in front of the coarctation, when the lips of the wound are widely separated by loops of waxed silk, so as to expose fully the face of the contraction, when attempts are made to insert a small, flexible, metallic grooved director, fig. 611, or a filiform guidte into its opening, upon which the necessary division may be effected as in the preceding operation. Failing in these efforts, the surgeon carefully and patiently dissects through the indurated and thickened tissues, until the urethra is opened below the stricture, after which a full- sized bougie is passed into the bladder, and the subsequent treatment conducted on general principles. Mr.Wheelhouse, of Leeds, has simplified the operation by opening the urethra, a quarter of an inch in front of the stricture, upon a grooved staff, which terminates in a hooked end, when the edges are held apart by forceps or waxed threads, and the hooked end of the staff inserted into the upper end of the divided urethra, through which that canal is held widely open at three points, and the operation proceeded with as described above, a catheter being inserted into the bladder along Teale’s probe-gorget. The operation is not very dangerous to life. I have myself performed it 26 times, with only 1 death; and of 43 cases, in the practice of Jameson, Rogers, Warren, and Gouley, all were successful. Of 35 cases in the hands of French and German surgeons, however, 8 were fatal. External urethrotomy, with or without a guide, should be reserved for traumatic strictures, for cases complicated with great induration and the presence of fistules, and for those rare cases of irritable coarctations in which the ordinary procedures are attended with violent shock, a severe attack of urethral fever, or even worse consequences. It should, never, if possible, be performed without due preparation of the parts and system, by rest in the recumbent posture, the use of anodyne suppositories, and a proper regulation of the diet, with the daily employment of the warm bath. After all operations upon the urethra, whether with the bougie or the knife, it will be found that the cure, as a rule, will be greatly expedited by medicated injections, con- sisting of acetate of lead, acetate of lead and opium, Goulard’s extract, sulphate of alum, or sulphate of zinc, in weak solution, thrown well back every eight or twelve hours, and retained for five to fifteen minutes each time. A weak solution of nitrate of silver is also sometimes beneficial. With the same view, I frequently employ a CHAP. XVI. ORGANIC STRICTURE. 783 Fig. 611. Grooved Director. Fig. 612. Author’s Fluted Catheter for the Application of Ointments. weak ointment of nitrate of mercury, as two or three grains to the drachm of simple cerate, applied with the aid of the fluted catheter represented in fig. 612 ; an instru- 784 DISEASES OF THE URINARY ORGANS. ment which I had purposely constructed for this kind of medication nearly a quarter of a century ago, and which I have often used with signal success. The ointment is rubbed into the furrows of the instrument, which is then passed into the bladder, and retained for a period of three to five minutes. Occasionally I use a weak ointment of iodoform, or of this substance and of nitrate of mercury. Hot-water injections are sometimes very sooth- ing, while a certain class of patients is most benefited by injections of cold water. Injurious Effects of Operations upon the Urethra.—The different methods of treatment now described are all liable, however carefully or judiciously conducted, to be followed by rigors, urethral fever, suppression of urine, and pyemia, as most of the subjects of stricture of the urethra are prone to renal and vesical disorders, and, therefore, easily effected by the most trivial operation performed for its relief. Apart from pyemia, rigors are of grave import* since they are denotive of at least three essentially different conditions. In the first, and mildest, class of cases, temporary and irregular chilly sensations indicate a nervous, irritable state of the system. In the second class of cases, a chill, often violent and prolonged, appearing usually within the first twenty-four hours, and followed by fever, profuse sweating and exhaustion, consti- tutes an attack of urethral fever. In the third class of cases, rigors, which appear in a few hours, and are rapidly succeeded by headache, vomiting, diarrhoea, drowsiness, or somnolence, thirst, scanty urine, pain in the loins, lowered temperature, feeble pulse, and urinous odor of the secretions and excretions, symptoms which, if they continue, are in their turn, followed by convulsions, coma, and death, conclusively point to suppression of the urine and uraemic intoxication. Much maybe done in the way of preventing or mitigating unpleasant nervous symptoms and rigors by judicious preparatory treatment, in accordance with the principles already laid down, and by bringing the system gently under the influence of quinine previous to the performance of an operation, along with the hypodermic injection of morphia at its conclusion. Nervous rigors readily yield to a hot toddy, and rest in bed ; urethral fever is best met with quinine and tincture of aconite; while signs of suppression of urine should be promptly combated by diaphoretics, infusion of digitalis, saline cathartics, and the local application of dry cups and hot fomentations over the region of the kidneys. Convulsions may be controlled by the inhalation of chloroform, and coma relieved by venesection, if the patient’s general condition be fair, and the head symptoms come on rapidly. In anoth n* class of cases, a still more serious effect is occasionally witnessed. I allude to the occurrence of pyemia, or the formation of matter in the joints, muscles, veins, con- nective tissue, and other structures. The disease sometimes resembles an attack of ordi- nary intermittent fever. Occasionally, again, it closely simulates gout or rheumatism. In whatever manner it makes its appearance, the case soon assumes a most threatening character. Arthritic symptoms, and the formation of matter in the connective tissue, joints, mus- cles, and viscera, must be relieved by leeches, blisters, iodine, and warm fomentations, medicated with laudanum and acetate of lead, and by the internal use of calomel and opium, aided, if necessary, by suitable stimulants, as carbonate of ammonium, quinine, iron, wine, brandy, and porter. Superficial abscesses must be opened by early and free inci- sions, both to moderate pain and to prevent further contamination of the system. Unfor- tunately, however, no mode of treatment, whatever may be its character, can avail much under such circumstances, death being the lot of almost every patient thus affected. When “surgical kidney,” or disseminated suppuration of the organ, the symptoms of which ai*e those of septicemia, are present, the ammoniacal and putrid decomposition of the urine must be prevented, by preserving the natural acidity of that secretion. INFILTRATION OF URINE. By the term “ infiltration,” as applied to the urine, is understood an escape of this fluid from the urinary passages, and its diffusion through the surrounding tissues. There are two forms of the affection, the vesical and urethral, both most unfortunate, as the urine, putrid and poisonous from long confinement, lights up severe inflammatory action, rapidly terminating in gangrene of the affected structures. The patient sinks into a low, typhoid condition, attended with hiccup and muttering delirium, speedily followed by exhaustion and death. Even limpid, colorless, or healthy urine, if accidentally effused into the tissues around the bladder, urethra, or prostate gland, is sure to give rise to very CHAP. XVI. CHAP. XVI. ABSCESS. 785 serious, if not fatal consequences, notwithstanding, as has been shown, again and again, by experiment, that such fluid, if injected under the skin in different regions of the body, is usually speedily absorbed, without causing any unpleasant effects, either local or con- stitutional. The very worst consequences may be expected when the urine has been long retained, and is loaded with decomposed, putrid, ammoniacal, or phosphatic matter. The vesical form of the lesion may be produced by rupture of the bladder from external violence, overdistension from urine, or perforative ulceration of the coats of the organ. Infiltration is occasionally met with after lithotomy, especially in the hands of ignorant operators, and is always a source of danger. The prognosis is generally very unfavorable, the treatment being in the highest degree unsatisfactory. When the urine has a tendency to advance towards the perineum, the most rational remedy obviously consists in making early, free, and dependent incisions, in giving vent to pent-up fluids, and in sustaining the system by the timely use of tonics, especially quinine, stimulants, and opiates in full doses. The urethral form of infiltration is more common than the vesical, but generally more manageable. If the rupture occur in the commencement of the membranous portion of the urethra, behind the triangular ligament, the case may remain obscure for several hours, or even days. The most reliable symptoms of the accident ai'e, pain and deep-seated throbbing; difficulty, if not utter impossibility, of voiding the urine, with, perhaps, a frequent desire to do so; a sense of fullness in the anus and rectum ; tenderness in the hypogastrium ; and excessive constitutional disturbance. By and by, the urine makes an effort to approach the surface, its progress being preceded and accompanied by erysipela- tous inflammation, marked by great heat, pain, redness, and swelling, and by a rapidly increasing typhoid state of the system. When the rupture occurs in the portion of the urethra which lies in front of the trian- gular ligament, between it and the bulb, the urine escapes into the connective tissue of the perineum, and proceeds forwards and upwards underneath the dartos into the scrotum, its passage being marked by a red, erysipelatous blush of the surface, and by enormous tumefaction, soon succeeded by black, gangrenous spots, and an emphysematous condition of the connective tissue. The fluid sometimes extends over the entire penis, the upper part of the thigh, the hypogastric region, and even the side of the chest. In a case recorded by Boyer, it affected the loins and back as high up as the scapula. The symptoms of infiltration of urine are occasionally most painfully simulated by erysipelas of the scrotum and penis, especially in persons of intemperate habits and dilapidated constitution. The disease, which generally advances very rapidly, is attended with enormous swelling and great local suffering, from the effusion of serum and plasma. The skin is of a reddish glossy hue, and freely pits on pressure. The patient is pale, feeble, and depressed ; the pulse is small, quick, and tremulous ; the respiration is frequent; micturition is difficult; and, if relief be not promptly afforded, gangrene ensues. The diagnosis is based on the history of the case, the absence of swelling of the perineum, and the facility with wffiich the catheter is passed. The prognosis is seldom flattering, although apparently the most desperate cases occa- sionally recover. The first, and, in fact, almost the only thing to be done, in the early stage of the affection, is to make large and dependent incisions, to afford vent to the pent-up and irritating fluids. A catheter should then be introduced into the bladder, and allowed to remain there during the cure. The best local applications, after the parts have been properly divided, are warm fomentations with acetate of lead and opium, hops, or poppy heads. When the sloughing process has fairly begun, the dead substance must be care- fully dissected away, antiseptics freely used, and the fomentations superseded by emollient poultices, with the addition of yeast, or weak solutions of nitric acid. ABSCESS. Abscesses, to which the term urinary is usually applied, are liable to form in the con- nective tissue around the urethra, fig. 613, leading, if improperly managed, to fistules and other mischief. Their ordinary site is the perineum, between the bulb of the urethra and the anus. A very common situation also is the upper part of the perineum, just behind the junction of the cavernous bodies of the penis, and, consequently, at the infe- rior portion of the scrotum. The next most frequent point is the scrotum itself, and, lastly, the under surface of the penis. Urethral abscesses are generally small and circum- scribed. 786 The exciting causes are various. The most common, perhaps, is the existence of a tight, organic stricture of the urethra, attended with attenuation and dilatation of the tube immediately posterior to it. During a violent effort at micturition, the canal gives way behind the seat of the obstruction, sending the urine abroad into the connective tissue. A few drops thus effused are often suf- ficient to cause an immense abscess, accompanied by great suffer- ing, both local and constitutional. The existence of the disease is, in general, easily determined. The perineum is of a reddish, erysipelatous appearance, swollen, painful, and tender on pressure; progression is difficult; trouble is experienced in micturition, especially if the case is already somewhat advanced; and there is usually more or less fever, attended, when there has been effusion of urine, with a tendency to delirium, fluctuation is best detected by inserting one finger into the rectum, and placing the other over the tumor in the perineum. The treatment is sufficiently simple. The antiphlogistic regi- men, rest, recumbency, leeching, and fomentations, will limit the morbid action; wdiile a free and timely external incision will prevent the diffusion of matter and urine. When the sac has been emptied, and the accompanying inflammation has, in great measure, disappeared, a catheter should be retained in the blad- der, to prevent the escape of its contents by the abnormal orifices, the edges of which are to be touched, from time to time, with nitrate of silver, to promote cicatrization. URETH11AL FISTULE. The most common site of urethral fistule, fig. G14, is that portion of the tube wrhich corresponds with the perineum and the scrotum ; the disease sometimes exists farther back, and, on the other hand, cases occur in which it is found near the anterior orifice. The abnormal channel, wdiether single or multiple, long or short, straight or devious, is origi- nally merely a sinus, or tubular ulcer, which is soon covered by granula- tions, and ultimately lined by an ad- ventitious membrane. A track of this kind occasionally contains a urinary calculus. The immediate cause of this affec- tion is the destruction of the mucous membrance, produced by ulceration, abscess, gangrene, or laceration, and followed by an escape of urine into the connectve tissue. Here, acting as a powerful irritant, the fluid speedily excites inflammation, which soon terminates in suppuration, if not in the death of the affected parts. When the matter is evacuated, or the slougli detached, the urine issues at the accidental opening, which now constitutes, in the true sense of the term, a fistule. The efficient causes are various. The most frequent, undoubtedly, is stricture, attended with dilatation of the tube behind the seat of obstruction; but it may also result from ill- managed attempts to pass instruments, the protracted sojourn of catheters and bougies, gonorrhoea, retention of urine, external violence, and the operation of lithotomy. The diagnosis is usually easy. An opening exists in some portion or other of the urethra, giving vent to urine either in drops, in jets, or in a continuous stream synchron- ous with the act of micturition. A probe of small size, introduced into the external orifice, readily enters the urethra, provided the abnormal passage is not very narrow’, oblique, angular, or sinuous. The treatment, although obvious enough, is not always easy. The first thing to be DISEASES OF THE URINARY ORGANS CHAP. XVI. Fig. 613. Urethral Abscess, the Tube being laid open ; a Stricture at the commencement of the Bulbous Portion ; and False Passages, one of which leads into an Abscess that sur- rounds the Membranous Por- tion. Fig. 614. Urinary Fistules. CHAP. XVI. URETHRAL FISTULE. 787 done is to seek for, and, if possible, to get rid of, the exciting cause. In most cases this will he found to be a stricture, probably of long standing, upon the removal of which the abnormal track ordinarily closes of its own accord. The best plan, after the obstruction has been relieved, is to use a soft catheter, rather over than under the usual size, to be perma- nently retained, unless it should prove to be a source of decided suffering. Conducted upon this principle, the treatment rarely fails in the more mild and uncomplicated forms of the malady. It sometimes, however, happens, after all obstruction in the urethra has been removed, that the fistule manifests no disposition to heal, but remains pervious to the urine. The occurrence may be owing to various circumstances. Very often it de- pends upon a callous condition of the parts, preventing the edges of the sinus from coming in contact. When this is the case, the object should be to destroy the secreting surface, and to promote the granulating process by stimulants and escharotics, especially nitrate of silver. In rebellious cases a heated wire, or a probe dipped in acid nitrate of mercury, may be inserted into the passage. When the fistule is obstinate and protracted ; when its internal orifice is uncommonly large, or when there are several openings of this kind; or, finally, when it depends upon an old stricture, so firm, narrow, and extensive that it cannot be destroyed in the ordinary manner, the only course left is to lay the parts open by an external incision, and to heal them over a catheter. Fig. 615. Fig. 616. Fig. 617 Urethroplasty. When the fistule involves the spongy portion of the urethra, and has been caused by chancre, or external injury, attended with loss of substance, the suture may be necessary, and the one usually selected is the twisted, made with short, slender needles, placed hardly a line and a half apart. The principal objection to the use of the suture, in any form, is its liability to tear itself out before the completion of the adhesive process, from the occurrence of chordee. The best preventives of such an accident are anodyne enemas, or suppositories of opium and camphor, with the free use of chloral and bromide of potas- sium, and the application of pounded ice to the perineum. Excision of the fistule has sometimes been practised beneficially, and there are few cases in which the edges of the track may not be pared with advantage. When the fistule is attended with considerable loss of substance, urethroplasty may be necessary. The refreshened edges of the opening may be united over a piece of India-rub- ber, after a large cutaneous flap has been dissected upon each side, as exhibited in fig. 615, or the integument may be raised subcutaneously, as in fig. 616, or the opening may be closed by a flap borrowed from the scrotum, as shown in fig. 617. The operation, how- ever, generally signally fails whatever care may be taken in its execution, owing to the difficulty of preventing the contact of the urine. Hence, it is a matter of paramount necessity to conduct off that fluid through the perineum until the parts have become per - fectly consolidated. A small opening in the lower part of the perineum directly in the middle line, will answer the purpose, provided patency be maintained with a gum-elastic 788 DISEASES OF THE URINARY ORGANS. catheter. The urethra must be kept perfectly free until complete union is effected. Any- thing short of this will be sure to interfere with, if not entirely prevent, the cure. FALSE PASSAGES. A false passage is an artificial canal communicating with the urethra, generally as a consequence of'the injudicious use of instruments, and is most common in the membra- nous and prostatic portions of the tube. The lesion is well seen in fig. 618, from a preparation in my cabinet. CHAP. X VI . Fig. 618. Stricture of the Urethra, with False Passage: Enlargement of the Prostate Gland, and Hypertrophy of the Bladder. The artificial route is commonly situated upon the floor of the urethra, chiefly because when an instrument is attempted to be introduced into the bladder, its point is almost always pressed in this direction, which also presents the greatest number of natural ob- stacles to its easy passage. The new channel, which is usually single, varies in length from a few lines to several inches, and may occur either as a cul-de-sac or as a distinct canal, the distal extremity opening into the urethra, or, perhaps, as occasionally happens, into the bladder, or even into the rectum. When the false passage consists merely of a cul-de-sac, little, if any, harm, will be likely to arise; but it is different when it opens into the bladder, or even when it runs up close to it, for then it may be followed by infiltration of urine, abscess, and even gan- grene. When it extends into the rectum, or the rectum and bladder, a permanent fistule may be the consequence. The formation of false passages is seldom indicated by any reliable symptoms. The most common are hemorrhage, pain, and a feeling of laceration ; but these, upon being carefully scrutinized, will be found to be of no value whatever as diagnostics, flow, then, is the existence of the lesion to be determined ? The only circumstances worthy of notice, so far as the surgeon is concerned, are, first, a peculiar grating sensation communi- cated to his hand while engaged in operating upon the urethra; secondly, a sudden slipping of the instrument from its position, or a feeling as if something had given way; thirdly, a deviation of the instrument from the normal direction of the canal; and, lastly, the oc- currence of unusual bleeding. The treatment is quite simple. Hemorrhage must be arrested, pain allayed, and further irritation by the use of instruments prevented. Rest and recumbency, light diet, purgatives, antimonials, leeches, fomentations, and the warm hip-bath will generally put a speedy stop to the local inflammation. Urinary infiltration is a rare occurrence, owing to the fact that the water, flowing in a direction opposite to that of the artificial opening, is unable to insinuate itself into it. CARCINOMA AND TUBERCLE. The urethra, like the urinary bladder, is liable to carcinoma and tubercle. These affections, however, are extremely rare, and their occurrence is interesting rather in a pathological than in a practical point of view. There are no symptoms by which in either sex, carcinoma of the urethra, in its earlier stages, can be distinguished from other affections. All treatment, except with a view to palliation, is futile. Should retention of urine occur, the morbid growth must be perfo- rated with the catheter, or, when this is impracticable, the urethra must be laid open behind the tumor. CHAP. XVI. DISEASES AND INJURIES OF PROSTATE GLAND. 789 SECT. IV DISEASES AND INJURIES OF THE PROSTATE GLAND. The prostate gland, from the peculiarity of its situation, and its intimate connection with the bladder, the urethra, and the seminal vesicles, is constantly exposed to inconve- nience and hardship, rendering it liable to various diseases ; but, until the age of puberty, it has merely a rudimentary existence, and is, therefore, seldom affected in any way. After its functional activity, however, is fully awakened, it becomes more liable to disor- der, and this tendency may be said steadily to increase as we advance in life. The affections of the prostate may be conveniently arranged under the following heads : 1. Inflammation. 2. Suppuration and abscess. 3. Ulceration. 4. Hypertrophy. 5. Prostatorrhoea. 6. Tumors. 7. Tuberculosis. 8. Hemorrhage. 9. Calculi. 10. Sac- ciform disease and fistule. 1. Acute Prostatitis Acute inflammation of the prostate seldom exists as a primary affection, except when it is produced by direct injury. Idiopathically considered, it is most frequently met with in middle life, when the genital organs are in their full vigor, and in active sympathy with the rest of the system. The most common exciting causes of acute prostatitis are gonorrhoea, stricture of the urethra, venereal excesses, horseback exercise, external injury, and suppression of the cutaneous perspiration. Gleet is occa- sionally followed by acute prostatitis ; and cases occur in which it is evidently associated with, if not directly dependent upon, a gouty or rheumatic diathesis. The characteristic symptoms are deep-seated, burning, and throbbing pain, gradually increasing difficulty in micturition, excessive scalding of the urethra as the urine flows over its surface, a feeling of weight and stuffing in the rectum, constant tenesmus and desire to relieve the bladder and bowels, and a flattened form of the feces. If the finger be inserted into the rectum, the gland may be distinctly felt as a solid, painful tumor, sometimes almost so large as to close the tube and seriously impede defecation. The at- tempt to introduce a catheter into the bladder will be exceedingly difficult, if not imprac- ticable, unless the surgeon possess more than ordinary skill in the management of the instrument. The local symptoms are generally accompanied by well-marked constitu- tional disturbance. Although this disease is seldom dangerous to life, or disposed to run into suppuration, yet, in view of the great suffering which it induces, the treatment should always be very prompt and decisive. Active depletion by the lancet, and by leeches to the perineum and anus, is always indicated, especially if the patient be at all robust, and should be prac- tised without delay. If the bowels are costive, the venesection is immediately followed by a brisk cathartic, consisting of castor oil, or calomel and jalap, assisted, if necessary, by enemas, defecation being performed in the recumbent posture. Fever is combated by antimonial and saline preparations, in union with morphia and aconite, to allay pain and reduce the heart’s action. Relaxation of the skin is promoted by hot steam, conveyed to the body by means of a tube connected with the spout of a tea-kettle. The genital or- gans, hypogastrium, and perineum should be enveloped in flannel cloths, wrung out of hot water and laudanum ; and the pain and straining, which so commonly attend the disease, should be promptly subdued by a full anodyne enema, opiate suppository, or hy- podermic injection of morphia. Great relief sometimes follows the use of the hot sitz- bath. The condition of the bladder is early attended to, retention of urine being relieved by the catheter, handled with the greatest gentleness. Absolute recumbency is indis- pensable throughout the whole treatment ; the diet must be of the blandest character, and drink of every description is abstained from, in order to secure repose to the inflamed parts. 2. Abscess—Acute inflammation of the prostate occasionally terminates in the forma- tion of an abscess, indicated by a marked increase of all the previous symptoms, local and constitutional. The pain is exceedingly violent, and is speedily followed by complete retention of urine. Severe rigors, alternating with flushes of heat, are present, and the patient soon becomes delirious. An examination by the rectum often detects fluctuation.. When the abscess tends towards the perineum, its advent is always preceded by great swelling, an erysipelatous blush of the surface, and an oedematous condition of the subcuta- neous connective tissue. The matter in this affection most generally finds an outlet at the neck of the bladder, but it may also discharge itself through the urethra, the perineum, or the rectum, and, in exceptional cases, into the pelvic cavity, at the groin, the thigh, or even the side, imme- diately below the false ribs. 790 The annexed cut, fig. 619, from a preparation in my cabinet, affords a good illustration of an abscess of the prostate, as it occurred in an elderly man, who died from the effects of the disease, ten days after the commencement of the first symptoms. The pus was of a thick, cream-like consistence, and of a yellowish color, its quantity being a little over a tea- spoonful. The inflammation had deeply involved the neck of the bladder. Abscess of the prostate is generally a dangerous affection. When recovery occurs, the patient may be troubled with a fistulous communication with the rec- tum, urethra, perineum, or bladder. The treatment consists in limiting the suppuration, and in affording a speedy outlet to the effused fluid. To meet the first indication, prompt recourse must be had to depletion, provided this has not already been carried sufficiently far, to antimonials, diaphoretics, anodynes, emollient applications, and the abstraction of blood, and by leeches from the perineum and hypogastrium. The second is fulfilled by an early artificial opening. If the abscess point towards the perineum, an incision should be made in the most prominent part of the swelling, with a long, straight, narrow-pointed bistoury, care being taken, on the one hand, to avoid the bowel, and, on the other, the bladder. When the matter points towards the rectum, it may readily be reached with a long, curved trocar. For some days after the operation the lower bowel should be kept as quietly as possible. When the abscess bulges inwards towards the urethra and the neck of the bladder, it may be punctured with a common silver catheter, with a sound with a conical beak and a small curve, or, what is better, with a lanceted stylet. The urine should be frequently drawn off with a gum-elastic catheter, or, if it can be tolerated, the instrument should be permanently retained in order to allow the water to flow off as fast as it reaches the bladder, and thus prevent its accumulation in the cavity of the abscess. The point of the catheter, as it is urged along, must be kept in close contact with the roof of the urethra, especially as it passes under the arch of the pubes. In obstinate cases the proper plan is to lay the perineum open. 3. Ulceration—Ulceration of the prostate is of infrequent occurrence and of difficult recognition. It may be induced by various causes, of which the principal are wounds, contusions, lacerations, and the presence of .calculous concretions in the substance of the organ. The symptoms are such as indicate the existence of chronic disease of this organ and of the neck of the bladder. Perhaps the most reliable circumstances, in a diagnostic point of view, are, the absence of vesical calculi, long-continued suffering, as a sense of weight, aching, and throbbing at the neck of the bladder, a constant secretion of thick, glairy mucus, a frequent desire to micturate, and an occasional discharge of blood, with excessive burning during the accumulation of the urine. The treatment is altogether unsatisfactory and empirical. Attention must be paid to the general health ; the patient should avoid exercise and the erect posture ; the bladder should be daily washed out with tepid water, either simple or medicated; and the affected surfaces should be lightly touched twice a week with a solution of nitrate of silver, in the proportion of about ten grains to the ounce of water, applied with a piece of soft sponge, projected from a silver canula. The best internal remedies are, balsam of copaiba, cubebs, and spirit of turpentine, largely diluted with demulcent fluids. Anodynes must be liberally used both by the mouth and by the rectum. In obstinate cases.or cases at- tended with great suffering the bladder should be freely opened, to allow the urine to drain off as fast as it descends from the kidneys. 4. Hypertrophy—Hypertrophy of the prostate is an augumentation of volume of this organ, produced by increased nutrition. There are several forms of the complaint, of which the most common is that to which the term senile has been applied, as it is a frequent accompaniment of old age. Any part of the organ may suffer. Most commonly the enlargement involves the entire gland, although not uniformly. Occasionally it is almost exclusively confined to the third lobe, even, perhaps, when the enlargement is so great as to cause retention of urine, and, ultimately, the patient’s death. The affection exists in various degrees, from the slightest increase of the natural volume of the prostate to the dimensions of a pullet’s egg, a walnut, DISEASES OF THE URINARY ORGANS CHAP. XVI. Fig. 619. Abscess of the Prostate. CHAP. XVI. DISEASES AND INJURIES OF PROSTATE GLAND 791 or a medium-sized orange. In rare cases, indeed, it, may even exceed the latter di- mensions. The greatest increase of volume usually occurs in the long axis of the organ, in consequence, no doubt, of a want of resistance in this direction. The annexed drawing, fig. G20, from a specimen in the collection of the late Dr. Valentine Mott, affords a good illustration of what may be called symmetrical hyper- trophy of both lobes of the prostate. Fig. 621, from one of my preparations, exhibits great enlargement of the gland in its an- tero-posterior diameter, with a mammil- lated appearance at its posterior extrem- ity, seemingly dependent upon an irregu- lar condition of the middle lobe. When one lateral lobe is more enlarged than the other, the more bulky one frequently encroaches upon the smaller, and thus pro- duces a lateral curvature in the neck of the bladder and the commencement of the urethra. Fig. 620. Hypertrophy of both Lobes of the Prostate. Fig. 621. Fig. 622. Hypertrophy of the middle lobe most generally pre- sents itself as a mammillary process, more or less ver- tical in its direction, and varying in size from that of the female nipple to that of a small almond, as in tig. 622. The free surface is usually smooth, rounded, and much broader than the adherent, which is often very narrow, as if it were inserted between the lateral masses by a distinct pedicle. Its position is commonly median, and as it always projects into the bladder, its tendency, especially when it is very large, is to raise and elongate the prostatic portion of the urethra. Cases occur in which there are as many as three or even four of these bodies, as in fig. 621, of varying size and shape. When the number is considerable, they sometimes partially invade the orifice of the urethra, and necessarily produce a corresponding degree of mechanical obstruction. In a specimen in my cabinet, both lateral lobes are much enlarged, while the middle is represented by three separate lobules, one central and the other lateral. Finally, the middle lobe is occasionally formed by a projection, apparently, of one of the lateral masses, as if it were a mere superaddition to the normal structure. In chronic hypertrophy, which is very common in elderly subjects, and which often exists without any material increase of bulk in the rest of the gland, the growth extends inwards towards the middle line so as to encroach more or less seriously upon the corres- ponding portion of the urethra, and constitute what is called the centric form of the disease. The consistence of a hypertrophied prostate is liable to considerable diversity, and General Hypertrophy of the Prostate. Hypertrophy of the Prostate with Mam- millary Enlargement of the Middle Lobe. 792 DISEASES OF THE URINARY ORGANS. occurs under two very opposite forms, the hard and the soft. In the first, which is the more frequent, the induration varies from the slightest increase of the natural consistence to the firmness of dense, fibrous tissue. Interspersed through its substance are numerous hypertrophied follicles. In the soft variety, the enlargement proceeds in a more uniform manner, and generally attains a greater magnitude than in the hard. The affected tissues are more or less elastic, and yield readily under the pressure of the finger. The follicles are larger and more conspicuous than in the first variety. Hypertrophy always arises under the influence of causes acting in a slow and continuous manner. Whatever, therefore, has a tendency to keep up habitual engorgement in the organ may be considered as being capable of producing it, augmented action necessarily occasioning an augmented afflux of blood, and a corresponding increase of nutrition. Amongst the more frequently enumerated causes of the affection are excessive venery, stricture of the urethra, disease of the bladder, horseback exercise, gonorrhoea, and stimu- lating diuretics. That these causes are all capable of inducing the disease, is no doubt true; but, on the other hand, it is equally certain that they are often accused when they are entirely innocent. Some of the very worst cases of hypertrophy of the prostate occur in old men who have led the chastest life, who have never been in the saddle, and who have all their lives been free from disease of the urethra. The senile form of the affection rarely occurs, at least not in any considerable degree, before the fiftieth year; slight evidences of it are occasionally met with at forty-five, and, indeed, even at forty, but this is exceedingly uncommon. Hypertrophy, not the result of old age, may arise at any period of life, under the influence of inflammatory excitement and vascular engorgement. The influence of old age in the production of hypertrophy of this organ has been greatly overrated, as will appear from the subjoined table of 312 examinations made at my request by my friend, Dr. John W. Lodge, in 1859, while resident physician at the Philadelphia Hospital. CHAP. XVI. Number. Age. Normal. Hypertrophied. Atrophied. 23 40 to 50 21 2 94 50 to 60 73 18 3 113 60 to 70 84 27 2 64 70 to 80 53 11 15 80 to 90 12 3 3 90 to 100 3 Total 312 246 61 5 In 100 dissections of the prostate after the age of sixty, by Dr. J. C. Messer, hyper- trophy was found in 35 per cent., atrophy in 20 per cent., and normality in 45 per cent. These results essentially coincide with those of Sir Henry Thompson, who states that the gland is hypertrophied in 35 per cent, after the fiftieth year. Professor Dittel,of Vienna, found hypertrophy of the prostate in 18 cases, and atrophy in 36 in the bodies of 115 indi- viduals, the youngest of whom was 52 and the oldest 100 years of age. The complaint depends essentially upon hyperplasia of the unstriped muscular and fibrous elements which constitute the chief bulk of the prostate, and which, during the progress of age, are liable to new growth similar to that so often witnessed in the uterus of elderly females. The glandular structure, which forms hardly one-third of the volume of the organ, of course participates in the morbid action, as is shown by the dilatation and epithelial proliferation of its acini, without, however, any development of new glands. Hence, hypertrophy of the prostate cannot be regarded as an adenoma, in the true sense of the term. In the denser forms of the affection, on the contrary, there is actual atrophy, and even complete disappearance, of the glandular substance, the organ being in the con- dition either of a myoma or a myomatous fibroma. Irritation of the neck of the bladder, and a frequent desire to pass the urine, are the symptoms which generally first attract the attention of the patient. By degrees, the dis- tress at the neck ot the bladder becomes more constant, as well as more severe, and there is not only a frequent desire to void the urine, but great difficulty in starting it. Slight pain is felt along the urethra, accompanied by a burning, smarting, or scalding sensation in the head of the penis, and a copious discharge of prostatic fluid. The rectum never feels entirely empty, even after the most thorough purgation, but as if it contained a CHAP. XVI. DISEASES AND INJURIES OF PROSTATE GLAND. 793 lump or ball, and the feces are often passed in a flattened form. At night the patient is occasionally disturbed by an involuntary discharge of seminal fluid. As the disease ad- vances, the symptoms become more aggravated, although they are still essentially of the same character. The general health, until now, perhaps, tolerably good, slowly declines. The urine, at first perfectly clear, and, apparently, natural, is gradually changed in its properties, and sometimes even in its quantity. It is generally thick, fetid, acrid, and highly alkaline, depositing, on standing, a great abundance of thick, ropy mucus, often streaked with phosphatic matter. The fluid is soon decomposed, if, indeed, it is not so before it is voided, and then always exhales a strong ammoniacal odor. Gradually mictu- rition becomes more and more difficult, and, at last, after months and, perhaps, years of the most cruel suffering, the urine is either retained, or is obliged to be constantly drawn off with the catheter. The diagnosis of hypertrophy of the prostate is generally not difficult. The disease, as previously intimated, is almost peculiar to advanced life. Hence, when a person who has attained the fiftieth, fifty-fifth, or sixtieth year, is laboring under the above train of symp- toms, the presumption is strong that the case is one of chronic enlargement of this body, and nothing else. The affections with which it is most liable to be confounded are, stric- ture of the urethra, urinary calculi, catarrh of the bladder, and stricture of the rectum. All, however, that is necessary in any case to determine the diagnosis is a digital examina- tion of the gut. For this purpose, the left index-finger, gently inserted into the tube, is moved about in different directions, first upwards along the middle line, and then succes- sively towards each side, noting, as it proceeds, the impression made upon it by the affected gland. In general, it will be found, as before stated, to be larger on one side than the other, and to feel like a hard, solid body, the surface of which is either smooth and uniform, or irregularly knobby. The exploration will be more satisfactory if a metallic bougie be previously inserted into the bladder. The existence of centric hypertrophy may be suspected when there is constant difficulty of micturition, without any appreciable disease of the urethra and bladder, as stricture of the former, and atony, paralysis, hypertrophy, calculi, or morbid growths of the latter. On introducing an instrument the point will probably be arrested by the lateral curvature of the gland, or by the centric projection of a portion of its substance, in the form of a tubercle, of varying size and shape. Such a condition of the organ may, as previously stated, be present, and yet the main body of the gland be entirely natural. The effects of hypertrophy of this gland upon other parts of the urinary apparatus are frequently very distressing. The organ which is most liable to suffer is the bladder, the muscular coat of which becomes greatly thickened and fasciculated from the constant ob- stacle to the evacuation of the urine. For the same reason, the mucous membrane is always chronically inflamed, and sometimes mammil- lated, ulcerated, or even sacculated. Another effect is the occasional formation of urinary calculi. The urethra, too, often undergoes important changes. In general, they are exclusively limited to the prostatic portion of the tube, which, in the more aggravated forms of the hypertrophy, is nearly always remarkably elongated and much diminished in size, causing thus serious mechanical obstruction to micturition and the introduction of the catheter. In enlargement of the middle lobe, the urethra is dragged up behind the pubic arch, and presents a falciform curve, as in fig. 623, from Thompson. Lateral curvature of the canal is occasionally met with, and is generally depen- dent upon an unequal outgrowth of the inner edges of the lateral lobes. In great centric development of the gland, the corresponding portion of the ure- thra is sometimes almost completely occluded. The ureters are seldom entirely sound. The most common lesions are shortening and dilata- tion, or alternate dilatation and contraction, with irregular thickening or attenuation of their walls. The kidneys also generally suffer, mostly from inflammation, attended with change of Fig. 623. Angular Curvature of the Urethra from Hypertrophy of the Prostate. 794 DISEASES OF THE URINARY ORGANS. chap. xvi. structure, size, and shape. Sometimes they undergo cystic degeneration. The seminal vesicles and testicles are occasionally involved, and there are few cases of great hyper- trophy of this organ in which the patient is free from disease of the anus and rectum, especially prolapse and hemorrhoids, evidently caused by the frequent and excessive straining consequent upon the difficulty experienced in micturition. In the treatment of hypertrophy of this body in its early stage, the patient should be taught the introduction of soft, vulcanized catheters, through the systematic use of which serious complications may be prevented. If the amount of residual urine be small, the instrument need not be used oftener than twice a day ; but if it be large, the urine should be drawn off every six or eight hours. At the approach of the first signs of obstruction, Mr. Harrison, of Liverpool, passes bellied bougies, with the view of subjecting the pros- tate to pressure and dilatation, and thereby regaining control over micturition, a plan of treatment which is most rational and deserving of imitation, particularly if it be con- joined with the administration of the fluid extract of ergot. Chagrin and disappointment, on the other hand, nearly always attend the efforts of the surgeon, however judiciously directed, in the more aggravated forms of the affection. The most ti-ustworthy remedies are rest in the recumbent posture, the abstrac- tion of blood from the perineum by leeches, anodyne suppositories, frequent clearance of the bladder with the catheter, a soluble condition of the bowels, the avoidance of sexual intercourse and horseback exercise, and a properly regulated diet, nutritious and concen- trated but non-stimulant. When the hypertrophy depends upon inflammatory new for- mations, benefit will accrue from the use of small doses of calomel repeated several times in the four and twenty hours, either alone or alternated with chloride of ammonium. When the exciting cause is manifestly of a syphilitic nature, the most suitable article will be iodide of potassium in combination with bichloride of mercury. Little, if any, benefit is to be anticipated from counterirritation, in any form, not even from vesication of the perineum with cantharidal collodion. Cauterization of the prostatic portion of the urethra is sometimes advantageous, by stimulating the absorbent vessels, so as to induce them to remove inflammatory deposits. Scarification has occasionally been practised, but seldom, if ever, with any ulterior benefit. Some practitioners have indulged in high laudations of the good effects of suppositories of iodide of potassium, and of the daily use of a bougie anointed with weak mercurial ointment. I have myself, however, never de- rived any relief from their employment. Injections of the bladder, as advised under the head of vesical catarrh, frequently affords great comfort, by dislodging the thick, ropy, and offensive mucus which so often collects in the bas-fond of this organ during the pro- gress of this complaint. When the obstruction to micturition is complete, and the capacity of the bladder is greatly diminished, so that a resort to the catheter becomes necessary nearly every hour, rendering the condition of the patient one of extreme misery, the permanent retention of a tube in the bladder above the pubes, as recommended by Sir Henry Thompson, or through the perineum, as practised by Mr. Lund, of Manchester, may be advisable to avert impending death, as the bladder is thus placed at rest, and prevented from con- stantly contracting on its contents. Crushing of the middle lobe of the prostate gland has occasionally been performed in cases in which this portion of the organ was a cause of retention of urine, the part being seized with a lithotrite and ground into small frag- ments, afterwards discharged along with the urine. The operation, however, is only applicable to the pedunculated form of the enlargement. When the tumor has a broad base, the proper procedure is perforation, either with a curved trocar or a conical silver catheter, a gum-elastic instrument being permanently retained until the new canal is measurably cicatrized. A surgeon who is rash enough to employ either of these expe- dients, should be prepared for the worst, as the issue must frequently be fatal. A safer plan, in such a condition, would be the lateral perineal section, and the removal of the middle lobe with the probe-pointed bistoury, the urine passing off by the wound until the parts are healed. Hypertrophy dependent upon the presence of morbid growths is entirely irremediable ; palliation is all that can be hoped for, and even this is generally very unsatisfactory. 5. Prostator rhcea—Prostatorrhoea, an affection which, many years ago, I was the first to describe, is, as the term implies, a discharge from the prostate gland, generally of a thin, mucous character, dependent upon irritation, if not actual inflammation, of the glandular elements of that organ ; and liable to be confounded with other lesions, as seminal losses, gleet, and cystorrhoea, from which, however, it is usually easily distin- guished. CHAP. XVI. DISEASES AND INJURIES OF PROSTATE GLAND. 795 Prostatorrhoea is rare in children and very young subjects, owing, no doubt, to the remarkably dormant condition of the genito-urinary organs in early life. It may, how- ever, occur even at a very tender age, especially in children laboring under stone in the bladder, prolapse of the bowel, or worms in the rectum, causing reflected irritation. After the twentieth year, the disease is sufficiently common, and instances are occasionally wit- nessed even in very old persons. As long as the prostate gland remains small and inac- tive, or is not brought fully under the influence of the genital apparatus, with which it is so intimately associated, it is comparatively infrequent. Although all classes of persons are liable to this affection, it has seemed to me to be most common in those of a sanguineo-nervous temperament, with strong sexual propensi- ties, leading to frequent indulgence of the venereal appetite, if not to positive venereal excesses, whether in the natural manner or by masturbation. An irritation is thus estab- lished in the organ, attended with more or less discharge of its peculiar secretion, normal or abnormal. Single and married men are, apparently, equally prone to it. Intempe- rance in eating and drinking, frequent horseback exercise, sexual abuse, and disease of the bladder, anus, and rectum, may all be regarded as contributing to its production and maintenance. The exciting causes are not always very evident. In most cases, the affection is traceable, either directly or indirectly, to venereal excesses, chronic inflammation of the neck of the bladder, stricture of the urethra, or disease of some kind or other of this canal. Sometimes it has its origin in disorder of the lower bowel, as hemorrhoids, pro- lapse, fissure, fistule, ascarides, or the lodgment of some foreign body. It is easy to conceive how reflected irritation might induce this disease. The connection between the prostate gland and ano-rectal region is very close and intimate, and, therefore, what- ever affects the one, will almost be sure, in time, to implicate the other, either from proximity of structure or as an effect of sympathy. Temporary prostatorrhcea is occa- sionally excited by the use of drastic cathartics, cantharides, turpentine, or, in short, whatever has a tendency to invite a preternatural afflux of blood to the prostate gland, the neck of the bladder, or the posterior portion of the urethra. Many of the most obsti- nate and perplexing cases of the disease that have come under my notice were the direct result of masturbation. The symptoms are sufficiently characteristic. The most prominent is a discharge of mucus, generally perfectly clear and transparent, more or less ropy, and of varying quan- tity, from a few drops to a drachm and even upwards, in the four and twenty hours. It is seldom puriform, and still more rarely purulent. When considerable, the flow keeps up almost a constant moisture at the orifice of the urethra, and it may even make a de- cided impression upon the patient’s linen, leaving it wet and stained, as in gleet, or gon- orrhoea, although in a much less degree. The most copious evacuations of this kind generally occur when the patient is at the water-closet, engaged in straining, especially if the bowels are constipated, or the rectum is distended with hard fecal matter so as to exert an unusual amount of pressure upon the prostate gland. The discharge, whether small or large, is often attended with a peculiar tickling sensa- tion in the prostate gland, from which it frequently extends along the whole length of the urethra, and even to the head of the penis. In many cases, the feeling is of a las- civious, voluptuous, or pleasurable nature, not unlike that which accompanies the earlier stages of sexual intercourse. Very often there is a “ dropping sensation,” as if the fluid were falling from the prostate gland into the urethra. Other anomalous symptoms some- times present themselves, as a feeling of weight and fatigue in the region of the prostate, anus, and rectum, or along the perineum, with, perhaps, more or less uneasiness in void- ing urine, and a frequent desire to empty the bladder. Some patients are troubled with morbid erections and lascivious dreams. The patient’s mind is generally very seriously involved in this affection. The dis- charge, even if ever so insignificant, occasions him the greatest possible disquietude; for at one time he imagines that it is a source of much bodily debility, or that it is produc- tive of weakness and soreness in the dorsolumbar region, especially if these symptoms happen to coexist; at another, that he is about to become impotent, under the delusive idea that the flow is one of a seminal character, an idea which not unfrequently haunts him day and night, and from which hardly anything can, perhaps even temporarily, divert his attention. His mind, in short, is poisoned, and the consequence is that he is incessantly engaged in trying to obtain relief, running from one practitioner to another, distrusting all, and affording none an opportunity of doing him any good. In the worst forms of the affection, his business habits are destroyed; he becomes morose and dyspeptic, and he 796 DISEASES OF THE URINARY ORGANS. CHAP. XVI. literally spends liis time in watching for the discharge which is the source and cause of his terrible suffering. The diagnosis is generally unequivocal. The affections with which the disorder is most liable to be confounded are the different forms of urethritis, especially gleet, sper- matorrhoea, and cystorrhcea. From inflammation of the urethra it is always readily dis- tinguished by the absence of pain and scalding in passing water, by the small quantity and transparent character of the discharge, and by the history of the case. In gleet, the secretion is always opaque, and usually leaves a permanent stain upon the patient’s linen. In spermatorrhoea, the discharge commonly occurs at night, during a lascivious dream, and is mucli more copious than in prostatorrhoea. In cystorrhoea, or chronic cystitis, the mucus, which forms the characteristic feature of the complaint, is only voided during mic- turition, and is invariably dependent upon organic disease of the bladder. In case of doubt, the suspected fluid should be examined with the microscope, and, in doing this, it must not be forgotten that the discharge in prostatorrhoea occasionally contains a few spermatozoa. The pathology of this affection seems to consist in an exalted functional activity of the follicular structure of the prostate gland, leading to an inordinate secretion and dis- charge of its peculiar fluid. That it is occasionally of an inflammatory nature is highly probable, but there is no reason to believe that this is generally or even frequently the case. In many instances, it is, apparently, due to reflex irritation, provoked by disease of the genito-urinary organs, the anus, and the rectum. The prognosis is generally favorable. The obstinacy of the discharge, however, is often very great, and a rapid cure need, therefore, seldom be anticipated, especially when the mind is totally absorbed in the local affection, as is so often the case in young men of a nervous, irritable temperament. In such an event, there is no complaint which, accord- ing to my experience, is more difficult of management, or more likely to result in vexation and disappointment. In the treatment of prostatorrhoea, one of the first and most important points is to ascertain, if possible, the nature of the exciting cause. With this view, the genito-uri- nary apparatus and the lower bowel should be thoroughly explored with the bougie, the finger, and even, if necessary, the speculum, so that any irritation that may be found in them may be promptly corrected, as a preliminary step to the employment of other mea- sures. The general health must be improved by exercise in the open air, by the cold shower-bath, by a careful regulation of the diet, and by a course of chalybeate tonics, in union with quinine and strychnia. Venereal excesses must be refrained from, as tending to keep up undue excitement in the prostate gland, the seminal vesicles, and the adjoin- ing structures. For a similar reason, drastic purgatives, horseback exercise, high-sea- soned dishes, condiments, wine, and alcoholic stimulants are interdicted. The bowels are maintained in an open condition. The best local remedies, according to my experience, are anodyne suppositories, the methodical introduction of the bougie, and injections of a solution of Goulard’s extract, in the proportion of about one drachm to ten ounces of water, repeated night and morning, and retained for at least five minutes at a time. If the patient is plethoric, blood may be taken by leeches from the perineum, and the system reduced by antimonial and saline preparations, in combination with light diet and other depressing measures. In all cases bromide of potassium and atropia, particularly the latter remedy, are indicated, while in obstinate cases cauterization of the prostatic portion of the urethra sometimes affords prompt relief. Whatever may be the plan of treatment, perseverance with an occasional change of prescription is indispensable to success. When there is deep mental involvement, hardly anything will effect a cure ; or, more correctly speaking, it will be almost impossible to induce the patient to believe that he is well, or that nothing serious ails him. Under such circumstances, the chief dependence must be upon travelling and an entire change of scene and occupation. Matrimony should be enjoined, if the patient is single. 6. Tumors or Morbid Growths—Carcinomatous formations of the prostate, which are always of the nature of medullary or encephaloid epithelioma, are extremely uncommon. They have hitherto been observed chiefly in advanced life, as soft, succulent, vascular, more or less ovoidal, moderately large growths, which exhibit a decided tendency to invade the associated organs, the pelvic lymphatic glands, and the general system. There are no signs by which encephaloid can be distinguished, with any clearness, from some of the other affections to which this body is liable. The most reliable evidences are, a discharge of blood with the urine, the occasional expulsion of cerebriform substance or organized clots, the frequent desire to pass water, and the ability to feel the enlarged gland through the rectum. No kind of treat- ment, either local or general, is of any service beyond palliation. Sarcomatous tumors of this gland, fig. 624, from Socin, are still more rare than the carcinomatous,from which they differ mainly in their clinical history, by their almost exclusive occurrence in early life, the average being four years, their rapid growth, their large volume, the absence of lymphatic involvement, and their extraordinary progress, the duration of life from the first symptoms to the fatal termination, averaging four months as against forty-nine months for medullary carcinoma. Retention of urine is the most prominent symptom, hemorrhage being witnessed only after the employment of the catheter. The treatment is palliative. Cysts occasionally exist in the pros- tate, as the result of obstructed and di- lated follicles or tubules; they vary much in size and number, but are usually very small. Their contents are transparent, fluid, and of a serous character. Old persons are most subject to them. When a body of this kind attains a large bulk, its inevitable tendency is, by the constant pressure which it exerts, to cause atrophy of the organ ; or, in other words, to usurp its place. Should the cyst, under such circumstances, burst, or be accidentally ruptured, a large cavity will be formed, which may afterwards act as a subsidiary pouch for the lodgment of urine and the development of calculi. Such a receptacle might seriously interfere with the in- troduction of the catheter. Fibrornatous myomas, the so-called prostatic glandular tumors, are not of uncommon occurrence in the enlarged organ of elderly subjects, in which they are found under two very distinct forms. In one of these the morbid growth is imbedded, more or less deeply, in the substance of the gland, where it is distinctly cncapsuled, and easily enucleated. Generally solitary, it is of a rounded or ovoidal shape, and ranges in volume from that of a pea to that of a filbert. In the other variety the tumor occurs as an outgrowth, con- tinuous with the organ by a narrow pedicle, the whole resembling a polypoid excrescence, of varying size and form, and often obstructing the orifice of the urethra. Both classes of tumors are identical in structure with that of the proper prostatic tissues, being com- posed of fibro-muscular and glandular elements, the former predominating. From this fact they are more correctly denominated fibro-myomatous growths, and should not be included among the adenomas, as there is no true hyperplasia of the gland-follicles. Their existence may be suspected, but cannot positively be affirmed during life, and surgery fur- nishes no means for their removal. I have on several occasions accidentally enucleated such growths in the lateral operation of lithotomy, and have found that the closure of the wound was thereby retarded. 7. Tuberculosis—The prostate gland is occasionally the seat of tubercles. The affec- tion, however, is also extremely rare, and is usually, if not invariably, associated with similar deposits in the seminal vesicles, urinary bladder, kidneys, testicles, and other organs. The malady is most common between the twenty-fifth and fifty-fifth years. In eighteen cases analyzed by Sir Henry Thompson, in his work on the Prostate Gland, the age of the youngest subject was eleven and of the oldest seventy-six years. The disease furnishes no characteristic symptoms, and every attempt to treat it upon scientific princi- ples must prove unavailing. When its existence is suspected, iodine may be administered internally, and counterirritation applied to the perineum. 8. Hemorrhage—The prostate gland is liable to hemorrhage, varying in degree from a few drops to several ounces. The occurrence, however, is very rare, and is chiefly met with in aged subjects, in consequence of the forcible use of instruments. Sometimes the most gentle catheterism will be followed by a smart flow of blood. The irritation of a calculus may also give rise to it. The diagnosis is uncertain, as it is difficult to determine the precise source of the bleeding. CHAP. XVI. DISEASES AND INJURIES OF PROSTATE GLAND 797 Fig. 624. Sarcoma of the Middle Portion of the Prostate. 798 DISEASES OF THE URINARY ORGANS. The prognosis is favorable or otherwise, according to the cause of the hemorrhage, as, for example, whether it is simple or traumatic, or dependent upon ulceration of the gland, or the presence of malignant disease. The treatment is to be conducted upon the same principles as in hemorrhage of the urinary passages generally. 9. Concretions and Calculi The prostate, like the bladder and the kidney, is liable to the formation of concretions and calculi, as seen in fig. 625, which generally become a chap. xvi. Fig. 625. Fig. 626. Prostatic Concretions. source of severe suffering, imperatively demanding surgical and other interfer- ence. They are entirely different, both in their structure and composition, from vesical concretions, and appear to be the result, at least in most instances, of disordered follicular secretion, depen- dant, in all probability, upon subacute or chronic irritation; old persons are most liable to their formation; they may, however, occur at almost any period of life. Sir Henry Thompson asserts that prostatic calculi are almost universally present after the age of twenty. In seventy persons examined by him after this period, lie found evidence of them in every one. The number of concretions is extremely variable; sometimes there is only one, while, at other times, there are so many as to render it difficult to count them. Their volume, which is generally in proportion to their number, varies from a poppy seed to that of a millet seed. Composed exclusively of phosphate of lime, they are of a spherical or ovoidal shape, of a firm consistence, and of a grayish, whitish, or brownish color. From a care- ful examination of their situation, in different stages of their development, I am satisfied that they are originally formed in the follicles and ducts of the prostate, as represented in fig. 626, from Socin, from which they either escape, or they remain, and gradually destroy its substance. A very remarkable specimen of prostatic calculus, delineated in 627, and now contained in the Museum of the Royal College of Surgeons in London, has been described by Dr. Herbert Barker, of England. Its weight was three ounces and a half, its length nearly five inches, and its circumference, at the thickest part, four inches and five-eighths. It had a rough, lobulated surface, and consisted of twenty-nine distinct pieces, clearly showing that it had been originally deposited in separate follicles of the prostate, the intervening struc- tures of which had been absorbed during the progress of its formation. There is no uniformity in the effects produced by these bodies. When small, they seldom cause much uneasiness, sometimes, indeed, not the slightest. At times, however, they are productive of gi’eat inconvenience, if not of excessive suffering. One of the most common occurrences is a dull, aching, wandering pain, with a sense of uneasiness in the perineum and neck of the bladder. The general symptoms do not differ materially from those of vesical calculi. Two Concentric Concretions in the Prostatic Ducts. Fig. 627. Prostatic Calculus. CHAP. XVII. AFFECTIONS OF THE TESTICLE. 799 The diagnosis is by no means always easy. When the finger is introduced into the rectum, and the prostate is pressed backwards with a large sound, the concretions may often be felt as so many hard, irregular projections, the position of which remains un- changed by any force that may be applied to them. When a considerable number are collected together, as it were, in a nest, they impart to the finger the feel of a bag of marbles, of a mass of clotted blood, or of a bag of air. Another sign upon which great reliance is placed is that the concretions can be felt only in one particular spot, and that they are generally more or less immovably fixed. Calculi of the prostate are usually associated with disease of the urinary apparatus, as stricture of the urethra, hypertrophy of the muscular coat of the bladder, vesical calculi, and disorganization of the ureters and kidneys. The gland itself is variously affected; generally, it is atrophied and partly sacculated. The treatment in the milder forms of the disease consists in improving the general health, and removing any local complications that may exist. The tendency to plios- phatic deposits is counteracted by the exhibition of the different acids, especially the nitric, either singly or in union with infusion of uva ursi and hops. The use of alkalies is also sometimes indicated. When the calculi project into the urethra, they may occa- sionally be detached with an instrument, and pushed back into the bladder, or an attempt may be made to seize and remove them with Weiss’s forceps. When they are encysted, or contained in a bag in the parenchymatous substance, the only way is to cut down to the organ upon a staff as in ordinary lithotomy. When the calculi lie in the connective tissue between the prostate and the rectum, extraction may advantageously be effected through the bowel, previously well dilated with the speculum. 10. Sacciform Disease and Fistule In consequence of abscess, ulceration, gangrene, or the presence of calculi, a pouch, sometimes as large as a pullet’s egg, is liable to form in the prostate gland, at the expense of its proper substance, its fibrous capsule alone remaining. In the majority of cases it communicates by a pretty large orifice directly with the bladder, so that, if a catheter is passed along the urethra, it is very apt to become arrested in it. Occasionally it opens into the rectum or upon the surface of the perineum, or in both situations, although this is very uncommon. A person thus affected experiences more or less pain and difficulty in voiding bis urine, which is generally mixed with pus and thick, ropy mucus ; there is constant uneasiness in the pelvic region, the general health suffers, and the slightest exposure, fatigue, or dis- order of the bowels, is sure to aggravate the local distress. When the sac communicates with the bowel, there may be an interchange of urine and fecal matter between the two reservoirs. Sometimes there is incontinence, at other times retention, of urine. The diagnosis can only be established by a thorough exploration with the catheter, aided by the finger in the rectum. The prognosis is unfavorable, as few cases admit of relief by treatment. When the suffering is very great, the best plan is to divide the parts freely, as in the rectovesical operation of lithotomy. CHAPTER XVII. DISEASES AND INJURIES OF THE MALE GENITAL ORGANS. SECT. I AFFECTIONS OF THE TESTICLE. The testicle is liable to congenital irregularities, wounds, inflammation, abscess, atrophy, cystic disease, various degenerations, morbid growths, and neuralgia. 1. Congenital Irregularities.— One of the testicles is sometimes absent, the increased size of the other generally atoning for the deficiency. Only a few instances of a well- authenticated character are upon record in which both organs were wanting. Sometimes one testicle is unusually small, and the other uncommonly large. I have met with two cases in which these structures seemed to exist simply in a rudimentary state, their volume hardly equalling that of a hazelnut. One of the men never experienced the slightest sexual desire; the other, however, had been married, but, although the connec- tion had lasted upwards of twenty years, no offspring had followed. A supernumerary 800 DISEASES OF THE MALE GENITAL ORGANS. testicle occasionally exists, but, in general, what is regarded as such an appendage is merely a fatty or fibrous tumor of the scrotum, or a portion of irreducible omentum, as in the celebrated case of Morgagni. Anomalies of the situation of the testicle sometimes occur. Of these, the most common is the retention of the organ in the groin, or in the inguinal canal; more rarely it remains in the cavity of the abdomen. The defect may he limited to one organ, or it may involve both ; and, what is singular, it now and then occurs in several members of the same family, as in a remarkable instance reported by me in the Western Journal of Medicine and Surgery, for May, 1841. In time, generally towards the age of puberty, or soon after, the organ passes down into the scrotum, hut the cases are not uncommon in which the retention is permanent. Besides being a source of pain and annoyance in such an event, from the compression of the abdominal muscles and other causes, the organ is prone to take on malignant disease and to induce hydrocele and hernia. It is asserted upon good authority that an undescended testicle is incapable of forming spermatozoa. If hernia should occur, the protruding parts, instead of issuing at the external ring, are very apt to be deflected out towards the anterior superior spinous process of the ilium, thus constituting, strictly speaking, an inguinal hernia or bubonocele. The tumor formed by an undescended testicle is liable to be mistaken for hernia; but from this it may generally be easily distinguished by its greater solidity, by the empty state of the scrotum, by the absence of impulse on coughing, and by the peculiar pain felt on handling the parts. When the tumor coexists with hernia, the symptoms will be of a mixed character. The treatment of retained testicle varies. When the organ lies in the groin, an attempt should be made by daily and long-continued tractions with the fingers, aided by gymnastic and other exercises, to get it into the scrotum. If it is only partially down, and there is at the same time a hernia, a truss with a small pad should be worn, the pressure being applied above the retained organ, which may then be gradually urged down by the means just mentioned. Nothing, of course, can be done when the testicle is retained in the abdomi- nal cavity. When the gland suffers excessive pain from the incessant compression of the abdominal muscles, extirpation may become necessary. Instead of being retained in the groin, the testicle sometimes descends into the perineum, lying at the root of the scrotum, near the anus, or close by the tuberosity of the ischium. Such an anomaly, of which interesting examples have been observed by Hunter, Ricord, Partridge, Vidal, Sands, Thomas G. Morton, myself and others, always constitutes a serious evil, as it must necessarily be attended with more or less inconvenience and risk of injury when the subject of it sits, or rides on horseback. Attempts have been made in some of the recorded cases to replace the organ by an operation, but thus far without suc- cess, and hence the best plan is to sacrifice it, if it is decidedly in the way of comfort. In an instance observed by Zeiss, the organ occupied the left side of the perineum, and offered a serious obstacle to the operation of lithotomy. Eckert and Vidal each relate an instance in tvhich one of the testicles, instead of pass- ing through the inguinal canal, emerged at the femoral ring; and Curling refers to one in which this gland was lodged behind the saphenous vein, in the upper and inner part of the thigh, about three inches below Poupart’s ligament. It was small and undeveloped. Finally, the position of the testicle in the scrotum is sometimes reversed, the free surface presenting posteriorly, while the anterior part of the organ is connected with the epididymis. 2. Wounds—Wounds of the testicle may be of various kinds, as incised, contused, punctured, lacerated, and gunshot; their occurrence is uncommon, and their treatment does not differ from that of similar lesions in other parts of the body. Great care should be taken to save as much structure as possible. When the wound extends through the spermatic cord, serious hemorrhage may arise, and it should, therefore, be the duty of the surgeon to seek for and tie every bleeding vessel. A violent contusion of the testicle may be followed by convulsions and death. Even in the milder grades of the injury there is often most intense pain, extending along the groins to the loins, and attended with a peculiar sickening sensation, sometimes amount- ing to complete syncope. The patient is obliged to double himself up for relief, breaks out into a copious sweat, and is seized with nausea, if not vomiting. The shock, in fact, is excessive. The suffering, however, is commonly very transient, and subsides either spontaneously or under the influence of cold air and gentle stimulants. More or less blood is generally extravasated, as a consequence of the lesion, either into the vaginal sac, or between the sac and the albugineous coat. * Sometimes the fluid is extensively effused into the connective tissue of the spermatic cord, the infiltration reaching, perhaps, as CHAP. XVII. CHAP. XVII. AFFECTIONS OF THE TESTICLE. 801 high up as the internal abdominal ring, the kidney, or even the diaphragm, as in the in- teresting case related by Petit. Wounds of the testicle are liable to occasion atrophy. In a case which occurred in the Crimean war, and in which a very slight injury had been inflicted by the fragment of a shell, the organ had nearly entirely disappeared at the end of five months by absorption. The other testicle was also diminished in bulk, although it did not seem to have been hurt in the first instance. A similar phenomenon was noticed by Jobert in some of the persons that were wounded in the insurrection at Paris, in July, 1830. When the testicle is completely denuded, whether by accident or disease, a covering may be formed for it by the transplantation of a flap of integument from the thigh and perineum. In a case reported by Professor Fulton, of Toronto, the proceeding was followed by the most gratifying results. The man had been wounded in a threshing machine, one testicle being torn off with a portion of the spermatic cord, and the other completely divested of skin. The greater portion of the flap united by the first intention. 3. Orchitis Inflammation of the testicle, technically called orchitis, may be acute or chronic, idiopathic or traumatic, primary or consecutive, common or specific. For an account of the syphilitic form of the affection, the reader is referred to the chapter on syphilitic diseases in the first volume. The acute form of common orchitis is seated principally in the epididymis, and is generally caused by gonorrhoea, the inflammation being transmitted from the urethra along the deferent duct. It may also be occasioned by external violence, great sexual excitement, the effects of cold, and by metastasis, as in mumps. During the existence of gonorrhoea, the most trifling circumstances, as the pressure of the pantaloons, exposure to wet, fatigue, and stimulating injections, may induce the disease. The epididymis, enlarged to twice or thrice its natural volume, is abnormally firm, and the vaginal tunic is distended with turbid serum, intermixed with flakes of lymph. The testis itself, as seen in fig. 628, is comparatively little increased in size. The part is exquisitely tender, and intolerant of the slightest pressure; the pain is of a dull, heavy, aching, sickening character, and extends upwards in the course of the spermatic cord as far as the loins, where it is often very severe ; the scrotum is hot, tense, red, and glistening; high fever is present, frequently accompanied by nausea and vomiting; and, if blood be drawn from the arm, it is usually found to be sizy and cupped. The dis- charge from the urethra is very much diminished, or entirely suspended, and the patient is often annoyed with nocturnal emissions, tinged with blood. In many cases great uneasiness is felt in the groin, abdomen, hip, perineum, and upper part of the thigh. When the epididymitis, as this affection is properly designated, follows upon gonorrhma, it usually comes on about the end of the third or the beginning of the fourth week of the attack of this disease, although it may occur much earlier, as well as much later. It often affects both glands, either simultaneously or successively. Verneuil has noticed the singular fact that orchitis, especially when accompanied by copious serous effusion into the vaginal tunic, is frequently complicated with inflammation of the throat. The power of furnishing spermatozoa is often seriously impaired, if not completely destroyed, by the effects of orchitis, or of this disease and of epididymitis, whether the result of gonorrhoea, syphilis, parotitis, or external injury. Hence, if both glands have suffered severely, the individual may be permanently impotent, although it is possible for the organs, ultimately, to regain their natural functions. Fortunately such a condition does not weaken the sexual appetite, or the power of gratifying it; and, as there is always an evacuation of seminal fluid during copulation, the subject of it is never aware of his real situation. It will thus be seen that orchitis is a grave affection, independently of the local and general suffering it occasions. A testicle retained in the groin may take on inflammation, and thus occasion a train of phenomena closely resembling strangulated hernia, especially when the accident occurs in the adult. The principal signs of distinction are, the absence of the testicle from the corresponding side of the scrotum, the history of the case, the uniform hardness of the Fig. 628. Acute Orchitis. swelling, the sickening pain produced on pressure, and the facility with which the bowels are relieved by purgative medicine. The two affections may coexist, and then the tumor will probably be hard at one point, and more or less soft at another. From the close proximity of the testicle to the peritoneum, the inflammation may readily be propagated to that membrane, and in this way a case, which is ordinarily comparatively harmless, may become one of a very dangerous character, occasionally terminating in sloughing and even in death. The treatment is rigorously antiphlogistic. If the patient is young and plethoric, blood is freely taken from the arm; the bowels are evacuated with senna and Epsom salt, or calomel and jalap; antimony is given in small doses, to keep up nausea; the recumbent posture is observed ; and the scrotum, suspended with a folded handkerchief, is diligently fomented with the lead and opium lotion. Cold applications, seldom agreeable to the patient, are often positively injurious. Blood may sometimes be abstracted advantage- ously by puncture from the veins of the scrotum, or by leeches from the groin, perineum, or inside of the thighs. Occasionally the animals are applied directly to the inflamed surface. When the swelling is very large, tense, and painful, a tolerably free incision should be made to afford vent to the pent-up serum, which, whenever the disease is unusually severe, is always present in greater or less quantity, and thus adds greatly to the patient’s suf- fering. In performing the operation, the testicle is grasped at its lower and back part with the left hand, while with the right a narrow, sharp pointed bistoury is plunged per- pendicularly into the fluctuating mass above and in front. The want of resistance and the escape of fluid will indicate that the instrument has been carried to the requisite depth. If prompt and decided relief do not follow this proceeding, the knife is reintroduced so as to divide tolerably freely, at one or more points, the albugi- neous tunic, in order to remove the excessive pressure which it exerts upon the inflamed and sensitive tubular structure beneath. Such an operation, however, will seldom be neces- sary. As soon as the disease loses its acute character, as it usually does under the above measures in three or four days, the gums should be gently touched with mercury, and the affected part compressed, as originally suggested by Fricke, of Hamburg, with a series of strips of adhesive plaster, each about six lines in width, and eight inches in length. The strips are applied as in fig. G29, which explains the process much better than any formal description. The first is placed circularly around the cord, just above the epididymis, as tightly as it can be borne; the second slightly overlaps the first, the third the second, and so on until the whole tumor is enveloped down to its base, when five or six vertical strips complete the dressing. The patient usually experiences some degree of pain during and immediately after the operation, and should this not sub- side in an hour or two the compression must be discontinued. The strapping requires to be renewed every twenty-four hours. The advantage of this treatment is that, while it rapidly sub- dues the disease and promotes the absorption of effused fluids, the patient is able to walk about and attend to business. Instead of adhesive strips, Dr. Octavius A. White, of New York, employs a compressor of thin, hard rubber, shaped like a shell, and laced in such a manner as to admit of being lengthened or relaxed at pleasure. A more efficient contriv- ance is the elastic compressor of Dr. A. L. Carroll, fig. 630, which is made of webbing, and provided with a strip of flexi- ble metal to isolate the testicle, and an elastic lacer to main- tain equable pressure. 4. Suppuration and Abscess—Orchitis does not often pass into suppuration, much less into abscess. When matter is about to form, all the symptoms are suddenly aggravated ; rigors come on, often attended with slight delirium; and the part is so painful as to be intolerant of the slightest manipu- lation and pressure. The pus, generally mixed with seminal fluid, is seldom of a healthy 802 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. Fig. 629. Carroll’s Elastic Compressor. CHAP. XVII. AFFECTIONS OF THE TESTICLE. 803 character, and, as it is confined by the albugineous coat, it is always a long time in reach- ing the surface. The abscess often breaks at several places, thus leaving unhealthy sores, which it is difficult to heal, and which not unfrequently lead to a total disorganization of the tubular structure. Suppuration of the testicle is most common in scrofulous subjects, and in persons affected with tertiary syphilis. The matter is sometimes encysted, as in fig. 631. When pus forms as a consequence of ordinary epididymitis, it is generally situated in the vaginal tunic, and not in the substance of the testicle. A very remarkable case of abscess in an undescended testi- cle has been related by Dr. M. M. Eaton, of Peoria, Illinois, in the Chicago Medical Examiner. The patient, sixteen years of age, had an exquisitely tender tumor, the size of an orange, in the right iliac region, and died under all the symp- toms of acute peritonitis. The testicle, increased to ten times its normal bulk, contained a large cavity, which communicated with that of the abdomen, the serous membrane of which was thickly coated with pus. The treatment consists in an early incision, or, rather, in a delicate puncture, especially when the fluid is situated in the substance of the testicle, the object being to save texture. The retention of pus in the parenchymatous tissue of the gland must be carefully guarded against, as being calculated to do immense harm by disorganizing the tubular structure. When the matter is allowed to find a spontaneous outlet, the opening is very liable to become the seat of fungus, consisting of a mass of tubular substance and unhealthy granulations, as seen in fig. 632, from one of my clinical cases. When the protrusion is small, or of recent standing, it may occasionally be successfully repressed by regular, systematic compression with adhesive strips; or, instead of this, the edges of the opening may be thoroughly pared, and approximated by several points of the twisted suture. In the more severe and intractable cases, the mass must be retrenched with the knife or scissors; this failing, castration must be performed, an operation which is the more proper, because the substance of the testicle is, under such circumstances, generally com- pletely destroyed, as I have repeatedly satisfied myself by dissection. 5. Chronic Orchitis.—Chronic inflammation of the testis may arise spontaneously, or succeed to an acute attack. The most frequent exciting causes are gonorrhoea, stricture of the urethra, chronic cystitis, and hypertrophy of the prostate gland. The disease is characterized by induration and swelling, which, beginning in the epididymis, where they are always most conspicuous, gradually extend to the body of the testis, forming a tumor four or five times the normal bulk, free from pain, and so slow in its advances as to escape notice until it has produced serious structural changes. This circumstance, together with the irregular shape of the tumor, is sufficiently diagnostic ot the nature of the affection. The hypertrophy, which may occur on both sides, is liable to be followed by suppuration of the parenchymatous structure, hydrocele of the vaginal sac, and thickening of the cord. In obstinate cases, the tumor, on section, exhibits a dense, fibrous texture, of a reddish or brownish color, interspersed with small cells. It was to this form of the disease that the term sarcocele was applied by the older surgeons. In the treatment of this affection, the indications are to remove any exciting cause that may still be in operation, and to promote the absorption of the effused matter upon the presence of which the hypertrophy depends. To fulfil the latter the patient is confined to his back, on light diet, and is slightly mercurialized. The best preparations for this purpose are calomel, blue mass, and protiodide of mercury, properly guarded with opium. The bowels are cleared out every other day with castor oil, sulphate of magnesium, or the black draught. Suspension of the scrotum is indispensable; and discutient lotions, tinc- ture of iodine, and local depletion by leeches or punctures are important adjuvants. Oint- ments are usually hurtful. In some instances, I have derived great benefit from com- pression, applied as in acute epididymitis. If matter forms, it must be promptly evacu- ated ; fungus is repressed with escharotics and the knife. Steady perseverance in this Fig. 631. Abscess of the Testicle. Fig. 632. Fungus of the Testicle. 804 treatment for six or eiglit weeks is indispensable to a cure. Castration is unwar- rantable, unless malignant action supervenes, which is not probable. 6. Fibrous, Calcareous, Osseous, and Fatty Degeneration The substance of the testicle, in consequence of protracted inflam- mation, occasionally undergoes the fibrous degeneration. The change consists in hyper- plasia of the interstitial connective tissue, which is gradually converted into white, grayish, or bluish filaments, narrow, dense, resisting, and interlaced in every conceivable manner. The new tissue interferes so much ■with the nutritive condition of the seminif- erous tubes as to occasion, at first, a diminu- tion in their size, and ultimately their entire destruction. When the transformation is complete, the organ is firm, solid, almost incompressible, inelastic, destitute of moist- ure, and creaks under the knife. Small cysts, containing serous fluid, are occasionally interspersed through it, and specimens are observed in which there are tolerably large cavities filled with whitish, jelly-like matter. The tumor rarely exceeds the volume of a common-sized orange. The vaginal and albugineous tunics often preserve their natural characters. The disease has no tendency to return after removal. The annexed sketch, fig. 633, from a preparation in my collec- tion, conveys a good idea of the peculiar structure of this morbid growth. The history of the case, the chronic course of the disease, the absence of pain, the freedom from lymphatic involvement, the integrity of the spermatic cord, and the great firmness of the tumor, readily serve to establish the diagnosis between this and other affections of the testicle. The microscopical characters of fibrous degeneration of the testicle, consequent upon tertiary syphilis, are well illustrated in fig. 634, from a drawing by Dr. Pack- ard. The patient, from whom I removed it, had been laboring under orchitis for nearly three years. The disease was at- tended with a large fungus and a most copious, fetid discharge; the general health was much undermined, and a painful node existed upon each tibia. The testicle was considerably reduced in size, and consisted mainly of fibrous tis- sue, interspersed with numerous nuclei, some adherent, others free. A more minute account of syphilitic orchitis will be found in the first volume. When this disease is fully formed, and the substance of the testicle is completely annihilated, the only suitable remedy is extirpation. In its earlier stages, its progress may sometimes be stayed by sorbefacient applications, aided by occasional leeching and strapping, and by gentle but protracted ptyalism. Calcification or ossification of this organ is of very infrequent occurrence. The deposit may take place in any part of the testis, but is most common towards its centre, and is generally accompanied with considerable enlargement. It is often of an earthy rather than a bony nature, being nearly destitute of animal matter, and closely resembling the earthy substance found in the lungs and bronchial glands. Such a formation is exhibited in fig. 635, from a specimen in my possession. The organ, removed from a man, aged DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. Fig. 633. Fibrous Degeneration of the Testicle. Fig. 634. Microscopical Characters of Syphilitic Orchitis. CHAP. XVII . AFFECTIONS OF THE TESTICLE 805 thirty, was greatly atrophied, and completely deprived of its natural structure. The albugineous tunic of the testicle is sometimes ossified, as in a specimen kindly presented to me by Professor McGuire, of Richmond, Virginia, removed after death from a colored man, sixty-five years old. The testicle was much enlarged, the parenchymatous structure was completely annihilated, and the bony shell, several lines in thickness, and laminated in ap- pearance, emitted, when struck, a peculiar sound, similar to that of a dice-box. The man had never complained of any pain. Calcification of the vaginal tunic is an occasional occurrence, but seldom occupies much extent, and is generally associated with the fibrous and cartilaginous degeneration. Finally, the testicle occasionally undergoes thz fatty degeneration, especially when it is habitually compressed, as when it is permanently retained in the groin, or imprisoned in an old rupture. In a case described by Follin, the form of the organ was normal, but its glandular texture was almost entirely replaced by a mass of yellow adipose matter and connective tissue. In other instances, the testicle is enlarged, and interspersed with cysts, some of large size, which are filled with atheromatous material, consisting of fat globules, granular corpuscles, and crystals of cholesterine in great abundance. The walls of the cyst are very thick, covered with granulations, and, in part, calcified. The inter- vening structure consists of broad bands of compact fibrous tissue, which isolate the cysts from the proper substance of the organ. In a third class of cases, the organ undergoes atrophy, as in the annexed sketch, fig. 636, from Curling, which represents the left testicle of a man, forty-six years of age, who died of dropsy, consequent upon disease of the kidney. The organ was reduced to one-fifth its natural size, and its wasted tubu- lar structure was inlaid with fat-globules. Fatty matter was also found beneath the vis- ceral layer of the vaginal tunic. Fig. 635. Calcareous Matter in the Testicle. Fig. 636. Fig. 637. Fatty Degeneration of the Testicle : 1, the Epididymis 2, Body of the Testicle ; 3, Fatty Deposit. Cystic Testicle. 7. Cystic Disease The testicle, as seen in fig. 637, from Curling, is sometimes the seat of cysts, varying in size from a mustard seed to that of a grape, a marble, or a pigeon’s egg, and due to dilatation of, or outgrowth from, the seminal ducts. They are 806 extremely delicate, vascular, gregarious, and filled with fluid, which, in accordance with their dimensions, may be gelatinous, glairy, and discolored by blood, fat-globules, and cholesterine, or, as more rarely happens, thin and watery, and analogous to the serum of the blood. Their number may not exceed six or eight, or there may be hundreds, if not thousands. In old cases, their coats are liable to become firm, opaque, and wrinkled, their contents being thick and glairy, like the white of egg, jelly, starch, or suet. The intermediate substance is connective tissue, at one time sparse and delicate, at another, dense, compact, and solid, in which nodules of cartilage are occasionally imbedded. The disease which is thus formed is of very slow growth, free from pain or constitutional dis- turbance, and most common between the twentieth and thirty-fifth year. In an instance noticed by Dr. F. H. Gross, it occurred in an infant. It usually begins in the rete of the testis, the structure of which, together with that of the body of the organ and of the epididymis, is ultimately entirely destroyed. The tumor may acquire the bulk of a large fist, or even of a foetal head, and is of an oval shape, opaque, heavy to the feel, and less fluctuating than hydrocele, with which it is liable to be confounded. The epididymis re- tains for a long time its natural outline. The spermatic cord and the glands of the groin are never contaminated, as in encephaloid. The veins of the scrotum are usually very conspicuous. The only remedy for this affection is excision, and it is gratifying to know that the operation, when properly performed, is never followed by relapse. Cystic disease of the testicle is sometimes associated with sarcoma, thus rendering the prognosis, as it respects relapse after operation, very unfavorable. Here, as in the female breast, the interstitial connective tissue is replaced by sarcomatous structure, by which a portion of the tubule is compressed and choked up, while the remainder is dilated into cysts, some of which are filled with fluid, the majority, however, being occupied by pedunculated, dendritic, or papillary masses of the new growth, thereby giving rise to the affection known as proliferous cystic sarcoma. Under the influence of irritation, these tumors are liable to take on new action, increase rapidly, and exhibit the malignant features of ordinary medullary sarcoma in this situation. Combination of cystic disease with carcinoma is also met with, the prognosis being still more unfavorable than in the former neoplasm. The nature of the disease may be suspected, but cannot always be positively ascertained during life, when the morbid growth advances with unusual rapidity, when it attains an extraordinary bulk, and when there is great enlargement of the subcutaneous veins, with a tendency to disease in the spermatic cord and in the lymphatic glands of the groin. In another class of cases, also very rare, the cystic disease occurs in union with chon- droma, the cartilage presenting itself either in the form of small, whitish nodules, occu- pying the connective tissue of the gland, or sending irregular, tortuous, or papillary pro- longations into the cysts and the lymphatic vessels. However this may be, the adventitious material bears a strong resemblance, both in appearance, structure, and composition to true hyaline fetal cartilage; its cells, however, are more delicate and more closely clustered together, and there is less uniformity in its color and consistence, especially the latter, which often exhibits no little variety, one portion being, perhaps, quite firm and almost dry, while another is very soft and succulent. The most important diagnostic phenomena are the extraordinary weight and hardness of the tumor, the former of which may reach four or five pounds. Important information in regard to the consistence of the morbid mass may be obtained from the use of the exploring needle. The prognosis does not differ from that of ordinary cystic disease of the testicle. 8. Tuberculosis Tuberculosis of the testis, in the form of cheesy nodules, is met with chiefly in young subjects of a strum- ous diathesis. The adventitious deposit is nearly always con- fined to the epididymis, and exhibits the same features as in the lungs and lymphatic glands. It occurs in small, isolated masses, or hard nodules, from the size of a pea to that of a bean, as in fig. 638, or in the form of infiltration, and, in time, often com- pletely subverts the whole organ, transforming it into a yellowish, curdy, friable, cheese- like substance. The gland is always indurated, more or less altered in shape, and some- what enlarged. Sometimes the tubercular matter is changed into a hard, cretaceous sub- DISEASES OF THE MALE GENITAL ORGANS. CUAP. XVII. Fig. 638. Tuberculosis of the Testicle CHAP. XVII. AFFECTIONS OF THE TESTICLE. 807 stance. The disease commences insidiously, is unaccompanied by pain or tenderness on pressure, sometimes remains stationary for months, if’ not years, and is often associated with phthisis and strumous disease of the bones. Ultimately, however, the skin becomes adherent, and of a livid hue, the tubercular matter softens, and the resulting abscess opens, leaving an ill-looking ulcer, which continues fistulous for a long time, discharging a thin, serous, or gleety pus, often intermixed with semen, and particles of the morbid product. The treatment is conducted upon the same principles as in tubercular disease in general. Due attention is paid to the secretions; the bowels are evacuated by mild aperients ; the system is invigorated by tonics and alteratives, as cod-liver oil, quinine, iodide of iron, or Lugol’s solution, with bichloride of mercury ; and a light, but nutritious, diet is enjoined, with regular exercise in the open air. In short, the aim should be to maintain the general health in as good a state as possible. Any inflammation that may be present is to be combated by leeches, medicated lotions, and rest in the recumbent position. Matter is evacuated by free incisions; fungous growth is repressed by escharotics, or removed with the scissors; and sinuses are treated by astringent injections, or laid freely open with the knife. When the disease is indolent, the part should be pencilled every day with dilute tincture of iodine, or rubbed with some discutient ointment, as that of the biniodide of mercury, diluted with six, eight, or ten times its weight of simple cerate. Compression by means of adhesive strips, applied as in epididymitis, often tends to promote the absorp- tion of the adventitious matter, and to hasten the resolution of the tumor. When the organ is completely subverted in its structure, and traversed by sinuses, the only remedy is excision. 9. Carcinoma—The only form of carcinoma met with in the testicle is the soft or ence- phaloid, or fungus hematodes. It is most common between the ages of thirty-five and forty-five, and never arises in impubic subjects. I have seen several instances of ence- phaloid of the testicle in which this organ was retained in the groin ; and a case has been reported by Mr. Johnson, of London, in which the malady affected a testicle that had never left the cavity of the abdomen. It has been thought, and not without reason, that a retained testicle is, relatively speaking, more liable to suffer in this wise than one in the scrotum. Carcinoma rarely, if ever, occurs on both sides. The disease, which is always rapid in its progress, and is occasionally associated with cysts, chondroma, and sarcoma, begins in the body of the testis, from which it soon spreads to the epididymis, then to the cord, and finally to the lumbar lymphatic glands. The tumor is of a pyriform figure, being larger below than above, and somewhat flattened in front, knobby and irregular, pulpy and elastic, heavy, opaque and devoid of fluctuation. The volume ordinarily does not exceed a large fist or foetal head. The disease is at first unattended with pain; but, as it advances, the suffering often becomes very great. In the latter stages of the complaint, the countenance exhibits the greenish-yellow hue so characteristic of the carcinomatous cachexia; and the tumor, red on the surface, and traversed by large subcutaneous veins, protrudes in its well-known form of a bleeding, brain-like fungus. Under the sloughing, discharge, and pain, of which the ulcer is the seat, and the conse- quent hectic irritation, the patient rapidly sinks. Death has been known to occur within four months from the first appearance of the disease ; but the average duration of life is nearly two years. The prognosis is unfavorable ; therapeutic measures are unavailing ; and ablation, however early performed, is nearly always speedily followed by a recurrence of the disease, at the cicatrice, in the spermatic cord, or in the inguinal and lumbar glands. 10. Sarcoma Of the malignant diseases of the testicle the most common is medullary sarcoma, but the distinction between it and medullary carcinoma, particularly as it extends to the lymphatic glands more frequently than the latter affection, is only possible with the aid of the microscope. From a study of 40 cases, including several of his own, Dr. S. W. Gross finds that sarcoma occurs earlier in life, being not uncommon in children, implicates the epididymis more frequently, grows more rapidly, attains a larger volume, and invades the cord less often, than carcinoma. In the former affection both organs are not uncommonly affected, while one alone is involved in the latter disease. Finally, the presence of cartilage is so frequent in spindle-celled sarcoma, that it goes far to establish the diagnosis. In 1870 I extirpated the left testicle of a healthy, robust man, thirty-two years of age, which had a uniform, full, firm, and dense feel, without elasticity or apparent fluctuation at any point. There was not the slightest inequality of its surface ; the scrotal coverings were sound and unadherent; the superficial veins were normal; there was no evident 808 DISEASES OF THE MALE GENITAL ORGANS. involvement of the lymphatic glands; and the sac of the vaginal tunic was free from fluid ; but the veins of the cord were enlarged and tortuous. After removal, the tumor, which had made its appearance nine months previously, and was latterly painful on pressure at its upper limits, was found to be of an ovoidal figure, somewhat flattened from side to side, and nearly nine inches in its transverse, by eleven inches in its vertical, circumference, with a weight of ten ounces. On section, the surfaces displayed a homogeneous, moderately firm structure, of a delicate rosaceous tint, with here and there points of linear injection, easily broken down on pressure, and exuding a milky juice on scraping. Its microscopic character was that of small x-ound-celled sarcoma. At the present date, three years and a half subsequent to the operation, there has been no return of the disease. Sarcoma does not always possess the flattering course as in the case just narrated. Thus, of 23 castrations in which the histories are complete after operation, collated by Dr. S. W. Gross, 3 were living free from recurrence for an average period of six years, 1 was alive with recurrence and enlargement of the lumbar and supraclavicular glands, while 19 were dead, with glandular implication and visceral deposits in 1G. The round- celled variety pursues a more rapid course and is followed by metastatic tumors more fre- quently than the spindle-celled. 11. Chondroma.—Of the different glands, next to the parotid, the testicle seems to be the favorite seat of the cartilaginous tumor, where, as already stated, it is usually combined Avith cysts or sarcoma, although pure forms, of a hyaline constitution, and rarely exceed- ing the volume of a hen’s egg, are met with. In the majority, if not all, of the instances, indeed, of association of cysts with chondroma, there is every reason to believe that the latter is the primary affection, the former being due to partial occlusion and ectasy of the seminiferous tubules, through the compression exerted upon them by the new material, developed at the expense of the intertubular connective tissue. Arising usually in the rete of the organ, the cartilaginous tumor very frequently shoots prolongations into the lymphatic vessels, which exist in great numbers between the tubules, thereby giving the mass a peculiar tortuous and ramified appearance. The diagnosis is based upon the weight, hardness, and slow progress of the growth. The prognosis is favorable, the few cases of assumed dissemination being really examples of sarcomatous chondroma. 12. Myomatous and other Tumors.—Among the rarer neoplasms of the testicles are muscular tumors, formed principally of striated fibres, examples of which have been reported by Rokitansky, Rindfleisch, and Billroth. Their presence may be suspected by their congenital origin, firm, elastic consistence, and small volume. Hydatids are so uncommon as not to demand any special notice. A few instances have been observed, chiefly among the inhabitants of the tropics, in which this organ contained a cyst, occu- pied by the jilaria medinensis, or guinea worm. Dermoid cysts are treated of in the section on affections of the scrotum. 13. Atrophy—Atrophy of the testicle may be induced by a great variety of causes, as excessive venery, masturbation, external violence, wounds, mechanical pressure from tumors, effused fluids, or enlarged veins, obliteration of the spermatic artery, lesion of the cerebellum, and the inordinate use of iodine, alcohol, and narcotics. Occasionally it fol- lows neuralgia and acute orchitis. The wasting, which is usually very gradual, is most common in young subjects, and often reduces the gland to a soft, pulpy structure, less than one-third the natural volume. The treatment is restricted, in great measure, to the removal of the exciting cause. Restoration of the normal bulk is hardly possible. 14. Neuralgia—Neuralgia of the testis is chiefly observed in young subjects, of a ner- vous, irritable temperament, and generally arises without any obvious cause, although in many instances if is referred to external violence, stricture of the urethra, or disease of the prostate gland, bladder, or rectum. In most of the cases that have fallen under my notice, it was connected with dyspepsia and neuralgia of other organs. Masturbation, veneral excesses, and varicocele occasionally induce the disease. In some cases it is of a distinctly malarial origin. It is characterized by constant uneasiness, excessive morbid sensibility, and violent darting pain, which, besides being frequently paroxysmal, is aggra- vated by the slightest motion and pressure, and always extends to the neighboring parts, particularly the spermatic cord, back, and groin. Occasionally the pain is of a dull, heavy, aching nature, circumscribed instead of diffused, and relieved rather than increased by exercise. During the height of the suffering the testicle is closely retracted, and intoler- ant of the slightest manipulation. In protracted cases, the general health is always ma- terially impaired; the digestive organs are disordered; and the patient is a prey to despondency and unpleasant foreboding. There is no swelling of the testicle, and gene- CHAP. XVII. CHAP. XVII. AFFECTIONS OF THE TESTICLE. 809 rally no perceptible alteration in its structure. Occasionally, however, it is very much wasted, if not entirely destroyed. The cord is usually sound. The treatment is similar to that of neuralgia in other parts of the body. After a pre- liminary course of moderate purgation, which should never be neglected, much may be expected from a combination of quinine, aconite, strychnia, and arsenic, as recommended in a former chapter. Low diet, mercury, and bloodletting generally aggravate the com- plaint. Stramonium is sometimes efficacious. The best local remedies are belladonna, aconite, and veratria, either in solution or in the form of ointment, rubbed on the scro- tum and groin twice in the twenty-four hours. Temporary relief often follows the appli- cation of warm water. In some instances I have derived signal benefit from the applica- tion of a small blister to the groin, succeeded by the endermic use of sulphate of morphia. How far firm compression of the spermatic cord with Bresehet’s instrument, or some similar apparatus, lately recommended by Professor William H. Hammond, may be worthy of reliance as a means of relief, can only be determined by further trials. The organ in all cases must be properly suspended and protected from pressure. Castration can never be justifiable, not even when there is hopeless atrophy, inasmuch as the neuralgia would be certain to locate itself upon some other structure. 15. Castration Excision of the testicle, rendered necessary on account of different diseases, is generally a very simple operation. When the integument is not involved, a single incision will suffice, extending from the upper to the lower part of the tumor, along its anterior surface; otherwise it must be of an elliptical form. Great care, however, must be taken not to remove too much substance, as will be likely to be done, if proper allowance be not made for shrinkage. The tumor during this stage of the operation is supported with the left hand, applied to its posterior surface. The next step consists in detaching the spermatic cord from the surrounding parts, and cutting it off just above the tumor, as in fig. 639 ; but be- fore this is done it is seized with a double hook, and drawn down, until its vessels are secured. A long, stout ligature being now passed through its connective tissue, but not tied, so that, in the event of secondary hemorrhage, the cord may at any moment be pulled out, the instru- ment is removed, and the organ rapidly detached from above downwards. In doing this, care must be taken not to wound the sound testicle, or to divide the scrotal septum. When the cord is diseased it may be necessary to extend the dissection into the inguinal canal, and to include the whole mass in a strong, carbolized catgut ligature previously to its division. In a case of incipient carcinoma of the testis upon which I operated in 1863, with the assistance of Dr. F. F. Maury, I included the entire cord, although perfectly sound, in a wire ligature left permanently in the groin. No unpleasant effects whatever followed. In a case in the practice of Mr. Chandler, of London, in 1807, in which the whole cord was tied with a single ligature, tetanus set in on the ninth day, and terminated fatally in forty-eight hours. Bleeding of the cord can always be effectually prevented by acupressure, the wire not being removed from the needle before the end of the third day. From three to six little arteries will generally require ligation, and it will be well not to slight any vessel of this kind, however insignificant, otherwise secondary hemorrhage will almost be inevitable. The edges of the wound should be approximated with metallic sutures, but not until the skin has become thoroughly contracted, which will seldom be under five or six hours. To prevent hemorrhage and promote cicatrization, the parts should be well supported, and kept constantly covered with a small bladder partially filled with pounded ice. Any tendency that may occur to inversion of the edges of the wound should be counteracted by the use of adhesive strips. Instead of employing the ordinary dressings, I have on several occasions brought the deep portions of the wound closely together by means of several twisted sutures, by trans- fixing the flaps near their points of junction, and then throwing the ligatures around the Fig. 639. Excision of the Testicle. 810 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. pins over the edges of the wound. The procedure not only greatly promotes union by the first intention, but is one of the best safeguards against the occurrence of hemorrhage. When disease of the testicle, requiring removal, is associated with scrotal hernia, the parts should be reduced previously to the operation, which should then be conducted in the usual manner, care being taken not to wound the sac. When a testicle, the subject of malignant disease, is situated in the groin, safe removal can only be effected by the most patient and cautious dissection. Unless unusual care be taken, there will be danger of wounding the peritoneum, if not also the bowel and omen- tum, especially if the affection coexists with inguinal hernia, and of thus lighting up fatal inflammation. The risk from this source has, however, been unduly exaggerated, since of 44 cases collected, in 1879, by Monod, the peritoneum was wounded in only four, of which one proved fatal. The principal incision should be carried in the same direction as in the operation for the relief of strangulated hernia, only somewhat higher up, and free use made of the grooved director in dividing the superimposed structures. As the diagnosis is generally obscure, the first step should be of an exploratory character. As the cord requires to be divided unusually high up, the securest plan is to include it, vessels and all, in a wire or catgut ligature left permanently in the parts. Ordinary castration is commonly a perfectly safe procedure. I have myself never met with any serious accident. The chief sources of danger are secondary hemorrhage, erysipelas, pyemia, and peritonitis. The latter affection will be most likely to occur when the dissection is extended very high up into the ingunal canal. Secondary hem- orrhage is a great evil after this operation, as, from the infiltrated condition of the con- nective tissue, it is not only very difficult to tie the bleeding vessels, but the disturbance thus occasioned may lead to copious and troublesome suppuration. A considerable num- ber of cases of successful self-castration have been recorded. 16. Bandages for the Testicle Various contrivances may be employed for supporting a diseased testicle, rest being of great importance in all affections of this organ, as well as in those of the vaginal tunic, the scrotum, and the spermatic cord. The article usually preferred is the ordinary gum-elastic bag, represented in fig. 640, or a bag made of knit Fig. 640. Fig. 641. Gum-elastic Suspensory. Mayor’s Suspensory Apparatus. silk, both of which have the advantage at once of softness, lightness, and efficiency. When the parts, however, suffer from acute disease, the better plan is to support them with a large soft handkerchief, the centre, folded cornerwise, being applied to the scrotum, and the ends attached to a circular belly-band. The same object may be attained by the use of Mayor’s suspensory triangle, exhibited in fig. 641. A band being fastened around the abdomen, as in the preceding case, the base of a piece of muslin, cut in the form of a triangle, is applied to the root of the scrotum, while the tails, brought up in front, are passed around the belly-band from before backwards, and tied in front into a double slip- knot. The apex of the triangle is next carried around the band in the opposite direc- tion, and pinned to the transverse portion of the tails. In many cases, the requisite sup- port may readily be afforded by a broad strip of muslin, the ends of which, spread with adhesive plaster, are carried obliquely upwards, over the abdomen, in the direction of the spinous processes of the iliac bones. CHAP. XVII. AFFECTIONS OF THE VAGINAL TUNIC. 811 SECT. II AFFECTIONS OF THE VAGINAL TUNIC. The principal affections of the vaginal tunic of the testicle are acute inflammation, hydrocele, and hematocele. ACUTE INFLAMMATION. Acute inflammation of this membrane is exceedingly frequent, but as it is generally associated with orchitis, it is often difficult to detect its true character. The most com- mon cause of the disease is repulsion of gonorrhoea, but it may also arise from external injury, as a blow, or wound, the application of nitrate of silver, or the injection of an irritating fluid, as iodine or port wine. A tight stricture of the urethra may likewise give rise to it. The attack, however induced, is usually rapidly followed by an effusion of serum and lymph, the latter of which is either commingled with the former, or it adheres closely to the inner surface of the affected membrane, occasionally presenting a lioneycomb-like appearance, as is sometimes noticed in the pericardium. The quantity of serum is gen- erally small. When the inflammation is intense, as, for example, after the injection of a hydrocele, the fluid is often of a reddish color, from the presence of hematin. The most prominent local symptoms are, more or less swelling of the testicle, severe pain, of a tensive, aching, or throbbing character, and exquisite tenderness on pressure, with a distressing sense of weight. The part feels hard, and the scrotum is of a reddish color. With a little care, distinct fluctuation may be detected, especially if the effusion is at all considerable. The patient is feverish and restless. The disease, if not speedily arrested, may terminate in suppuration. The treatment must be strictly antiphlogistic. Recumbency, depletion, and abstinence from food are of paramount importance. The testicle is carefully suspended, and kept constantly wet with a strong solution of lead and opium. If the morbid action is unusu- ally severe, leeches may be applied. The excessive pain and tension are most effectually relieved by an early incision, in order to afford free vent to the pent-up fluid. HYDROCELE. Hydrocele is an accumulation of water in the vaginal tunic of the testicle, or in a serous cyst of the spermatic cord, between this gland and the abdominal ring. A similar affec- tion occasionally exists in a hernial sac. It is most common in adults, but may occur at any period of life ; sometimes, indeed, it is congenital, and, on the other hand, it is occa- sionally met witli at a very advanced age. Thus, in a case which I attended with Dr. Wilson Jewell, the patient was ninety-one years old, and the tumor contained not less than twenty-four ounces of limpid fluid. The affection, which sometimes forms very rapidly, usually arises without any obvious cause, and presents itself in several varieties of form, as the simple, the encysted, and the complicated. Hydrocele of the Vaginal Tunic Hydrocele of the vaginal tunic may be single or double, although the latter is infrequent, especially in this country. It appears, how- ever, to be sufficiently common in the East Indies, for of 1000 cases of the disease, treated at the Native Hospital at Calcutta, it was double in 370. It occurs with nearly equal frequency on both sides. The fluid, varying in quantity from ten to twenty ounces, is generally thin and limpid, but in old cases, or when there is disease of the testicle, epididymis, or serous membrane, it is apt to be thick and of a yellowish, amber, or citron color. Sometimes it is red, brownish, or slightly greenish ; and in several instances under my observation it was of chocolate hue, or of the color of black coffee, probably from the presence of hematin, purulent, fibrinous, or intermixed with particles of cholesterine. It is free from odor, saline in taste, and coagulable by heat, alcohol, and the dilute acids ; circumstances which show its affinity with the serum of the blood from which it is derived. Cases have been noticed in which it had a lactescent appearance, and consisted of albumen, intermixed with leucocytes and fatty matter. Now and then spermatozoa are found in it, but much oftener in encysted than in ordinary hydrocele. The presence of lymph in the vaginal tunic of the testicle has been noticed by numerous observers. The fluid, which is of a whitish appearance, is spontaneously coagulable, and con- sists largely of two substances analogous to, if not identical with, casein and butter, with 812 traces of sugar and chloride of sodium. In a case reported by Dr. C. H. Mastin, there was a veritable lymphocele upon the vaginal tunic, about the size of an ordinary English pea, formed, apparently, by some obstruction in the afferent vessels interfering with the passage of their contents. The bursting of such a swelling into the sac of a hydrocele accounts for the presence of the lactescent character of the fluid. The quantity of fluid in hydrocele is subject to much diversity ; in this country it rarely, on an average, exceeds sixteen, eighteen, or twenty ounces. Cases, however, occur, in which it is much greater. Thus, Dr. Jones, physician to Franklin and Washington, has recorded an instance, in his work on Surgery, of two gallons; and Professor May has com- municated to me the particulars of the case of a negro, sixty years of age, of seventy-two ounces, the tumor measuring nearly twelve inches in length, by twenty-three inches in circumference. Gibbon, the historian, had a hydrocele which contained a gallon and a half of fluid. The largest accumulations of this kind generally occur in the inhabitants of tropical climates, particularly in those of the East and West Indies. The vaginal tunic in this affection is commonly unaltered; but in old cases it is some- times very hard, opaque, thickened, fibrous, cartilaginous, or even partially calcified. Instances are recorded in which its inner surface was studded with fine sandy matter, evidently the result of former inflammation. The cavity of the vaginal tunic is occasion- ally intersected by fibrinous bands, or even divided into distinct compartments, forming a sort of multilocular tumor; and examples are ob- served in which it contains serous cysts, hydatids, or cartilaginous concretions. The albugineous coat is seldom changed. The same is generally the case with the testicle; but this organ is sometimes en- larged and preternaturally firm, and the disease is then termed hydroscircocele. Fig. 642, from a preparation in my collection, exhibits the appear- ance of the parts in the more common forms of hy- drocele. When the quantity of liquid is very great, its pressure upon the testicle, especially if long-con- tinued, may cause more or less atrophy, if not com- plete destruction of the parenchymatous structure. This variety of hydrocele forms as a slow, chronic swelling, with little or no pain, and no discoloration of the skin ; elastic ; fluctuating ; smooth on the sur- face ; movable, but unaffected by pressure and posi- tion ; translucent under transmitted light; of an ovoidalor pyriform figure ; gradually ascending from the lower part of the scrotum upwards ; and varying in size from a small fist to that of a foetal head. The testicle lies at the posterior part of the tumor, towards its inferior third, and the spermatic cord may generally be easily felt in its natural situation. The swelling is sometimes contracted at the middle so as to give it an hour-glass appearance, and not unfrequently it assumes an elongated pyramidal form, being larger above than below. In old cases, or where the accumulation is very considerable, amounting to fifteen or twenty ounces, it is very hard, tense, and devoid both of fluctuation and translucency. The testicle is occasionally situated in front of the fluid, either as a con- genital occurrence, or as the result of injury inflicted in tapping; and in a number of in- stances I have met with it at the bottom of the tumor. Not long ago I treated a case in a youth of fourteen years, in which the organ was suspended at the top of the fluid. The diagnosis is determined by the history of the tumor, by its gradual increase from below upwards, by the absence of pain, by the sickening sensation experienced on making pressure in the situation of the testicle, by the want of impulse on coughing, and by the peculiar shape of the swelling. By darkening the room, and then holding a candle oppo- site the tumor, while one hand is placed in front and the other behind it, a certain de- gree of translucency is generally perceived. Instead of conducting the examination in this wise, an instrument called the photoscope may be used, without the trouble of DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. Fig. 642. Hydrocele of Vaginal Tunic. CHAP. XVII. HYDEOCELE. 813 excluding the light from the patient’s apartment. It consists of a tin-tube, blackened on the inside, about seven inches in length by one inch and a quarter in diameter at the larger end. The other extremity, which tapers down to nine lines, is furnished with a wooden eye-piece. The translucency will be rendered most distinct by placing the hands in front and behind the tumor, as in the ordinary exploration. In hernia, with which this affection is most liable to be confounded, the swelling begins at the abdominal ring and gradually descends; the spermatic cord is situated at the back part, and the testicle at the bottom ; there is a distinct impulse on coughing; and the con- tents disappear on pressure, or on assuming the recumbent position. Moreover, in scrotal hernia there is generally an unusual fullness in the groin, increased on coughing, with an appearance of active motion, owing to the distension of the bowel. In hydrocele, as well as in sarcocele, the groin, especially in the milder cases, retains its natural aspect and feel, and the tumor may be thrown about more, being easily pushed upwards, downwards, or laterally; a procedure which is either very difficult, or quite impracticable, in scrotal her- nia, on account of the angle formed by the protruded parts. It is hardly possible that a hydrocele should be confounded with a varicocele. Hydro- cele occurs at all periods of life; varicocele chiefly in young persons soon after the age of puberty. In hydrocele the tumor is tense, fluctuating, and elastic; in varicocele, soft, doughy, and vermiform in feel. In the former, the swelling is fixed or stationary ; in the latter, it may be made to disappear by lifting up the scrotum, and pressing the blood out of the enlarged varicose veins. In sarcocele, cystic disease, and encephaloid of the testicle, the tumor feels heavier than in hydrocele, its shape is more irregular, the surface is less smooth, there is an entire ab- sence of translucency, and the gland is deprived of its natural sensibility. In all obscure cases, an exploring needle, carefully inserted, will reveal the true nature of the affection. Treatment Hydrocele is unattended with danger, but as it incommodes by its weight and bulk,thepatientisin time induced to apply for relief. The disease occasionally disappears spontaneously during the treatment of other affections ; in some instances a cure is effected by the accidental rupture of the sac by external violence; and sometimes the fluid is removed by the use of blisters, tincture of iodine, spirit of camphor, pustulation with tar- tar emetic, and lotions of chloride of ammonium. When the tumor has attained a certaiu bulk, nothing short of tapping is found to answer, and this operation may be performed either with a view to a palliative or a radical effect. The palliative treatment is indicated chiefly when the patient is very old and feeble, or so timid as to be unwilling to submit to the radical operation; when the tumor is very bulky ; or, lastly, w7hen the disease is complicated with sarcocele, enlargement of the spermatic cord, scrotal hernia, or stricture of the urethra. It con- sists in evacuating the fluid from time to time with a lancet, bistoury, or trocar, the patient being erect, seated in a chair, or placed in the recumbent pos- ture. The tumor, rendered tense by grasping it be- hind with the left hand, is punctured at its anterior part, just below the middle, by inclining the instru-. ment obliquely upwards and backwards, in order to avoid injury of the testis. If a trocar be used, the perforator is now withdrawn, and the canula pushed into the sac, where it is retained until all the serum has escaped. When the operation is over, the scro- tum is supported with a suspensory bag, the punc- ture being left uncovered. Undue excitement is avoided by observing for a few days light diet and the recumbent posture. If this precaution be neg- lected, acute inflammation of the vaginal tunic may arise, followed by suppuration, abscess, or slough- ing. The operation usually requires to be repeated in four, six, or eight months. The annexed cut, fig. 643, exhibits the manner of grasping and pierc- ing the tumor. The vaginal tunic may also be emptied by acu- puncture, performed with a cataract needle, intro- duced at four or five different points of the tumor. A slight oozing, or a thin, thread- like stream occasionally follows the withdrawal of the instrument; but, in general, the Fig. 643. Operation of Tapping a Hydrocele, the Trocar Entering the Tumor. 814 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. serum, instead of escaping externally, gradually, infiltrates the connective tissue of the scrotum, whence it is removed in two or three days by absorption. Acupuncture is ap- plicable chiefly to recent hydrocele, and is followed less quickly by reaccumulation than after the fluid has been evacuated by the trocar or knife. A hydrocele has sometimes been cured by the accidental rupture of its sac. In a case under my observation such an effect followed upon a severe blow of the tumor against the pummel of the saddle during a ride on horseback. Dr. Lente has reported the par- ticulars of a case in which a hydrocele of considerable size was succeeded by a large hematocele by the accidental rupture of the vaginal tunic. In such an event, the proper treatment is to open the parts freely at once, before the blood has had time to undergo coagulation. For the radical cure of hydrocele, the principal operations are incision, excision, cauteri- zation, the seton, and injection. Of these, the first three are nearly obsolete, and will, therefore, require but little notice. Incision, the most ancient method of all, consists in laying the sac freely open with a knife, and dressing the wound simply with lint, or some irritating substance. Acute in- flammation soon succeeds, followed by suppuration, and the part finally heals by the granulating process. Incision is objectionable in common cases, but may be advanta- geously resorted to when the tumor is multilocular, or when it contains cysts, hydatids, or cartilaginous concretions. Incision of the sac under antiseptic precautions, combined with stitching its edges to those of the scrotal incision, a procedure which originated with Volkmann, is at present much practised by German surgeons, but as it is not more effectual than milder measures, it is not deserving of imitation. Excision, which is also of considerable antiquity, was revived, in 1755, by Douglas, of England, and is performed by cutting away a portion of the serous sac with a pair of scissors, the cord and testis being left intact. The after-treatment is the same as in incis- ion. A modification of this operation, proposed by Mr. Kinder Wood, consists in opening the tumor with a broad-shouldered lancet, and snipping off’ a small piece of the vaginal tunic, previously hooked up with a tenaculum. The puncture is closed with adhesive plaster. The opei’ation, however, rarely succeeds. The treatment by cauterization, much employed during the last century, is completely exploded. The caustic Avas applied in the same manner as for making an issue; the sloughing extended to the serous membrane, which, after evacuation of the fluid, grad- ually contracted like an ordinary abscess, and was ultimately obliterated by adhesion or granulation. The use of the seton for the radical cure of hydrocele originated with the Arabians, and was much in vogue in the fourteenth century. Pott strongly recommended it, and it has always had many warm advocates, on account of its simplicity, its freedom from danger, and its great certainty. The operation is performed in the same manner as in the method by injection, except that the puncture is made a little lower down. After all the water has escaped, the eanula is pushed on towards the superior part of the scrotum, where a counteraperture is made by the reintroduction of the perforator. The instrument being withdrawn, a piece of braid, or narrow strip of muslin, well oiled, is passed through the eanula by means of an eyed pi-obe. The operation is finished by removing the eanula, and tying the ends of the seton loosely in front of the scrotum. Sometimes a few thx*eads, or a piece of thin twine, introduced with a curved needle, will answer the purpose. Whatever substance be selected, the proper plan is to let it remain from twenty-four to forty-eight houx-s, or until the scrotum is qixite hard, and at least one-fourth as large as before the operation. The part meanwhile should be well suspended, and the patient kept on his back. For the first few days after the removxil of the seton, fomentations of acetate of lead and opium are the most eligible; and these may be gradually, but cauti- ously, succeeded by spirituous lotions, dilute tinctui-e of iodine, or mercurial ointment. The cui-e is usually completed within a fortnight. I have performed this opei’ation many times, and have never known it to be productive of xxny ill effects. It is, however, not infallible. I have met with two cases, both iix men of advanced age, in whom it was followed by signal failure; in one after the seton had been retained for three weeks, and in the other eighteen days. The hydi-ocele in each was complicated with enlargement and induration of the testicle, but in neither did the quantity of water exceed a pint. The treatment by injection, alluded to by Celsus, was introduced into general practice by Sir James Earle, who published a treatise upon it in 1791. The apparatus i-equii-ed CHAP. XVII. HYDROCELE. 815 for the operation is a rounded trocar and canula, and a rubber syringe, or gum-elastic bag, furnished 'with a nozzle and stopcock. Almost any kind of fluid may be used, as lime- water, milk, simple water, dilute alcohol, wine, spirit of camphor, and solutions of alum, zinc, nitre, chloride of sodium, tannic acid, nitrate of silver, or corrosive sublimate. Earle was in the habit of employing port wine and water, in the proportion of two-thirds of the former to one of the latter. At present, the favorite injection is tincture of iodine, either pure or diluted with three to five parts of water. In performing the operation, the patient sits, stands, or lies, as maybe most convenient, the hydrocele being punctured in the same manner as in the palliative method. After the water, however, has been evacuated, the canula is pushed in as far as possible, and the vaginal tunic carefully nipped around it with the thumb and forefinger. The tube of the syringe is then applied to the orifice of the canula, and the stimulating liquid is gradually injected until the sac is slightly distended. It is rarely necessary to throw in more than two or three ounces, especially if the fluid is brought in contact with every part of the sur- face of the serous sac, as it readily may be by compressing the scrotum with the hand. In general, the injection is retained from two to five minutes, or until the patient complains of a slight sickening sensation, and of pain in the part and in the spermatic cord, when the liquid is squeezed out, and the canula withdrawn. The wound may be let alone, or be closed with a strip of adhesive plaster. When pure tincture of iodine is used, from two to three drachms are injected, and permitted to remain permanently in the sac, from which it disappears by absorption. Usually, however, it is best to throw in several ounces of a weak solution, and to remove it as soon as it causes pain or other inconvenience. When the tumor is comparatively small and recent, a cure may occasionally be effected by injecting a small quantity of tincture of iodine with the hypodermic syringe, the water in the sac being left undisturbed. Dr. Ogier, of Charleston, who has suggested this mode of treatment, asserts that the fluid quickly disappears by absorption and he substantiates his statement with a report of twelve cases. In double hydrocele, it is best to operate upon both sides at the same time. The chief objections to the treatment by injection, are, first, its liability to occasional failure ; secondly, the escape of the injection into the connective tissue of the scrotum ; thirdly, the difficulty of regulating the amount of inflammation; and, fourthly, the occur- rence of extensive suppuration, abscess, and even sloughing. In a case which I witnessed in a young robust mechanic, twenty-six years of age, a patient of Dr. Mellwain, the injection, consisting of port wine and water, was followed by tetanus and death. The vaginal tunic was considerably thickened, and contained several ounces of sero-sanguino- lent fluid, intermixed with pus and lymph; but no adhesions had taken place between the opposite sides. The attack made its appearance on the eighth day after the operation. Dr. Valentine Mott’s favorite treatment of hydrocele was an injection consisting of a solution of one drachm of sulphate of zinc to a pint of water. In this way he cured a large number of cases without any serious mishap in any. Instead of iodine and other fluids, Dr. R. J. Levis employs an injection composed of deliquesced crystals of carbolic acid and glycerine, from one drachm to a drachm and a half of the latter to about ten per cent, of the former, introduced through a long nozzled syringe, and pressed about in such a manner as to bring it into contact with every portion of the serous surface. The injection causes some smarting, or burning, but this is speedily followed by a sense of numbness, and no unpleasant effects, it is asserted, occur afterwards. The patient during the first twenty-four hours is permitted to walk about, but after this period he is confined to his bed and treated antiphlogistically. The operation is not infallible; and in a case at the College Hospital, last autumn, it was followed by an effusion of at least ten ounces of pure blood into the vaginal tunic of the testis. I have in a number of cases effected rapid cures of hydrocele, both in adults and chil- dren, by laying open the vaginal tunic by a small incision, and, after all the fluid had been discharged, mopping the sac freely with equal parts of tincture of iodine and alcohol, or iodine variously diluted. In no instance have any unpleasant symptoms followed this procedure. Excellent cures of this complaint have been performed by the insufflation of various irritating substances, as a small quantity of red oxide of mercury, nitrate of silver, sul- phate of copper, or acetate of zinc, reduced to a fine powder, and permanently retained. Mr. Harvey, of Bristol, England, has generally succeeded in accomplishing the object by enveloping the scrotum for a few hours in a warm vinegar poultice. Pleindoux, of Nismes, has been equally successful with strong alcoholic fomentations. I have no ex- perience with any of these expedients. 816 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. Hydrocele has sometimes been treated by electropuncture. The operation, which originated with Dr. Pechioli, of Italy, is performed by introducing at different points of the tumor two slender acupuncture needles, four inches in length, and connecting one to the positive and the other to the negative pole of a DanielPs constant battery. The action may be maintained from five to forty minutes. The process, which is not free from pain, is best adapted to recent cases, and is occasionally followed by a cure. In general, however, it requires to be several times repeated at intervals of two or three days. In old hydroceles, of large size, the best plan always, according to my experience, is to draw off the water eight or ten days before an operation is performed for the radical cure. The shrinkage which takes place after the operation greatly diminishes the size of the tumor, and the chances of speedy relief, attended with comparatively little suffering, is thus greatly increased. Too much stress cannot be laid upon this procedure. Whatever measures be adopted for the radical cure of hydrocele, it is of great moment that the patient should be in sound health at the time, as when this precaution is neglected, the most simple operation may be followed by serious consequences, or, indeed, even by the patient’s death. The most common effects to be looked for are, inordinate swelling, abscess, erysipelas, orchitis, and sloughing of the scrotum. Pyemia is a pos- sible, but remote, contingency. The treatment after all operations for hydrocele must be conducted upon strictly anti- phlogistic principles ; the patient is confined at rest in the recumbent posture ; the scrotum is properly suspended ; and lotions of acetate of lead and laudanum are freely applied, especially if the inflammation threatens to run too high. The bowels are duly opened, and the diet during the first few days is suitably restricted. On the other hand, if the action is inadequate, as not unfrequently happens in elderly persons and in very chronic cases, the patient is ordered to walk about, or the scrotum is occasionally kneaded with the hand, to excite the requisite degree of inflammation. If the operation, whatever it may be, fail, it must, in due time, be repeated, or another, better adapted to the emer- gency, must take its place. The great swelling which occasionally supervenes upon some of these procedures from overaction and accumulation of serum, or serum, blood and lymph, must be met by free incisions and the usual antiphlogistic appliances. Congenital Hydrocele—In congenital hydrocele, the original communication between the peritoneum and the vaginal tunic continues open instead of being obliterated, as it is in the ordinary form of the complaint; and, hence, the fluid passes readily from one of these cavities into the other, as the bowel does in congenital hernia. The intervening canal is seldom larger than a goose-quill. The tumor, which is smooth, translucent, and fluctuating, and which usually appears soon after birth, is prolonged into the groin, and receives an impulse on coughing; it is larger in the erect than in the recumbent posture, and by gentle pressure its contents may be gradually forced into the abdomen, the testicle remaining in the scrotum. The indication is, first, to obliterate the neck ot the sac, so as to cut off the communication with the perito- neal cavity; and, secondly, to encourage the removal of the fluid by absorption. This may usually be fulfilled by the constant pressure of a spring-truss, and the use of discutient lotions, iodine, or acupuncture. In adults, or in obstinate cases, the ordinary treatment may be required. The use of the seton and of injections before closure of the intervening canal, is liable to be followed by inflammation, which, extending to the peritoneum, might endanger life. Encysted Hydrocele—A hydrocele of the testis may be encysted, as in fig. 644, the fluid being contained in an adventitious sac, distinct from the vaginal tunic, and composed of a thin, delicate serous membrane. The tumor is small, perhaps not larger than a common marble, tense and elastic, with little or no fluctuation and translucency, and filled with a limpid, colorless, almost uncoagu- lable fluid. The testicle is in front or at the side, seldom at the back, as in simple hydrocele ; and the disease is commonly devel- oped beneath the serous investment of the epididymis, although it may arise also between the vaginal and albugineous coats of the gland. When the tumor consists of two cysts, it has sometimes a lobulated appearance. I his form of hydrocele very frequently contains spermatozoa, Fig. 644. Encysted Hydrocele. CHAP. XVII. HEMATOCELE . 817 on which account it is termed by some writers spermatocele, caused, as Mr. Curling, by whom it has been so well described, conjectures, by the rupture of some of the semi- niferous tubes, and the escape of their contents into the sac of the tumor. A more plausible theory, however, is that the cyst is an outgrowth from one of the tubes of the epididymis, with which a distinct communication has been demonstrated by Luschka and other observers. When no such direct communication between a tube and the cyst can be traced, it is, nevertheless, highly probable that it originated in this way, and subsequently lost its connections. The spermatozoa sometimes exist sparingly, at other times in great numbers, and they have been found at various periods of life, from the thirtieth to the seventy-fifth year, in cysts of all sizes, from that of a filbert up. When very numerous, they impart a lactescent or opaline appearance to the fluid in which they are contained, and when the fluid has remained for a while in a glass vessel, they subside to the bottom, leaving the lower portion more opaque than the upper. What is remarkable is that these bodies are often as lively as in fresh semen. The encysted hydrocele seldom requires interference; if it do, it may readily be removed with a seton, consisting of a single cord of saddler’s silk, retained until there is sufficient evidence of the existence of obliterative inflammation. An injection of dilute tincture of iodine is also a good remedy; and in rebellious cases, the tumor may be freely incised, and treated with a tent. Hydrocele in Childhood.—Hydrocele occurs in children. The tumor is remarkably translucent, soft, fluctuating, and seldom larger than a hen’s egg. The water often dis- appears spontaneously ; and, when treatment is required, the means should always be much milder than in hydrocele of the adult. A cure may frequently be effected in a few days by pencilling the scrotum with iodine, or by the use of some discutient lotion, as chloride of ammonium, alum, acetate of lead, or a combination of equal parts of alcohol and camphorated spirit, with the addition of a small quantity of Goulard’s extract. In several cases, I have suc- ceeded perfectly by letting out the waler with a lancet, and then strapping the part with adhesive plaster, as in orchitis. When these means fail, acupuncture may be resorted to, the parts being pricked at several points with a small needle; or the tumor may be tra- versed with a filiform seton, consisting of a delicate thread, either pure, or wet with tincture of iodine, and retained from twelve to twenty-four hours ; not longer, lest undue inflammation should ensue. It is impossible, in the treatment of hydrocele in children, to be too cautious. Such is the excessive sensibility of the vaginal tunic at this period of life that the mildest operation is sometimes followed by a frightful amount of inflammation, endangering both part and system. Hernial Hydrocele The sac of an old scrotal hernia, after the obliteration of its neck, sometimes becomes dropsical, constituting what is termed oscheohydrocele. The tumor is of considerable bulk, pyramidal, fluctuating, translucent, and occupied by a viscid, amber-colored fluid. The diagnosis is easy, and the treatment is the same as in ordinary hydrocele. Occasionally, the two diseases coexist, as is shown in the adjoining sketch, fig. 645, where the sac of an inguinal hernia is situated immedi- ately above a small hydrocele of the vaginal tunic. HEMATOCELE. By a hematocele, exhibited in fig. 646, is understood a collection of blood in the vaginal tunic of the testicle. The swelling is either globular or pyramidal, being larger below than above, opaque, tense, heavy, and nearly free from fluctuation. The blood, vary- ing in quantity from a few ounces to half a gallon, is of a dark-brown color ; or, if some time has elapsed, of the color of coffee grounds, partly fluid and partly coagulated. In old cases it is occasionally lamelliform and organized, as in an aneurismal sac. The vaginal tunic may be natural, opaque and wrinkled, thickened and indurated, or soft and pulpy. The testis is generally sound. The hemorrhage may be caused by the spontaneous rupture of a vessel; but usually it is referable to a wound, bruise, or blow. The complaint may occur alone, or in union with hydrocele, when it is commonly produced by tapping. In a case of hematocele, described by Bochard, in a man, fifty- Fig. 645. Hydrocele associated with Hernia. 818 DISEASES OF THE MALE GENITAL ORGANS CHAP. XVII. one years of age, the tumor extended into the abdomen, and was lost in the bottom of the left iliac fossa. Hematocele is distinguished from other affections by its sudden development, its solid feel, the absence of trans- lucency, its dark color, its obscure fluctuation, and the fact that it is almost always occasioned by external injury. The indication is to prevent inflammation, and to encourage the removal of the effused blood by sorbefacients, of which a strong aqueous solution of chloride of ammonium, with the addition of a little vinegar, is generally the most power- ful. Acetate of lead and Goulard’s extract are also excel- lent applications. If these means fail, and the blood acts as a foreign substance, causing pain, swelling, and suppura- tion, a free incision is made along the centre of the tumor, and the wound healed by the granulating process. "When there is much thickening of the vaginal tunic, it may be necessary to cut away a portion of the diseased membrane. If the extrava- sation coexists with hydrocele, the tumor is evacuated with a lancet, and immediately after traversed with a seton. SECT. Ill AFFECTIONS OF THE SCROTUM. The scrotum is liable to wounds, inflammation, different kinds of eruptions, hypertrophy, tumors, varix, and carcinoma. 1. Wounds of the scrotum, of whatever nature, are treated as similar lesions in other parts of the body. If the edges are properly approximated, they generally heal with astonishing rapidity, even when the integument is involved to a great extent, or when both testicles are completely denuded. Considerable hemorrhage often attends, demand- ing the free use of the ligature. The parts should be well supported during the cicatri- zation. Gunshot wounds of the scrotum, of which I have seen numerous cases, generally readily heal under simple water-dressing. When complicated with injury of the urethra, and an escape of urine, they are liable to be followed by extensive sloughing, necessitating free incisions. Such an effect is best prevented by the timely use of the catheter. 2. Hematocele of the scrotum is usually caused by a strain, blow, or kick, producing a rupture of some of the vessels of the part, the contents of which are extravasated into the connective tissue below the skin. Blood is also, at the same time, frequently effused into the spermatic cord and the vaginal tunic of the testicle. The scrotum is of a dark, livid color, feels unusually heavy and doughy, and suddenly increases very greatly in bulk. The affection is similar to extravasations of blood in other regions, and requires similar treatment. 3. Inflammation of the scrotum may present itself in various forms, as the simple, traumatic, and erysipelatous, of which the latter is the only one requiring even a passing notice. It may exist by itself, or in union with similar disease in other parts of the body, and demands particular attention on account of its liability to terminate in sloughing. Elderly persons, of dilapidated constitution and intemperate habits, are its most frequent subjects. The disease is characterized by extensive swelling, from the infiltration of sero-plastic matter ; the parts feel doughy and inelastic, readily pitting on pressure ; the pain is of a smarting, burning nature; and the surface is of a pale-reddish, glossy appear- ance. More or less constitutional disturbance is present, the symptoms not unfrequently assuming a typhoid type. Extensive sloughing may occur, exposing the testes merely suspended by their cords. There is a form of erysipelas of the scrotum, which, from the peculiarity of its symp- toms, is very liable to be mistaken for infiltration of urine. It was originally described by Robert Liston, under the name of “inflammatory oedema,” and often follows upon sores, abrasions, or eruptions upon the genitals and neighboring surfaces and fistules upon the perineum and anus. The case progresses rapidly; there is enormous swelling of the scrotum and penis, of a glossy-reddish aspect, very painful, and pitting deeply on pres- sure ; the pulse is small, quick, and tremulous; the respiration is frequent and embar- rassed ; the countenance is pale and dejected; micturition is difficult, if not impractica- ble ; the strength soon gives way; and, if relief is not speedily afforded, the parts are attacked with gangrene, followed by death. In the worst forms of the disease, the swelling Fig. 646. Hematocele of the Vaginal Tunic of the Testicle. CHAP. XVII. AFFECTIONS OF THE SCROTUM. 819 extends to the groins, hypogastrium, perineum, and upper and inner regions of the thigh. In a case recently under my care, in a man of middle age and intemperate habits, the size of the scrotum fully equalled that of the head of a child one year old. The diagnosis of this form of erysipelas rests mainly upon the history of the case, as the absence of previous urinary trouble, the rapidity and great extent of the swelling, and the facility with which the bladder may be reached by the catheter. The treatment consists in attention to the general health by means of tonics, stimulants, and alterants, and in the application of tincture of iodine, with saturnine and anodyne fomentations, the parts being suspended in the usual manner. Tension is relieved, and matter evacuated, by suitable incisions. 4. A peculiar sloughing disease occasionally occurs in the scrotum of young children. In a case which I saw many years ago in an infant two weeks old, an eschar, about an inch in diameter, suddenly formed over the right testicle, leaving the vaginal tunic per- fectly denuded, and producing an angry-looking sore, with hard, glossy edges, reposing upon black-colored connective tissue. The spermatic cord was indurated, tumid, and remarkably tender on pressure. The constitution did not seem to suffer much. In the course of twenty-four hours after these symptoms were discovered, the vaginal sac became distended; and, on puncturing it, a considerable quantity of sero-purulent fluid, of a yellowish color, followed the lancet. A small portion of the membrane now sloughed, leaving the gland quite bare. Under the use of nitrate of silver and a yeast poultice, granulations gradually sprouted up, and the infant got well without any constitutional treatment. 5. Psoriasis sometimes forms on the scrotum, the skin of which becomes cracked or fissured, red, inflamed, thickened, and affected with the most intolerable itching. The disease, which is often associated with psoriasis of the perineum, anus, groin, and inside of the thighs, is produced by various causes, both local and constitutional, and is mostly met with in middle-aged and elderly subjects, of a delicate skin, and light complexion. It is frequently very intractable, and then always constitutes a source of excessive suffering. In the treatment of this affection, diligent search must be made for the exciting cause, the removal of which alone often promptly arrests the morbid action. In general, it will be found to be intimately connected with disorder of the constitution, or derangement of the digestive organs, thus pointing to the necessity of a properly regulated diet, the employ- ment of purgatives, and the exhibition of alterants, as blue mass and ipecacuanha, along with antimonial and saline preparations. Iodide of potassium and corrosive sublimate are sometimes useful. The best local remedies are weak solutions of iodine, acetate of lead, and bichloride of mercury. In my own practice, however, I have found no appli- cation so soothing and effectual as the dilute ointment of nitrate of mercury, in the pro- portion of three to five grains to the drachm of simple cerate. Zinc ointment is also a very excellent remedy. 6. Hypertrophy of the scrotum, sometimes existing as a congenital defect, is usually the result of long-continued distension and pressure consequent upon hernia, hydrocele, varicocele, and other tumors. It presents itself in varying degrees, from slight increase of the parts to the development of a tumor of large bulk and firm consistence. The treat- ment is palliative and radical; the former consisting in steady, systematic suspension, the latter, in careful retrenchment, either with the knife, or, what is preferable, because less likely to be followed by troublesome hemorrhage, the ecraseur. 7. The sebaceous tumor is occasionally met with in this situation immediately beneath the skin, which is generally so thin and transparent as to allow the contents of the growth to be distinctly visible. It sometimes occurs in considerable numbers. In one case, that of a young man, twenty-four years of age, recently under my care, upwards of one hundred existed, from the volume of a millet seed up to that of a pea. In another case, which I saw along with the late Professor Pancoast, the whole scrotum was literally covered with seba- ceous tumors. They were very hard, rounded, ovoidal or angular in shape, closely grouped together, perfectly insensible, and speckled upon the surface as if they contained earthy matter. The largest were fully the size of an ordinary hickory nut. The patient was an elderly man, the subject of epithelioma of the anus. The sebaceous tumors had made their appearance at the age of twenty-three years. Interference is unnecessary, unless the tumors are so large as to incommode by their bulk and weight, which, however, is seldom the case. 8. The cystic tumor of the scrotum is very uncommon. It is composed, as the name implies, of cysts filled with serous fluid, and interspersed with fibroid substance, its original seat being apparently in the subcutaneous connective tissue. The number of cysts is 820 variable, from twenty to thirty having been found in a single tumor, new ones being, doubtless, from time to time added to the old. Their volume ranges from that of a millet- seed to that of a pea; they are of a spherical or globular shape, and as they increase in size and number, as they always do very slowly, they encroach upon the scrotum, impart- ing to it a rough, nodulated appearance, which, with a faint sense of fluctuation, and a certain degree of elasticity, affords the only evidence of their existence. The proper remedy is excision. An excellent illustration of the character and structure of this variety of morbid growth is furnished in figs. G47 and 648, from Curling. DISEASES OF THE MALE GENITAL ORGANS. c HAP. XVII . Fig. 648, Fig. 647. Cystic Tumor of the Scrotum, Exhibiting its External and Internal Characters. A cystic growth, the size of an apple, perfectly translucent, and filled with an unctious, yellowish fluid, has been described by Bauchet as having been situated in the connective tissue of the scrotum. It was firmly connected with the integument, fluctuated distinctly under pressure, and was supposed to have had its origin in one of the sebaceous follicles of the skin. 9. The fatty tumor of the scrotum, also extremely rare, generally presents itself as a small nodule in the connective tissue, imparting, while it is small, the idea of the existence of a third testicle. It is of a doughy, inelastic feel, and seldom attains much bulk, although in a case operated upon by Dr. Gilman Kimball, of Lowell, a growth of this kind, consisting of numerous hard masses of pure fat, weighed two pounds. The diag- nosis is usually very obscure, but this is so much the less to be regretted, as the only remedy is extirpation. In the case just referred to, the parts presented the characteristics of an old scrotal hernia. 10. The fibrous tumor of the scrotum is of uncommon occurrence. It is developed in the connective tissue, and is characterized here, as elsewhere, by its tardy growth, by its firm, dense consistence, by its sense of heavy weight, by the absence of pain, tender- ness, and lymphatic involvement, and by the unimpaired state of the constitution. It is most frequent after middle life, and is capable of acquiring an enormous bulk. Some years ago I operated upon a colored man, twenty-five years of age, removing a mass of this kind weighing nearly five pounds. It was of an ovoidal form, larger below than above, and was eight inches and a quarter in length by thirteen in circumference at its widest part. Its surface was perfectly smooth, and adherent, in the greater portion of its extent, to the vaginal tunic, by loose connective substance. The testicle was situated at the lower extremity of the tumor, and, with the exception of being slightly flattened, had undergone no appreciable alteration. The deferent duct, also perfectly sound, ran along the posterior surface of the tumor. A section of the mass exhibited a smooth, uniform surface, of a pale grayish color. It was slightly elastic, almost incompressible, and remarkably solid, offering great re- sistance to the knife. A thin slice of it was opaque, and nearly as tough as sole leather. The tumor had been growing for upwards of five years—during the last eighteen months very rapidly—but caused no other inconvenience than what resulted from its weight and CHAP. XVII. AFFECTIONS OF THE SCROTUM. 821 bulk. The spermatic cord, the skin of the scrotum, and the glands of the groin were per- fectly healthy. The patient recovered from the operation, but died some months after- wards of pulmonary phthisis. Fig. 649 exhibits the form and gross appearances of the tumor; the testicle is seen at the base, to the left of the middle line. It is possible that many neoplasms described as fibrous tumors of the scrotum are in reality myomas, as in a case observed by Forster. Be this as it may, the fibrous growth, when very old, may be partially transformed into earthy matter, as in similar forma- tions of the uterus, or be inlaid, as it were, with car- tilage and even bone. A remarkable tumor of this kind has been reported by Dr. John G. Kerr, of Can- ton. The mass, which weighed five pounds after excision, was inlaid with large quantities of bony matter, exhibiting all the minute characteristics of osseous tissue. The patient, who made a good re- covery, was only twenty-eight years old. 11. We occasionally meet with an omental tumor in the scrotum, dependent upon the protrusion and en- largement of a portion of omentum, originally a part of an inguino-scrotal hernia. In time the extraabdominal mass contracts firm adhesions to the peritoneal sac in which it is contained, and consequently becomes irre- ducible. By the constant pressure and friction exerted upon it in the various movements of the body, the sub- stance gradually increases in bulk and hardness until a tumor is formed, varying in size from that of an orange to a large fist. In some cases the tumor is of such magnitude as to encroach seriously upon the penis. The diagnosis is based upon the history of the case, and the firm, incompressible nature of the growth. Almost the only tumor with which it is liable to be confounded is the fibrous. The insertion of the exploring needle is gen- erally followed by the escape of a little serous, or sero-oleaginous, fluid. During extirpa tion it can usually be readily unfolded so as to bring into view its true structure. Unless the tumor be very large, causing great mechanical inconvenience, the safer plan is to let it alone, even after it has been exposed, inasmuch as the operation is liable to be followed by peritonitis, or, if the patient survive, by hernia. 12. Earthy concretions, from the volume of a pea to that of an almond, now and then form in the scrotum, their number being sometimes quite considerable. Of a dull whitish, or grayish color, they are of a cretaceous consistence, and are composed mainly of phos- phate and carbonate of lime, cemented together by a small quantity of animal matter. They are of tardy formation, and are found exclusively in middle-aged and elderly sub- jects, in connection with hypertrophy of the scrotum. The proper remedy is excision. 13. The scrotum sometimes contains cysts communicating with the urethra, or the urethra and bladder, and filled with calculi. The composition of the latter is variable, but, in general, they consist of uric acid; they are usually very smooth, ovoidal or spherical in their shape, and from the size of a millet seed up to that of a Lima bean. Occasionally their bulk is enormous, as in a case mentioned by Graefe, the weight of which was twenty-six ounces. The patient, a shoemaker, had suffered for twenty years; he was in the habit of supporting the scrotum with a pad, and the concretion escaped one day during exertion in defecation. The number of calculi is sometimes remarkable, nearly as many as one hundred having been found in a single cyst. The cyst itself is commonly very thick, dense, and rough, especially in old cases. The only available treatment is excision. 14. The scrotum is liable to be transformed into a hard, fibrous mass, constituting what is termed elephantiasis. The enormous magnitude which this disease may attain is almost incredible. Titley removed from the scrotum of a negro a tumor of this kind, which weighed seventy pounds, and extended nearly down to the feet, as seen in fig. 650. Baron Larrey has detailed the particulars of one which was supposed to weigh one hundred and twenty pounds. In the medical museum of Montpelier is a diseased mass of this charac- ter, preserved by Delpech, the weight of which is one hundred and sixty pounds. In my private collection is a specimen of elephantiasis, presented to me by Dr. Bozeman, of New Fig. 649. Fibrous Tumor of the Scrotum. 822 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. York, of forty pounds. The mass began to appear early in life, and grew until the patient, a colored man, was twenty years old, when it was excised by that distinguished surgeon. The adjoining cut, fig. 651, exhibits an excellent view of this tumor. Fig. 650. Fig. 651. The disease, seldom observed in this country or in Europe, is sufficiently frequent in China, India, Asia, Central Polynesia, Africa, South America, and the West Indies. Externally, the morbid growth is rough and fissured, and its surface, particularly in old cases, is covered with yellowish, scaly crusts, the detachment of which leaves many small, herpetic sores, emitting a thin, ichorous discharge. The skin is very thick and indurated ; the connective tissue is firm and callous; the bloodvessels are remarkably large, varicose, and ensheatbed by lymphoid cells; and the swelling is indolent, incommoding rather by its weight and bulk than by its pain. In its shape it is mostly pyriform, but sometimes ovoidal, or globular. The testicle is not necessarily implicated in the disease, nor is the spermatic cord so much indurated and enlarged as in some of the other disorders of the genital apparatus. The morbid mass occasionally ulcerates ; and a case has been related by Ilendy in which it was invaded by mortification, causing the death of the patient. The disease is often complicated with hydrocele or scrotal hernia. Sir J. Fayrer has described a variety of this affection to which he has applied the term nrevoid, as it is composed, in part, of erectile tissue, immediate'y underlying the surface of the morbid growth. Its occurrence is uncommon. In the early stage of this disease relief may be attempted, although even then with hardly any prospect of success, by means of sorbefacients and systematic compression, steadily pursued for many months together. When the growth has acquired a large bulk the only remedy is excision, performed with special reference to the avoidance of hemor- rhage and shock, which have nearly always proved fatal when the tumor has been of ex- traordinary size. If I had to deal with such a case, I should, after the preliminary ap- plication of Esmarch’s bandage, be tempted to cut away the mass piecemeal at several sittings, tying the vessels as they are divided, and using the actual cautery to sear, if necessary, the raw surface. Or, instead of this, removal might be effected partly with the knife, and partly with the ecraseur. Or, perhaps, the best plan of all would be that suggested, and so happily practised, by Brett, Fayrer, O’Farral, and others, of elevating the tumor and pressing out its venous blood immediately prior to the excision. In an Titley’s case of Elephantiasis of the Scrotum. Bozeman’s case of Elephantiasis of the Scrotum, CHAP. XVII. AFFECTIONS OF THE SCROTUM. 823 operation performed by the latter in 1842, an enormous mass of this kind was successfully removed in eight minutes, with the loss only of five ounces of blood, and the preservation of the genital organs. Liston and Key, in a similar case, each lost his patient upon the table, while that of Dr. Bozeman died nearly a fortnight after the operation from perito- nitis caused by extension of the inflammation along the spermatic cord. Both testes were included in the incisions, and the man lost twenty ounces of blood. One of the most successful operations of this kind upon record was performed in 1837, by Dr. Picton, of New Orleans. The tumor, which had existed for ten years, weighed fifty-three pounds. In the case of a negro, twenty-two years of age, in the hands of Dr. J. S. Thebaud, of New York, the result was equally gratifying, notwithstanding the large volume of the tumor, the weight of which was fifty-one pounds and a half, and the greatest circumfer- ence forty-eight inches. A full report of the case is contained in the New York Medical Journal for May, 1867. Dr. Esdaile, of Calcutta, has performed the operation upwards one hundred and sixty times, with a mortality of only five per cent., and in no instance, he adds, was death directly due to the operation. Of 136 cases in the hands of Dr. G. A. Turner, formerly of Samoa, only two were fatal. In 113 cases operated on at the Medical College Hospital of Calcutta, from 1859 to 1867, 21 died, giving a precentage of 18.58. Pyemia, diar- rhoea, and exhaustion were the chief causes of death. Great size does not seem to compro- mise the result. In four successful cases in the hands of Clot-Bey, of Egypt, the weight was, respectively, 65, 70, 80, and 110 pounds. The testicle and penis may almost always be saved when the weight of the tumor does not exceed fifty pounds. 15. The scrotum has been known to contain dermoid cysts filled with various kinds of foetal remains, as pieces of bone, cartilage, teeth, hair, sebaceous matter, and even cere- bral tissue. Remarkable cases of this description, all, as it seems to me, examples of monstrosity by inclusion, have been reported, among others, by Dietrich, Eke, Andre, Velpeau, Verneuil, and Van Buren. The tumor, which is always congenital, and which ranges in size from an egg to that of a fist, is more or less irregular in shape, and varies very greatly in consistence, some parts being exceedingly hard and dense, while others are comparatively soft, or soft and even fluctuating, especially when, as occasionally happens, the affection is complicated with hydrocele. The developmental force of the tumor is far from being uniform ; in general, it keeps steady pace with that of the body, very much as in the natural state; in some cases, however, it is retarded, and in others it proceeds with unusual vigor, so that, ultimately, the mass attains a much larger bulk than common. Occasionally, in consequence, appa- rently, of the disintegration of some of the foetal structures, it takes on inflammation and suppuration, followed by the partial escape of its contents. No instance has yet been recorded where sucli a tumor became the subject of malignant disease. The foetal re- mains are generally described as being situated in the testicle, but this is by no means always the case, as this organ has sometimes been found to be perfectly sound. The diagnosis is deduced chiefly from the history of the case, especially its congenital origin, and stationary character, and from the irregularity of the consistence of the tumor. Not unfrequently some of the foetal bones can be distinctly felt through the coverings of the scrotum, and sometimes they are distinguishable by the eye, finger, or probe, as they lie in the fistulous openings of the tumor. Velpeau, in an instance of the kind, based his diagnosis upon a tuft of hair protruding at an ulcer. In ten cases collected and ana- lyzed by Verneuil, the discrimination was accurately determined prior to excision only in two. The affections with which it is most liable to be confounded are, sarcoma, tubei’cular disease, and syphilitic degeneration, all of which occasionally occur at a very early period of life. A careful observer would hardly mistake such a tumor for a hydrocele or a scrotal hernia. Excision constitutes the proper treatment. The testicle may sometimes be saved, but in most cases it is so intimately involved in the tumor as to require to be sacrificed. In the case of Velpeau, in which this organ was left behind, a long and tendious dissection was required, and the patient, a man, twenty-seven years of age, died of purulent infec- tion soon after the operation. 16. Varix of the scrotum is uncommon, and is observed chiefly in old, bulky hydro- celes and ruptures. In the case from which fig. 652 was taken, a man, nearly fifty years of age, a patient at the College Clinic, the affection was conjoined with varix of the legs, abdomen, and penis. The enlargement, although enormous, created no particular inconveni- 824 DISEASES OF THE MALE GENITAL ORGANS. CHAP. xvn. ence. The patient was a common laborer, fifty years old, otherwise in good health Should the disease become a source of suffering, relief must be sought in suspension and astringent lotions ; or, if need be, in subcutaneous ligation. Verneuil has described two cases of erectile venous tumors, evidently depend- ent upon varicosity of the subcutaneous scrotal veins, and marked by a tendency to spontaneous inflammation. 17. A peculiar varicose affection of the lymphatic vessels of the scrotum, constituting lymphangiectasis, occasionally occurs. Dr. Carter, of Bombay, who has called particular attention to the subject in connection with a case in an adult Hindoo, de- scribes the disease as consisting in a singularly corrugated and thickened condition of the skin of the scrotum, accompanied with numerous tubercles from the size of a pin’s head to that of a pea, soft to the touch, and, when punctured, giving vent to a copious flow of milky fluid. The inguinal glands on both sides were much enlarged, of a doughy consistence, and diminishable under the pressure of the finger. The discharge alternated with a chylous condition of the urine. I saw a similar case of lymph- angiectasis in the summer of 1868, at the clinic of Professor Vanzetti, of the University of Padua. The disease had existed for five years, and large quantities of lymph were discharged every few days. 18. Carcinoma of the scrotum is generally of the epithelial kind, and seldom occurs before puberty, its favorite period of attack being from the thirtieth to the fortieth year. It is most common in chimney- sweeps; hence it has by some been named the chimney- sweeper’s cancer, seen in fig. 653. The affection ordinarily begins at the base of the scrotum, in the form of a small, wart-like excrescence, covered by a thin, scaly crust. After this has continued for a time, the hardened cuticle sloughs, leaving a superficial, painful, ill-looking ulcer, with indurated and everted edges. The surface of the sore has a red, excoriated aspect, and discharges a thin, sanguinolent fluid, often highly irritating and offensive. In this way the morbid process gradually extends, until at length a large surface of the scrotum, together with the vaginal tunic, and the exterior of the testicle, is involved in the disease. In this advanced stage, the connective tissue around the sore is generally white and hard; and the inguinal glands on one or both sides are enlarged, injected, and, sometimes, filled with carcinomatous matter. The progress of epithelioma of the scrotum is generally comparatively slow' ; the local and constitutional suffering is for a long time slight, and death seldom occurs under four or five years. A case has been reported of a chimney-sweep wdio lived upwards of forty years with a disease o this kind. The diagnosis of epithelioma of the scrotum is sufficiently easy, the peculiar appearance, situation, and feel of the tumor, and the history of the case, always serving to distinguish it from other affections. The only remedy is early and free excision, before there is any lymphatic involvement. 19. Sarcoma of the scrotum is very uncommon. It may begin either in the skin, or, as is more commonly the case, in the subcutaneous connective substance, from which, as it increases, it gradually extends to the other structures. Curling mentions a case in which he removed a melanotic tumor of this kind from the scrotum of a man, thirty-two years of age. It w'as of a dark color, and about the size of a small walnut, with a narrow pedicle. The disease returned soon after the operation, in the vicinity of the cicatrice, and, gradually invading the inguinal and lumbar lymphatic glands, carried off the patient, but not until after the lapse of six years. 20. Amputation of the scrotum may be required on account of simple hyperti’ophy, elephantiasis, or malignant disease. The operation, in the more ordinary forms of these affections, is readily performed with the knife, with the precaution of avoiding the testicle, and tying up the bleeding vessels immediately after the completion of the incisions Secondary hemorrhage is what is principally to be dreaded after such an operation, ant should, therefore, be specially guarded against. The edges of the wound should be ap- Fig. 652. Varix of the Scrotum and Penis. Fig. 653. An aggravated Example of Chim- ney-Sweeper’s Cancer, with much Destruction of the Superficial Tex- tures. CHAP. XVII. AFFECTIONS OF THE SPERMATIC CORD. 825 proximated with the interrupted and twisted sutures, x’etained for an unusual period, otherwise extensive separation will almost be certain to occur, the wound having a great tendency to gap. Excision of the scrotum, for the cure of elephantiasis, has already been Fig. 654. Henry’s Scrotal Forceps. described. In cases of simple hypertrophy, attended with excessive elongation, the redundant portion may generally be advantageously removed without any risk of hemor- rhage, either with the ecraseur or the instrument of Dr. M. H. Henry, of New York, sketched in tig. 654. SECT. IV AFFECTIONS OF THE SPERMATIC CORD. The spermatic cord is liable to injury, inflammation, abscess, hydrocele, accumulations of blood, and various kinds of tumors. In absence of the testicle, the cord is generally very small, and the deferent tube terminates in a rounded cul-de-sac in the groin. 1. Wounds and Contusions Wounds and contusions of the spermatic cord generally coexist with similar lesions in the neighboring parts. When severe, they may be followed by wasting of the testicle, especially when they involve the deferent tube. Copious hemorrhage may attend the division of the cord, and should always be promptly checked with the ligature, the opening being, if need be, carefully enlarged to afford the required access. 2. Inflammation and Abscess Inflammation of these structures rarely exists as an independent affection ; in general, it is caused by an extension of disease from the testicle, as in gonorrhoea or syphilitic orchitis. It is characterized by great hardness, pain, and tenderness of the cord, accompanied by a sense of weight, and more or less constitutional disturbance, and is to be treated upon general antiphlogistic principles, with the addition of mercury and the iodides, if the attack is of a specific nature. The disease occasionally passes into abscess, but such an occurrence is very uncommon, and requires no particular notice. 3. Hydrocele—Hydrocele of the spermatic cord occurs under two varieties of form, the encysted and the diffused, the first being by far the more common of the two. In the encysted hydrocele, fig. 655, the tumor is distinctly circumscribed, of an oval figure, from the size of a small marble to that of a hen’s egg, and filled with a limpid or pale straw-colored fluid. Fluctuation and translucency, never well marked, may be entirely absent. The swelling, which is movable, free from pain, and distinct from the testicle, receives no impulse in coughing, and cannot be emptied by pressux-e; cii’cum- stances which clearly distinguish it from hernia and hydi-ocele of the vaginal tunic. It may be situated at the upper part of the sci’otum, just below the external ring, or even in the inguinal canal. The cyst of which it is composed, and which is, sometimes, very dense, thick, opaque, or even of a fibrous, cartilaginous, or calcified texture, is generally single, and originates, either adventitiously, or, as is more probable, in an impei-fect obliteration of the tubular prolongation of the peritoneum, lying under cover of the com- mon integument, superficial fascia, and fibres of the cremaster muscle. The affection, although it occurs at all periods of life, is most common in infants. It may vanish spon- taneously, and should never be interfered with so long as it does not cause any serious inconvenience. In all cases demanding treatment, fair trial should be given to mild means; if these fail, as they genei-ally do in adults, the best remedy is a slender seton, introduced with a small curved needle, and retained until the part is slightly inflamed. The operation, however, is not devoid of risk, and should, therefoi-e, be performed with gi-eat care. In a case mentioned by Curling, severe inflammation extended along the cord into the pelvis, causing suppuration in the iliac fossa, and, for a time, seriously endangering the patient’s life. Pott i-elates a case treated by incision that proved fatal on the seventh day from inflammation. In the child a simple puncture is often sufficient 826 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. to effect a cure. When this fails, the retention of a single thread in the sac for twelve to twenty-four hours will be sure to provoke obliterative action. Fig. 655. Fig. 656. A very rare form of congenital hydrocele of the cord is sometimes observed, the sac communicating directly with the peritoneal cavity, but not extending far, if at all, beyond the external inguinal ring. In a case in a child two years old, at the College Clinic, the tumor was of a cylindrical shape, two inches and a half in length, and marked by an hour-glass constriction. The affection is liable to be confounded with inguinal hernia, with which, in fact, it occasionally coexists. Nannoni relates the par- ticulars of a case, in which, supposing the disease to be of the lat- ter character, he tied the sac, causing the death of the patient, a child six years of age. In diffused hydrocele, fig. 656, the fluid accumulates in the con- nective tissue of the cord, the meshes of which, scarcely percepti- ble in the natural state, are converted into cells, from the size of a pea to that of a hazelnut. Gradually some of these cells give way, from the pressure of their contents, and thus one or more large cavities are formed, which are always most distinct at the base of the swelling. The hydrocele, at its commencement, is of a cylindrical shape; but, at a later period, it becomes pyramidal when the patient stands, and oblong, or nearly of equal dimen- sions throughout, when he is recumbent. In is inclosed in a membranous sheath, which is covered by the cremaster muscle, and extends from the testicle, which is below, to the external ring, into the inguinal canal, and occasionally even into the ab- dominal cavity. A tumor of this description lias a uniform sur- face and definite shape, is slow in its formation, is not attended with any considerable pain, and is separated from the vaginal tunic by a distinct septum. It is liable to be confounded with omental hernia, but is distinguished from it by not receiving an impulse in coughing, by its imperfect removal under pressure, by the fluctuation at its lower part, and by the change of figure which it undergoes in the recumbent position. Acupuncture will Encysted Hydrocele of the Cord. Diffused Hydrocele of the Cord. Encysted Hematocele of the Cord. CHAP. XVII. AFFECTIONS OF THE SPERMATIC CORD. 827 sometimes effect a cure, especially if aided by pressure with a compress and roller; but a small seton is a safer and surer remedy. Free incision, as practised by Pott, is not to be thought of. As long as the tumor is small, and produces no pain or inconvenience, interference is unnecessary. 4. Hematocele—Hematocele of the spermatic cord, fig. 657, is uncommon, and is nearly always associated with, or consequent upon, encysted hydrocele. It occurs in two varie- ties of form, the traumatic and spontaneous. The symptoms are similar to those of ordi- nary hematocele. The tumor is hard, small, semifluctuating, and filled with grumous blood, or bloody serum, which imparts to it a dark color. The only disease with which it might be confounded, especially in its earlier stages, is inguinal hernia; but from this it may generally be easily distinguished by the history of the case, the irreducibility of the swelling, and, if need be, by the introduction of the exploring needle. The tumor some- times acquires an enormous bulk and weight. Thus, in a case reported by Mr. Bowman, of London, it reached down to the knee, and was so heavy as to require both hands to raise it. The treatment is the same as for hematocele of the vaginal tunic of the testicle. Care is taken not to make too free an incision, lest difficulty should arise in securing the vessels, the rupture of which has caused the disease. 5. Varicocele Varicocele is a dilated and tortuous state of the veins of the spermatic cord. It generally occurs soon after puberty, but occasionally later, and now and then I have met with it as early as the eleventh year. It is almost exclusively confined to the left side, for the reason, chiefly, as Professor Brinton, of this city, has shown, that the left spermatic vein, at its entrance into the emulgent, is unprovided with a valve, whereas such an arrangement exists distinctly on the right side, where the veinembogues into the vena cava. Besides, the left vein is naturally considerably longer than the right, and its direction, also, is more at a right angle with the current of the blood. The affection may be induced by whatever has a tendency to facilitate an afflux of blood to the genital organs, or to serve as a habitual barrier to its return to the heart. Hence, the most common causes are, venereal excesses, masturbation, chronic disease of the scrotum and testicle, riding on horseback, bodily fatigue, and pressure on the spermatic vessels from distension of the iliac portion of the colon, the presence of tumors in the groin or pel- vis, and the wearing of ill-constructed trusses. Constant relaxa- tion of the scrotum, however induced, powerfully predisposes to the formation of the disease. It is very probable that there ex- ists in many cases, if not in most, a natural tendency to this enlargement. What corroborates this idea is that it often be- gins very early in life, before the causes here referred to can exert any injurious influence, and the fact that it occasionally occurs in several members of the same family. Varicocele is usually slow in its progress, and is attended with a dull, heavy, aching pain, which often extends up the cord of the groin and even to the back. In some cases the pain is of a neuralgic nature. A sense of weight is commonly experienced in the testicle, which is liable, eventually, to become soft and shrunken, from the pressure of the enlarged and distended veins. The scrotum of the affected side is very subject to perspiration and is often remarkably flabby, elongated, and pendulous, es- pecially after exercise. The general health rarely suffers ; but in many cases there is a gloomy and melancholy state of the mind, almost bordering upon alienation, and unfitting the patient for active exertion. When the disease is fully developed the veins are convo- luted, knotty, elongated, harder in some places than in others, and irregularly dilated, some of them being more than six times the ordinary volume, as seen in fig. 658. Their parietesare very thick, dense, and rigid at some points, and very brittle and at- tenuated at others. In cases of long standing, some of the ves- sels are completely obliterated by adhesive inflammation, or by the formation of fibrinous concretions. Phlebolites are also occasionally found in them. The connective tissue does not experience any particular alteration, but the veins of the testicle itself are often considerably enlarged, as are also those which ramify between the vaginal and albugineous coats. Fig. 658. Varicocele. 828 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. The tumor resulting from the enlarged and dilated veins is of an elongated, conical shape, irregular and compressible, feeling very much like a bundle of cords, a cluster of earth-worms, or a mass of the intestines of a rat. It has neither the regular outline and elastic feel of hydrocele, the firmness and globular character of sarcocele, nor the doughy consistence of scrotal hernia. The distended vessels are frequently distinctly visible through the skin. When the tumor is very voluminous it may extend from the lower margin of the testis to the external ring; and in this case there is always considerable enlargement of the subcutaneous veins of the scrotum. Although the symptoms of varicocele are usually well marked, the diagnosis is not always readily determined. The affection for which it is most liable to be mistaken is scrotal hernia, especially that variety in which the omentum is concerned. In order to distinguish between the two diseases, the patient is placed on his back, and the scrotum held up until it is entirely empty; the finger is then applied to the external ring, and the patient requested to rise, when, if the tumor be a varicocele, it will immediately reappear, whereas, if it be a hernia, the bowel will be unable to descend. A more certain mode of determining the diagnosis is to compress the neck of the swelling, in the erect posture, when, if composed of intestine, it will remain stationary, but become more tense if it consist of dilated veins. Treatment—The treatment of varicocele is palliative and radical. The former, which, in ordinary cases, is alone resorted to, consists in wearing a suspensory, of which the best is that of Morgan, of Dublin, represented in fig. 659, in washing the parts frequently with cold water, or some astringent lotion, and in carefully avoiding everything tending to favor a determination of blood to the sper- matic vessels. To obtain full advantage from these measures, the patient must pay strict attention to his bowels, and refrain from horseback exercise, fatiguing walks, protracted standing, dancing, warm bathing, and venereal excesses. The radical cure is required when there is a great deal of local suffering, with danger of atrophy of the testicle ; or, when the patient’s mind is so much affected as to render him not only wretched but utterly unfit for busi- ness. The disease, as is well known, is a cause of dis- qualification for admission into the army and navy, and I have in several instances considered myself justified in performing the operation solely on this account. When there is much mental distress, I should not hesitate to interfere, although the enlargement should be comparatively insig- nificant, in order to restore the patient to comfort and usefulness. Almost innumerable operations have been proposed and performed for the radical cure of this complaint. With some of the ancients the actual cautery was a favorite remedy. Gooch and other surgeons have reported cases cured by castration ; some prefer ligation, others excision, of the affected veins; occasionally the spermatic artery has been tied, as in the cases of Maunoir, Graefe, Jameson, and Amussat ; in the hands of Breschet, com- pression with a pair of flattened screw-forceps is said to have frequently succeeded ; Sir Astley Cooper has recommended excision of a portion of the scrotum ; and Velpeau, I)avat, Fricke, Grossheim, Reynaud, and Vidal have each devised and practised ingeni- ous subcutaneous operations for its relief. The method which I formerly employed con- sisted in exposing the enlarged veins, and strangulating them with the twisted suture. The scrotum having been rendered tense by grasping it behind with the left hand, a ver- tical incision, about an inch in length, was made over the anterior part of the swelling, down to the vessels, which were then carefully isolated from the accompanying duct, artery, and nerves, by a few touches of the point of the scalpel. A slender darning needle was next passed underneath the enlarged trunks, and secured by passing around it a stout thread, in the form of the figure 8. The operation was finished by closing the wound with the twisted suture. In twenty-four hours the large needle Avas removed, and the strangulated mass divided with a narrow bistoury. I had performed this operation with the most gratifying results in fifteen cases, when one of my patient’s unexpectedly perished from phlebitis and pyemia ; a circumstance which led me to abandon it. For many years past, I have limited myself altogether to subcutaneous ligation, which I believe to be perfectly safe under all circumstances, as well Fig. 659. Morgan’s Suspensory. CHAP. XVII. AFFECTIONS OF THE SPERMATIC CORD. 829 as permanently successful. The operation, which should always be preceded by a proper preparation of the system, consists in tying the enlarged veins, previously isolated from the deferent tube, while the patient is in the erect posture, with a stout cord, well waxed, or, what is less likely to cause trouble, a silver wire, passed with along spear-shaped needle,from before backwards, in such a manner as to leave two apertures, one in front and the other behind, as is easily done, simply by compelling the instrument to retrace its steps. Or, instead of this, the operation may be performed, as I have in a number of instances, by making only one puncture, by carrying the extremity of the needle around the enlarged veins, beneath the scrotum, and then pushing it out at the opening of entrance. Whichever method be adopted, the ligature must be firmly tied either over a broad perforated button, as sug- gested by Professor William H. Pancoast, or, as I am in the habit of doing, over a narrow compress and a piece of cork, split through the middle, care being taken to tighten the ligature afterwards every two days or even oftener, in order to render the pressure more effective. If wire be used, the ends are twisted instead of being tied. The interposition of a piece of rubber-tubing, through which constant elastic tension is maintained, as advised by Levis, and represented in fig. 660, obviates subsequent tightening of the ligature, which is ordinarily a source of not a little suffering. I seldom withdraw the cord before the end of the twelfth day, when the veins are generally sufficiently divided and occluded to prevent a return of the cir- culation. Should this not be the case sev- erance should be effected with the knife, any bleeding that may follow its use being checked with Monsel’s salt. The patient is kept in bed upon light diet, with the scro- tum well suspended, and constantly wet with lead-water, half a grain of morphia being administered immediately alter the operation, which is always performed with the aid of an anaesthetic. The hardness and swelling, consequent upon the ligation of the veins, gradually disappear spontaneously, or under the influence of sorbefacient applications. Subcutaneous ligation is, I conceive, the only safe operation for varicocele, and fur- nishes, in every respect, the best results. In the many cases in which I have employed it, no untoward symptoms of any kind have occurred. In a few, and a few only, was there a partial return of the complaint after the lapse of several years, but in none did this cause any serious inconvenience. AVhen the scrotum is very flabby and pendulous, it will add very greatly to the comfort of the patient and the permanency of the cure to retrench the superfluous portion with the ecraseur or the knife, care being taken, in the latter event, to tie every bleeding vessel, and to approximate the edges of the wound with the interrupted and twisted sutures, as I have done in a considerable number of instances. On several occasions I have obtained very satisfactory results from the use of the continued sutures after this operation. Breschet’s operation is as cruel as it is unscientific; ligation of the spermatic artery is useless; and any procedure in which the affected veins are denuded is fraught with danger on account of its liability to be followed by phlebitis, erysipelas, and pyemia. Good results of the subcutaneous ligation with the carbolized catgut ligature have recently been reported, among others, by Dr. Duncan, of Edinburgh, and Dr. Senn, of Milwaukee, and the operation is no doubt a perfectly safe one ; but whether the permanent effects will be as good as in the ordinary procedure is undetermined. The knot, in the operation thus performed, is made to sink into the little wound, and the ligature generally disappears by absorption within the first fortnight. Dr. Senn informs me that he has now carried this method into effect eight times, and that some of his cases examined two years after the operation remained perfectly well. Kocher ties the enlarged veins at two points, and then divides them subcutaneously with a tenotome; a plan also pursued by Professor Briggs, of Nashville. Senn also uses two ligatures, but does not cut the veins. Excision of the scrotum for the relief of varicocele is merely a palliative measure; it was so regarded by Sir Astley Cooper, the originator of the operation, and is still so viewed by most surgeons. Eventually the trouble is sure to recur in all its former force. Fig. 660. Method of Obtaining Constant Tension by Rubber Spring. 830 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. 6. Fatty Tumors The spermatic cord is liable to accumulations of adipose matter, constituting what is called a fatty tumor. The deposit begins in the connective tissue, and occurs either as a distinct, circumscribed tumor, as in fig. 661, composed of numerous lobes, held together by fibrous tissue, or as an elongated, undefined mass, extending for many inches along the cord. The morbid growth is sometimes associated with hernia of the groin, and, from its doughy, inelastic feel, indolent char- acter, and fixed position, is liable to be mistaken for an irreducible omentum. From hydrocele of the cord it is distinguished by the tar- diness of its development, by the absence of fluctuation, and by the variable form of the tumor. So long as it causes no inconvenience, no surgical interference is required, but extirpation will be necessary when it becomes painful or oppressive from its weight and bulk. 7. Cystic Tumors A cystic tumor, consisting either of a solitary, oval, or globular sac, or a group of cysts, of variable size and shape, has occasionally been seen in the spermatic cord, but the occurrence is too infrequent to be of any practical interest. Nannoni states that he had met with hydatids in the spermatic cord, but as he has not given a detailed account of the case, it is uncertain whether the dis- ease was really of this character. 8. Sarcoma.—The cord is liable to sarcoma, which occasionally ac- quires an enormous volume. As the disease does not differ in this situation from sarcoma of the testicle, the mere mention of its occur- rence is all that is demanded. 9. Spasm The spermatic cord is occasionally the seat of spasm, evidently caused by irritation of the cremaster muscle, either as a result of external injury, disease of the kidney, the passage of a cal- culus along the ureter, or stricture of the urethra. The spasm comes on suddenly, and is characterized by the forcible retraction of the tes- ticle, which is firmly pressed against the external abdominal ring. The patient usually experiences more or less pain and tenderness in the part during the continuance of the attack, as well as for some time after. The affection is to be treated with anodyne fomentations, the cold douche, soothing embrocations, and the belladonna plaster, with attention to the source of the irritation. 10. Specific Diseases.—Finally, the spermatic cord is liable to syphilitic and carcino- matous diseases. In syphilitic sarcocele, the cord, especially in the lower portion of its extent, is generally very much thickened and indurated, feeling like a piece of sole- leather, painful and tender on pressure. Great enlargement of the cord also frequently exists in encephaloid and other forms of carcinoma of the testicle and scrotum, but it is questionable whether it suffers primarily from these affections. SECT. Y AFFECTIONS OF THE PENIS. This organ is liable to abnormties, inflammation, gangrene, wounds, morbid erections, ulcers, degeneration of its sheath and septum, carcinoma, sarcoma, and a peculiar incur- vation usually associated with abnormal shortening. Malformations of the penis are commonly dependent upon imperfect development of the urethra, as is exemplified in epispadias and hypospadias, in which the organ is always ab- normally short, and more or less curved. Extraordinary brevity is an occasional occur- rence, and is at times, if indeed, not generally, associated with congenital defect of the testes. A stunted development of the glans is not uncommon, especially when there is a very short and tight prepuce. Inordinate size, whether in diameter or length, may be so great as to constitute monstrosity. A double penis is occasionally seen, as in the remarkable case recorded by Dr. Alan P. Smith, of Baltimore, in which the two mem- bers, destitute of prepuce, lay side by side like the barrels of a shotgun, the urethra of each opening into a separate bladder. Lateral curvature of the penis is not uncommon, and deviations of the pectiniform septum are also occasionally witnessed. 1. Inflammation of the penis may either begin in this organ, or be propagated to it from the neighboring parts, as the scrotum, groin, or pubes. Generally caused by exter- nal injury, or specific disease, as chancre or gonorrhoea, it occasionally assumes an ery- sipelatous character, and produces great pain and swelling of the entire organ, accompa- Fig. 661. Fatty Tumor of the Spermatic Cord. CHAP. XVII. AFFECTIONS OF THE PENIS. 831 nied with a constant tendency to erections. The affection, however induced, is easily recognized, and usually promptly yields to the ordinary antiphlogistic measures. Suppuration and abscess of the cavernous bodies of the penis are occasional occurrences, the result generally of external violence, or of an extension of inflammation from the urethra or the head of the penis. Great swelling commonly attends, and the pain is always of a throbbing, pulsatile character. High fever is often present. Free and early incisions are the proper remedies. The more severe forms of inflammation of the penis are occasionally followed by gan- grene, especially when the disease has been induced by chancre in a person of an anemic, broken-down constitution. The destruction may involve the entire organ, or it may be limited to certain portions, as the glans or prepuce. A ease of mortification of the penis, strangulated by a key-ring, causing the death of the patient, may be found in Ranking’s Abstract for 1845. The treatment must be conducted upon general principles. When gangrene follows upon erysipelas or chancroid, it is generally limited to the cutaneous tissues. The penis occasionally suffers from gangrene in paraplegia ; and a case in which the disease arose spontaneously has been recorded by Mr. Partridge, of London. The man, who was forty years old, on being admitted into the hospital, was in a low, typhoid con- dition, and the organ was black and cold nearly down to the scrotum, where it ultimately dropped off. 2. Wounds of the penis may be accidental or self-inflicted, and may present themselves in various forms and degrees. Whatever their character may be, they are apt to be fol- lowed by copious hemorrhage, and by troublesome erections. The bleeding thus pro- duced may generally be temporarily controlled by compression of the dorsal artery of the penis, made by grasping the organ firmly at its root with the thumb and index finger. Gunshot wounds of the penis are uncommon, perforation of the organ being rendered difficult by the toughness of the envelops of the erectile tissues. After the battle of Bull Run, I saw a case in which the ball passed completely through the head of the penis, leaving two openings, which, however, soon healed. When the missile carries away a portion of the urethra, infiltration of urine may occur, especially if the use of the cathe- ter is neglected ; in any event, a fistule will be likely to be left. A gunshot wound of the root of the cavernous bodies is liable to be followed by impotence, from the inability of the patient to command erections. Dr. S. W. Gross has recorded a case in which a conical ball lay encysted in one of these structures, its point presenting towards the pubes, from which it was separated about one inch. The man experienced so little inconve- nience that he refused to have it extracted. Of 309 cases of gunshot wounds of the penis which occurred during our late war, 268 recovered, and 41 died, chiefly from com- plications with other injuries. The treatment must be regulated by the same precepts as in similar injuries in other parts of the body. When the organ is partially separated by a clean cut, stitches should be freely used, along with strips of collodion and splints, care being taken afterwards to prevent displacement by guarding against the occurrence of erections. In the event of complete severance, reunion may reasonably be expected to ensue, provided the parts are promptly and securely restored to their natural position over a catheter. Cold water- dressing ordinarily constitutes the best application. 3. Laceration of the fibrous sheath of the cavernous body of the penis is occasionally met with ; generally as a consequence of a blow while the organ is in a state of inordi- nate erection, during sexual intercourse, or in the act of masturbation. The occurrence of the accident, of which interesting cases have been reported by Mott, Rusclienberger, Rathburn, Huguier, Bins, and other observers, is generally denoted by a feeling as if something had suddenly given way, instantly followed by collapse, and a copious extrava- sation of blood, distending the organ in every direction, and rapidly diffusing itself over the neighboring parts, as the scrotum, perineum, and even the pubes. Sometimes a dis- tinct noise is heard at the moment of the rupture, not unlike the crack of a whip. The penis is commonly inclined a little towards the sound side, and the seat of the injury is readily distinguished by the finger. When the urethra is torn, extensive infiltration of urine will be likely to occur, and may be followed by mortification and death, as in the cases reported by Huguier, Demarquay, Bins, and others. If the patient recovers, the organ sometimes remains permanently unfit for sexual intercourse. The treatment of this affection is by rest of the penis in an elevated position, with dis- cutient applications, as saturnine and spirituous lotions, followed by dilute tincture of iodine, soap liniment, and tincture of arnica and camphor. If blood is extensively effused into 832 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. the cavernous structure of the penis, a free incision should be made to squeeze out the clots, otherwise they may become intermixed with lymph, and thus undergo partial or- ganization, much to the detriment of the functions of the organ. When the urethra is ruptured, the catheter must be promptly inserted to prevent urinary infiltration, or, if this have already taken place, free incisions must be made. An interesting case of laceration of the urethra in the act of coition in a man, thirty years of age, has been recorded by Dr. Louis Bauer. The accident was succeeded by copious hemorrhage, and extensive infiltration of blood into the penis, scrotum, perineum, and groins. The catheter was inserted with difficulty, and, although it was permanently retained, an abscess formed, followed by a troublesome fistule. Rupture of the superficial veins of the penis generally occurs from blows or falls ; and may be attended with copious extravasation of blood, necessitating the employment of re- frigerant and sorbefacient lotions for its removal. 4. A singular case of luxation of cavernous bodies of the penis, in a child six years of age, has been recorded by Nelaton. In taking hold of the organ, a few days after the accident, to pass a catheter, it was found to be destitute of substance, as if, in fact, it were a mere cutaneous tube, similar to the empty cocoon of a silk worm. The missing bodies were lodged in the scrotum, from which they were drawn by a to and fro move- ment into their natural position by means of an instrument used for tying deep seated arteries. The final result of the case is not stated. 5. Strangulation of this organ is generally caused by the application of a ligature, fillet, or metallic ring, designed either as a means of relieving incontinence of urine, or as a self-inflicted punishment for morbid erections. When the constriction is unusually tight, or long continued, mortification may ensue, as in the celebrated case of J. L. Petit ; or mortification and death, as in a case communicated to me by Dr. Kelly, of Manayunk, the patient being a man fifty-seven years of age, who had slipped a ‘k bridal ring” over the root of the penis, where it soon excited violent inflammation. The treatment, in such an occurrence, obviously consists in dividing the foreign substance, whatever it may be, with the scissors, file, or pliers, and then scarifying, if need be, the infiltrated and distended parts. Sometimes the object may be effected by winding a stout, well-waxed silk thread, or narrow elastic tape around the penis, so as to constrict the organ as firmly as possible as far as the ring, beneath which the cord is then passed with a curved needle, when it is easily untwisted, thus carrying the ring with it. Mr. Liston met with a very curious case of disease of the penis in a man upwards of fifty years of age, who early in life, had slipped a brass curtain ring over the organ to prevent incontinence of urine. Inflammation and ulceration soon followed, and by degrees the ring became concealed below the skin, where, after many years of comparative harmless- ness, it was finally incrusted with calculous matter, seriously interfering with micturition, and ultimately necessitating an operation for its removal. 6. Phlebitis of the penis is uncommon. I have, however, observed several well-marked cases of it in the dorsal veins, as an effect, apparently, of irritation produced by sexual intercourse. Sometimes it is a consequence of gonorrhoea. The disease, which is occa- sionally associated with angeioleucitis, is characterized by a phlogosed, turgescent appear- ance of the organ, and by a tender, corded, and enlarged state of the dorsal veins, ex- tending as far back as the root of the penis. Rest and elevation of the organ, the appli- cation of saturnine and anodyne lotions, light diet, and a brisk purgative, constitute the proper treatment. 7. Morbid erections of the penis may be produced by inflammation, followed by an effusion of lymph into the cells of the cavernous bodies, as in a case which I treated in a young mechanic, in which the priapism continued for nearly four weeks, despite the most rigid antiphlogistic measures. It came on soon after intercourse, and was attended with excessive pain, a phlogosed condition of the organ, and inability to urinate, along with much constitutional disturbance. For several months after the violence of the dis- ease had abated, the penis remained small, flaccid, and incapable of complete erection. Sometimes the priapism is occasioned by an effusion of pure blood, when, if the fluid be not removed, the individual may become permanently impotent. Priapism of a severe character sometimes supervenes upon injury of the spine and cerebellum. It may also be caused by the inordinate use of cantharides, by irritation of the prostate gland, urethra, anus, or rectum, and by congestion and various organic affections of the lesser brain. In children, troublesome priapism may be occasioned by an adherent prepuce. In the case of a young man, reported to me by Dr. Joseph W. Knight, of Louisville, CHAP. XVII. AFFECTIONS OF THE PENIS. 833 the priapism was occasioned by the sudden withdrawal of the penis in the act of emission during the venereal congress. The erections were distressingly painful, and continued uninterruptedly until death, upwards of two weeks from their commencement, the organ being all the time icy cold and as hard as a board. Ordinary cases of priapism are treated with cold applications, and the liberal use of anodynes and of bromide of potassium. In the more severe forms, bleeding at the arm and by leeches, active purgatives, antimonials, and even slight ptyalism may be necessary. Saturnine and anodyne lotions are indicated in cases attended with plastic deposits, and ice may also be used with great advantage, but its effects must be carefully watched. If retention of urine takes place, relief must be afforded with the catheter. When the morbid erections depend upon an effusion of blood, free incisions should be made to turn out the clots; if not all, as many as possible. Priapism, dependent upon irritation of the cerebellum, may require the application of leeches to the occipital region, and the establishment, in obstinate cases, of an issue in the nape of the neck. When it arises from irritation of the bladder, urethra, or prostate gland, one of the most valuable remedies, after the removal of the irritating cause, is bromide of potassium, in large doses, thrice a day, with an anodyne enema at bedtime. 8. TJlcers of the penis, specific and non-specific, are described in the chapter on syphilis, and need not, therefore, detain us here, beyond the statement that the subject is one of great practical importance, both as it respects the peace of mind and the physi- cal welfare of the patient. I am satisfied, from much observation, that the most simple ulcers of the penis are frequently mistaken for syphilitic, and that, in consequence of these errors of diagnosis, persons are constantly subjected to severe courses of mercury that would get well in a very few days under the most simple treatment. Many a consti- tution is permanently ruined in this way. 9. As a rare occurrence I may allude here to a singular case, communicated to me by Dr. C. C. Shoyer, of Kansas, in which a calculous concretion was imbedded in the head of the penis, of a man who had been lithotomized twelve years previously. The substance was apparently composed of uric acid, and its site was indicated by its hardness and by a small opening upon the surface of the organ. 10. The pectiniform septum of the penis is subject to the fibrous and osseous trans- formations. I recollect a singular instance of this kind in a patient of Dr. George McClellan, for whose relief he was obliged to perform an operation. The man was between fifty and sixty years of age; the disease had been coming on gradually ; and the organ was curved towards the perineum to such a degree as to interfere materially with copulation. The operation, which consisted in the excision of the offending substance, was entirely successful. Such a lesion, as may readily be conceived, might become a cause of impotence. Tfrie fibrous sheath of the cavernous body is sometimes affected in a similar manner as the pectiniform septum. The transformation, according to my observation, is most com- mon in subjects from thirty to forty years of age, and usually occurs in small patches, from the size of a three-cent piece to that of a dime. Persons much addicted to sexual intercourse are, I believe, most liable to it. When several such spots exist, they may materially interfere with the erection of the penis, and thus become a soui-ce of great mental annoyance to the individual, seriously compromising his happiness. The treatment of these affections is not very satisfactory. In their earlier stages, bonefit may accrue from the application of sorbefacients, and subcutaneous scarification ; but when the deposit is old, firm, and thoroughly organized, nothing short of excision will answer. The operation is sufficiently easy, and is not attended with any serious hemorrhage. 11. Carcinoma of the penis occurs chiefly in the epithelial form. It usually begins as a little wart, tubercle, or fissure, on the head of the organ or the foreskin, from which it gradually spreads to the other structures, until the greater portion is destroyed. The resulting ulcer is at first quite small and superficial; by and by, however, it becomes broader and broader, and, at last, throws out a cauliflower-like fungus. There is now a profuse discharge of thin, sanious, and offensive matter, the inguinal glands rapidly enlarge, and the patient is harrassed with severe, lancinating pains, darting up towards the abdomen, his constitution being at the same time completely undermined by the local disease. Carcinoma of the penis is most common in elderly men, and its occurrence is generally supposed, although I think erroneously, to be favored by the existence of a long and tight prepuce. Epithelioma of this organ pursues a comparatively tardy course, and does not, as a 834 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVI i. rule, relapse so soon after removal as carcinoma in most other parts of the body. In one of my cases, that of a medical gentleman, upwards of fifty years of age, twelve years have elapsed since the operation, and still there is no sign of a return of the malady. Sooner or later, however, the disease breaks out again, despite all that can be done to prevent it. When amputation is performed, the knife must always be carried freely through the sound tissues. No operation is, of course, proper when there is serious lymphatic involve- ment, hardly even as a palliative measure, unless the parts are very painful, extremely fetid, or the seat of exhausting hemorrhage. 12. Melanosis of this organ is very uncommon. The only case, in fact, of which I have seen any account is one recorded by Dr. Charles Murchison, of London. It occurred in a man, fifty-four years of age, beginning as a small excrescence on the pre- puce, from which it gradually extended to the head of the organ, was of a dark brownish, almost black color, bled when rudely touched, and was the seat of acute pain. It had been progressing for two years when the man died, and had coexisted with melanosis of the liver, pleura, lymphatic glands, and other structures. 13. Sarcoma of the penis is another very uncommon disease. The only instance of the kind I have ever seen occurred in the hands of Dr. W. G. Porter, to whom I am indebted for the following history of it. The patient, a colored man, forty-four years of age, was admitted into the Presbyterian Hospital, on the 25th of August, 1880, on account of a tumor which he first noticed during the previous March at the root of the penis, and the origin of which he ascribed to an injury received in lifting a heavy pack- age. The growth rapidly increased in size until it was about the volume of a foetal head. It surrounded the entire organ in the posterior portion of its extent, and sent a finger-like process downwards and backwards between the spermatic cords into the perineum. During the four weeks in which the man remained in the hospital the tumor increased but slightly in size, but his health and strength were much impaired. Dr. Porter performed excision on the 27th of September through an incision, extending from the pubic sym- physis over the tumor on the right side of the penis to the scrotum. A portion, which was closely attached to the sheath of the penis, and, at one point, dipped down into the structure of the right cavernous body, was included in a ligature, and the rest of the mass, weighing one pound and a half, dissected out. There was but little hemorrhage, and the man rallied well from the effects of the ether. Severe tympanites, however, set in the night after the operation, followed by great oedema of the penis, and, on the third day, by gangrene, death occurring on the 1st of October from exhaustion. A microscopic examination of the tumor by Dr. Seiler revealed the existence of spindle cells. The annexed cut, fig. 662, represents the appearance of the parts at the time of the operation. Fig. 662. Sarcoma of the Penis. 14. Incurvation of the penis is a congenital affection, complicated with abnormal brevity and hypospadias or malformation of the urethra, which is either deficient, or opens some distance behind its usual situation. The consequence is that the organ is bent very considerably backwards towards the scrotum, exhibiting thus not only an unseemly appearance, but interfering materially with copulation. Occasionally the penis points upwards, as in epispadias. In both affections it has generally a thick, bulbous unseemly configuration. For the relief of this defect, an ingenious operation, originated by Dr. Physick, and since practised by the late Professor Pancoast, myself, and others, may be performed. The procedure, which, in principle, is essentially similar to that of Barton for the relief of anky- losis, simply consists in the excision of a Y-shaped portion of the cavernous bodies, the CHAP. XVII. AFFECTIONS OF THE PENIS. 835 first incision being made a few lines behind the bead of the penis. The portion excised should be just large enough to remedy the deformity, and no more. No skin is removed, and care is taken not to interfere with the urethra. The arteries, generally three or four in number, being secured, the edges of the wound are carefully approximated by the interrupted suture, carried through the fibrous sheath of the cavernous bodies, the edges of the integument being tacked together separately. The organ is then placed in an elevated position upon a rubber, felt, or leather splint, and kept constantly wet with cold water. Erections are controlled by the usual means. The stitches are removed in from eight to ten days. No untoward symptoms follow the operation, and the result is most gratifying, except that the penis is a little shorter than before. The operation of effacing the curve in hypospadias by dissecting up the spongy from the cavernous bodies is very objectionable, inasmuch as, although the penis is thereby considerably elongated, it necessarily destroys the urethra at the seat of the wound, and throws the orifice of the tube so far back as to interfere materially with the comfortable evacuation of the urine. The inconvenience that is thus occasioned is certainly not compen- sated for by the increased length of the organ. Two men on whom the operation was per- formed in this manner by ditferent surgeons, expressed to me great dissatisfaction at the result, declaring they hardly ever voided their urine without wetting their drawers and pantaloons. 15. The cavernous bodies of the penis are liable to aneurism, consisting in an abnormal dilatation of their cells. The affection, which is exceedingly uncommon, may be either congenital or acquired, and is characterized by the existence of a soft, spongy mass, sus- ceptible of temporary expansion, and the seat of faint pulsation. It rarely involves the entire circumference of the cavernous bodies, much less their entire length. The diag- nosis may usually be readily determined by the history of the case, and the peculiar nature of the enlargement. The skin generally remains sound. Albinus has recorded the particulars of such a growth which was punctured under the supposition of its being an abscess. The consequence was a copious hemorrhage, of which the patient died in a few days. The most reliable remedies are injections of subsulphate of iron, and subcu- taneous ligation. When the case has been neglected, or the organ has become enormously enlarged, amputation may be required. Malgaigne has recorded a unique case of traumatic aneurism of the dorsal artery of the penis in a young man who injured himself with his pocket-knife. After the wound was healed, a tumor formed near the root of the organ, progressively increased in size, fluctuated distinctly under pressure, and, on being laid open, and the clots turned out, it was found to have been fed by the vessel in question. 16. A case in which a horn grew upon the head of the penis, in a man, twenty-two years of age, has been recorded by Dr. P. A. Jewett, of New Haven. It was of a brownish color, lamellated, insensible, and three inches and a quarter in length by three- quarters of an inch in diameter at the base, gradually tapering to a point. Other benign tumors have been observed, either in connection with the glans or the cavernous bodies, but their occurrence is so rare that they do not demand special consideration. Excision is, of course, the only resource. In Jewett’s case, the growth did not return. 17. Neuralgia of this organ is not uncommon. I have met with it frequently. The disease is most common in young and middle-aged subjects, is usually associated with neuralgia in other parts of the body, especially of the testis and spermatic cord, is nearly always of a periodical character, particularly when it is of malarial origin, and demands the same kind of treatment as neuralgia in general. The urethra, bladder, prostate gland, and rectum should always be carefully examined in obstinate cases, as neglected irritation may act as an exciting cause. A feeling of heat along the penis, either localized or diffused, is an occasional concomitant of the disease. 18. Amputation of the penis, rendered necessary on account of carcinomatous disease, is one of the easiest pi-ocedures in surgery. The integument being slightly retracted by an assistant, and the cavernous bodies transfixed by an acupressure pin to prevent retrac- tion of the stump, the surgeon embraces the penis, behind the seat of the disease, with a pair of slender polyp-forceps, inclining a little obliquely from behind forwards, and then, with one sweep of a small catlin, or large bistoury, severs it from above downwards. The arteries being drawn out and tied, the mucous membrane of the urethra is tacked at four different points to the edges of the cutaneous portion of the wound, to prevent contraction of the canal, so liable to follow the ordinary operation. No catheter need be inserted during the cure. When the bleeding from the cavernous bodies is, as sometimes happens, unusually trouble- 836 DISEASES OF THE MALE GENITAL ORGAN'S. CHAP. XVII. some, the best way to arrest it is to transfix them with an acupressure needle, tightened by a ligature passed around it elliptically, as in the common harelip pin. 1 he instrument is removed at the end of twenty-four hours. In a case of amputation of the penis close to the pubes, Mr. Henry J. Tyrrell, of Dublin, in 1873, drew a narrow tape tightly round the organ behind the pin, and thus readily secured each artery at his leisure by gradually loosenfng the cord, retraction of the stump as well as hemorrhage being thus effectually prevented. The late Mr. Hilton, of London, suggested what may be regarded as an improvement on the old plan of amputation of this organ. It consists in dividing the spongy structure of the urethra about a quarter of an inch in front of the cavernous bodies, in splitting the urethra longitudinally, and in tacking the lateral flaps thus made by suture to the margin of the integument. By this procedure retraction of the urethra is prevented, and cicatrization promoted. Humphry has improved this operation by dissecting up the skin of the penis and folding it back half an inch, the cavernous bodies being severed at this level, while the spongy body is left long. Removal of the penis may also be effected with the ecraseur. The integument should be drawn well forward, and the instrument worked very slowly to prevent hemorrhage, a gum catheter being at the time in the bladder. The parts usually heal very rapidly. After ablation of this organ the urine should be voided through a gum-elastic funnel, carefully fitted to the stump, otherwise, as it cannot be projected, it will fall upon the patient’s feet, irritate the scrotum and thighs, and even soil his clothes. To prevent the inconvenience arising frofn this state of things, Dr. J. W. Howe, in a case recently under his charge, formed with complete success a pair of artificial nymphse in order to afford proper direction to the stream of urine, by dissecting up the loose skin of the stump and of the scrotum from the urethra and the spongy body for a distance of an inch along the middle line, and then stitching together the edges to the integument. SECT. VI AFFECTIONS OF TIIE PREPUCE. The prepuce is liable to various kinds of ulcers, warty excrescences, phimosis, paraphi- mosis, hypertrophy, and the formation of calculous concretions. 1. The herpetic ulcer is observed chiefly in young adults, on the inner surface of the prepuce, or at the junction of the skin and mucous membrane. It manifests itself by in- flamed spots, of a bright-red color, varying in size from that of a millet seed to that of a split pea. Small vesicles soon succeed, of a globular shape, remarkably transparent, agglomerated, and containing at first a serous, and subsequently a puritorm, fluid. On the internal surface these vesicles lead to the development of thin, flat Scales, which fall off about the fifth day, leaving a corresponding number of round, yellowish excoriations ; on the external surface, rough, irregular scabs form. By running together, these ulcers occasionally form one unbroken sore, occupying nearly the whole of the prepuce. The disease is very apt to recur, and is usually attended with some itching, but rarely with pain. The exciting causes are friction, want of cleanliness, and disorder of the digestive organs. Persons of a delicate skin, and of a red complexion, are most liable to its attacks. The diagnosis between herpes and chancre is described in the chapter on syphilis. The treatment consists in the use of a brisk purgative, and a light, cooling diet, with frequent ablutions of the affected surface, and the steady appli- cations of lint saturated with weak solutions of tannic acid, zinc, or lead, or with very weak yellow wash, as one-fourth of a grain of bichloride of mercury to the ounce of lime-water. Zinc ointment, chloral ointment, and the dilute ointment of nitrate of mercury are also excellent remedies. Dusting the part with calomel, and keeping it constantly covered with dry lint, often afford prompt relief. Mercury should never be used internally. 2. The psoriasic ulcer is most frequently met with in per- sons whose foreskin is unnaturally long, moist, and tender. It is an obstinate and painful disease, characterized by deep cracks, chaps or fissures, on the edges of the prepuce, which becomes gradually thickened, hardened, and so corrugated as to occasion phimosis. The number of ulcers is sometimes very considerable they are very tender and unseemly; are apt to bleed when in- jured, are extremely difficult to heal; and, if large, are attended with a copious, puriform discharge. Small, brownish-looking scales occasionally form on these sores. Fig. 663. Warts on the Penis. CHAP. XVII. AFFECTIONS OF THE PREPUCE. The causes and treatment of psoriasis of the prepuce are similar to those of herpes. When the disease is unusually obstinate, slight ptyalism, maintained for several weeks, is sometimes necessary. 3. The prepuce and head of the penis, as seen in fig. 663, are liable to the development of warty excrescences or papillary growths, as a consequence, chiefly, of gonorrhoea, or of impure connection with females laboring under leucorrhoeal and other discharges. Although they may occupy any portion of the organ, they are most common around the neck, at the side of the frenum, and at the margin of the prepuce, where they often occur in immense numbers, from the size of a pin-head up to that of a small hickory-nut; they are usually of a conical shape, with a rather small pedicle, rough, fissured, or tuberculated, of a firm consistence, of a bright florid color, and of fibrous structure When these vege- tations are very numerous, they form a large tumor, or a series of agglomerated masses beneath the prepuce, discharging an abundance of horribly fetid pus. They frequently bleed on the slightest touch, and are always extremely prone to recur after extirpation. The most effectual remedy for these warty excrescences, in their earlier stages, is chromic acid, applied with a piece of soft wood, their surface having previously been divested of moisture. Repetition is effected every third or fourth day, the parts being in the mean time frequently washed, and kept asunder by the interposition of dry lint, which is also one of the best means for preventing relapse. In the more simple cases excellent results are produced by sprinkling the growths thoroughly twice a day with equal parts of subacetate of copper, tannic acid, and powdered savin. When the ex- crescences are very large, old, and sessile, hardly anything short, of excision does any good. The operation is easily performed with the scissors, but is always very painful, and occasionally quite bloody. Dry lint is applied after the bleeding has ceased, and the next day the surface is gently touched with chromic acid. If the patient object to the knife, a good substitute will be found in the Vienna paste, care being taken that its influence do not ex- tend into the sound parts. When the repullulating disposition is very strong, iodide of potassium, with minute doses of bichloride of mercury may be given, although, in general, constitutional means are unnecessary, if not useless. 4. Phimosis, fig. 664, consists in a contraction and elongation of the prepuce, attended with an inability to uncover the head of the penis. It presents itself in two varieties of form, the congenital and the acquired. In the first, of which I have met with five cases in one family, the narrowing of the prepuce de- pends chiefly, if not exclusively, upon the short, tight, and undeveloped condition of the mucous membrane, the skin and connective tissue being perfectly natural; in the other, all the structures are condensed by inflammatory deposits, the result usually of gonorrhoea, balanitis, chancre, or some other disease. However induced, the affection requires prompt attention, as it always interferes with cleanliness and comfort, if not also with copulation. It has been supposed that, by retaining the irritating secretions of the sebaceous follicles, it might become an exciting cause of carcinoma of the penis and prepuce, an opinion, however, which is not sustained by the results of my experience. A tight and adherent foreskin, especially if complicated with a narrowed orifice, may impede the development of the penis, and occasion irritability of the bladder, the formation of preputial calculi, painful micturition, incontinence and retention of urine, stone in the bladder, hyperoesthesia of the genital organs, attended with more or less priapism, reflex paralysis of the lower extremities, impotence, epilepsy, and various other anomalous and distressing symptoms. To Dr. Sayre the profession is mainly indebted for being the first to call attention to some of these troublesome affections. In a case recently admitted into the Jefferson College Hospital, a tight and elongated prepuce gave rise to symptoms closely simulating those of coxalgia. Congenital phimosis, attended with difficult micturition, is an occasional, if, indeed, not a frequent cause of rupture. Of fifty consecutive cases of this defect admitted into the Children’s Hospital, London, thirty-one were found by Mr. Kempe to be associated with inguinal hernia, or inguinal and um- bilical; in none had the complication been noticed at birth. The results of these obser- vations have been fully confirmed by those of Dr. Edward Swasey, of New York. It is worthy of remark that effects similar to those here described may be produced by a nar- row or contracted meatus, habitually interfering with the flow of urine. When the contraction is associated with unusual elongation of the prepuce, the proper Fig. 664. Phimosis. 838 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. procedure is circumcision. With this view the redundant parts, steadied with a pair of slender forceps, applied obliquely immediately in front of the head of the penis, are cut off with one sweep of a long bistoury from above downwards and from behind forwards. Care should be taken to interfere as little as possible with the frenum. The contracted and tightened membrane is then, if necessary, divided with the scissors. Any little arteries that may bleed are secured with fine ligatures, when the muco-cutaneous edges of the wound are approximated with four sutures, placed at equidistant intervals. Elevation of the penis, with cold water-dressing, recumbency, light diet, and a purgative the morn- ing after the operation, constitute the after treatment. The sutures are removed at the end of the third day. When a person affected with phimosis is laboring under the hemorrhagic diathesis, the safest plan is to use the ecraseur, or galvanic cautery, or to include the redundant parts in a ligature, as, in such an event, the use of the knife might be followed by fatal bleeding. When phimosis is unattended by elongation, relief may be afforded by slitting up the pre- puce in front, along the middle line, over a grooved director, as far back as the posterior extremity of the glans, the edges of the wound being afterwards tacked together by several points of the interrupted suture, as seen in fig. 665. The angles of the flaps are gradually rounded off, assuming, ultimately, a very seemly appearance. Or, instead of this, the con- tracted structures may be divided, as suggested by Cullerier, at three or four points, with a delicate pair of scissors, the sharp blade of which is thrust into the connective tissue, and carried as high up as the origin of the prepuce, while the blunt-pointed one glides harm- lessly over the head of the penis. A more simple procedure, one which I have repeatedly practised, is to stretch and tear the mucous membrane with a pair of dressing forceps, and then to evert and turn back the prepuce, keeping it behind the corona until cicatri- zation has taken place. In circumcision, performed according to the Hebrew rite, the skin of the prepuce is cut off with a broad, sharp knife from behind forwards and from above downwards, when the mucous membrane is torn with the thumbs and index fingers, as far back as its posterior attachment. A narrow “ punk” roller carried several times around the wounded part behind the head of the penis completes the operation, being the only dressing used. A Rabbi, of this city, recently informed me that he had performed circumcision 886 times without any untoward accident. I have heard of several cases in which the operation was followed by death from erysipelas or hemorrhage. The acquired form of phimosis often disappears of its own accord, or under the influenee of sorbefacient applications, as mercurial ointment, saturnine lotions, or dilute tincture of iodine, and frequently-repeated pressure with the thumb and finger. When intractable, it must be treated upon the same principles as congenital phimosis, by excision, or exci- sion and incision. Fig. 665. Operation for Phimosis. Fig. 666. Fig. 667. Paraphimosis. Paraphimosis, the Parts being highly Inflamed and Swollen, When phimosis is complicated, as it occasionally is from the irritation caused by the lodgment of sebaceous matter, with adhesions of the mucous membrane to the head of the penis, a long and tedious dissection may be required to sever the connections. In general, liowever, they are so slight as to yield readily under the pressure of the finger. The parts should afterwards be kept asunder by means of lint spread with cerate. The penis, in most such cases, is short, thick, and stumpy, evidently from want of development. CHAP. XVII. AFFECTIONS OF THE PREPUCE. 839 5. Paraphimosis, fig. 666, the reverse of phimosis, is a stricture just behind the head of the penis, caused by the retraction of the foreskin. When the constriction is very tight and protracted, it may produce not only violent suffering but mortification of the strangulated tissues. Even the milder forms of the affection, if not promptly remedied, generally give rise to great swelling, pain, and tenderness, owing to the copious deposits of fibrin and serum, especially the latter, which always arise within a short time after the occurrence of the displacement, as a consequence of the resulting inflammation. These effects are well shown in fig. 667. The accident is most common in young boys who, in their eagerness to uncover the head of the penis, draw the prepuce forcibly back, and are afterwards unable to restore it to its natural situation. It may also arise during copula- tion and during the progress of various diseases of the penis. The proper treatment in paraphimosis is to restore the parts as promptly as possible to their natural relations, which may always be done without difficulty soon after the acci- dent, but often not without great trouble, when severe inflammation and swelling exist. The proper procedure, in ordinary cases, consists in applying pressure to the head of the penis and the dislocated prepuce in opposite directions, by means of the thumbs and fingers, arranged in the manner exhibited in fig. 668. The best plan usually is to squeeze out the blood as thoroughly as possible from the turgid glans, before an attempt is made to push the prepuce forwards. Sometimes this object may be greatly facilitated, especially in recent cases, by pouring upon the part, from a considerable height, a steady stream of cold water. When the prepuce is hard and oedematous, the serum should be well drained off by numerous little punctures before any effort is made at reduction. When the thumbs are dispropor- tionately large, so that they cannot be advantageously applied at the same time, the parts should be drawn forward with the thumb and fingers of one hand, while the head of the penis is pushed in the opposite direction with the thumb and fingers of the other hand. Re- placement, in obstinate cases, may occasionally be readily effected by compressing the head of the penis firmly with a piece of narrow braid, or pack thread, thus reducing its bulk to the smallest possible dimensions. The principle of the treatment is similar to that employed in the removal of a ring from a finger. When restoration is impracticable by the means now described, the strangulation should be relieved by a small incision carried through the constricted integument, just behind the crown of the penis. The operation is generally as simple as it is effectual. Now and then, however, the surgeon is signally baffled, even when the parts are extensively divided at several points, as in the case of a lad, fourteen years of age, a patient at the College Clinic, in whom the paraphimosis had existed for ten days. The prepuce and head of the penis were much swollen and oedematous, and, although they had been thoroughly drained of serum, all the efforts I could employ proved unavailing, notwithstanding the system was completely relaxed by chloroform. Cold water-dressing for the first few days, and afterwards sorbefacient applications, will be necessary to place the parts in a healthy con- dition. In recent cases of paraphimosis, the plan of Mr. Forster, of London, is worthy of trial. It consists in placing the patient upon his back, and then lifting him up bodily by grasp- ing the penis firmly with the right hand behind the seat of the constriction. There is no danger in the operation, as the organ readily bears all the strain that can be thus applied, and the prepuce invariably slips forward into its proper place. 6. Enlargement of the prepuce, amounting sometimes to enormous deformity, is liable to occur; generally as a consequence of interstitial deposits from severe and long-con- tinued inflammation, such as that which attends phimosis or paraphimosis, especially the latter. Occasionally a good deal of serum accompanies the plastic effusion, giving the parts a pale, rose-colored, oedematous aspect, and readily admitting of pitting under pres- sure. When the new formation becomes organized, as it is apt to do when the irritation is protracted, the prepuce may acquire a most unnatural bulk, causing great deformity, and seriously interfering with, if not entirely preventing, copulation. The treatment, in the milder forms of the affection, is sufficiently simple, being limited, in great measure, to the use of sorbefacient applications, as dilute tincture of iodine, or a Fig. 668. Reduction of Paraphimosis. 840 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. weak solution of chloride of ammonium, aided by frequent punctures, to facilitate drainage, especially when there is much distension from serous deposits. Sometimes strapping answers a good purpose. When the enlargement is unusually great and firm, or presents the characteristics of a genuine hypertrophy, incommoding by its weight and bulk, the only feasible procedure is retrenchment with the knife or ecraseur. 7. When the prepuce is very long and narrow, it may act as a receptacle for calculous concretions, of which some very curious examples are upon record. They are usually composed of uric acid, and vary in size from a mustard-seed to that of an almond. Their shape is spherical, or ovoidal, their surface rough or smooth, their color grayish or pale ash. They are formed directly from the urine, which, owing to the difficulty of its escape through the narrow orifice of the prepuce, deposits its salts in the abnormal pouch, which is always more or less hypertrophied in consequence. These concretions sometimes exist in extraordinary numbers. Thus, in a specimen in my possession, presented to me by Dr. John G. Kerr, of Canton, China, there are not less than one hundred and three, varying from the volume of a pin’s head to that of a pea, their aggregate weight being two drachms. In another specimen, removed by the same gentleman from a man forty-five years old, there is a solitary calculus, closely re- sembling, in size and shape, the head of the penis. The affection seems to be very com- mon in China, as Dr. Kerr met with six cases of it in one year; and last February he communicated to me the particulars of twenty-three cases in which more or less numerous concretions were found in connection with phimosis. Persons thus affected are of course unable to copulate. Dislodgment of these bodies is always readily accomplished by incision of the prepuce. If the parts are greatly hypertrophied, the necessary retrenchment is effected immediately after the extraction. 8. Hypertrophy of the prepuce, or of the prepuce and penis, is occasionally observed, principally in the form of elephantiasis. In the latter event, it is generally associated with elephantiasis of the scrotum. The disease, which sometimes commences at an early period of life, is most frequently met with in the inhabitants of warm climates, and may proceed to such an extent as to occasion not only great deformity but complete impotence. In a case related by Wadd, the organ was fourteen inches in length by twelve inches and a half in circumference. The skin is usually very rugose, hard, thick, and insensible ; the connective tissue is changed into a dense fibroid substance ; and the cavernous bodies and head of the penis are abnormally large, as well as increased in consistence. Micturition is generally sufficiently easy, and the patient is sometimes able to command erections, even when the organ has acquired an enormous bulk. The only remedy for this affection, in its more advanced stages, is excision, performed in such a manner as to save, if possible, a sufficiency of skin for the denuded organ. When the disease is in its ineipiency, it may sometimes be arrested by a mild mercurial course and by sorbefacient applications. 9. Ncevus of the prepuce is of rare occurrence, and exhibits no peculiarities entitling it to special notice. When of long standing, it may form a tumor of considerable bulk, involving the head and body of the penis, and thus greatly complicating the case. The only instance of nmvus of the prepuce with which I have met occurred in a gentleman forty years of age, who consulted me on account of a growth of this kind, as large as an almond, situated at the junction of the skin and mucous membrane. It had existed from an early period of his life, and was a cause of sexual incapacity. Ablation was readily effected with the knife, only a few small vessels requiring ligation. When such a tumor is of inordinate size, or involves both prepuce and penis, it should be removed with the ecraseur or ligature, as a safer means than the knife. 10. The prepuce is occasionally cleft longitudinally, as a congenital defect, the opening extending from its base to its extremity. The edges of the fissure are red and callous, and separated at a variable distance. When the flaps are large, the best plan is to refresh and to unite them by suture, as in the operation for harelip, otherwise they should be retrenched, especially if they interfere with copulation. 11. The frenum of the prepuce is sometimes at fault. Thus a person may be much annoyed by its excessive shortness. The defect, which is generally congenital, may interfere with the retraction of the foreskin, and even with copulation, by drawing the head of the penis downwards and backwards, especially when the attachment of the part extends as far forwards as the urinary meatus. The proper remedy is division. Owing to the irregular cicatrization consequent upon chancroid the head of the penis sometimes assumes a lateral or dorsal curvature during erection, necessitating a similar operation. CHAP. XVII. GONORRHOEA. 841 Several cases have fallen under my observation in which great vexation was expe- rienced in consequence of the destruction of the frenum by disease or accident. In one of my patients the suffering thus produced amounted almost to monomania. When the case assumes such importance as this, an attempt may be made to remedy the defect by an operation similar to that for harelip, the contiguous surfaces of the prepuce and head of the penis being carefully pared and accurately kept together by means of the twisted suture. In the instance above mentioned the result was highly gratifying. SECT. YII GONORRHOEA. Gonorrhoea is an inflammation of the mucous membrane of the urethra, produced by the contact of a specific virus. Of the essential nature of the virus nothing is known beyond the fact that it resides in the purulent matter to which its presence gives rise, and that it requires a mucous surface for the development and display of its peculiar action. Placed in contact with the cutaneous tissue, or with any other tissue than the mucous, it is incapable of causing any other effect than ordinary pus; the part, it is true, may slightly inflame, and even suppurate, but the fluid thus derived possesses none of the properties of gonorrhoeal matter, and is, therefore, wholly innocuous. The disease pro- duced by it is strictly of a local nature, is almost exclusively limited in its action to the mucous membrane of the genito-urinary organs, and has the faculty of gradually wearing itself out, or of disappearing spontaneously. In all these respects, as well as many others, it differs essentially and characteristically from the poison of syphilis, which is capable, not only of inducing a severe local disease, but also of contaminating the whole system, the blood, as well as the solids, and thus engendering a diathesis which is transmissible from the parent to the offspring. How long the virus of gonorrhoea retains its infectious properties, after it has awakened the specific inflammation, is a question which has not been satisfactorily settled; much will, doubtless, depend upon circumstances, the period being comparatively short in some cases, and the reverse in others. The poison of gonorrhoea has, as already stated, a predilection for the genito-urinary mucous surfaces. In the male, the parts usuall}r affected are the urethra, the head of the penis, and the inner surface of the prepuce; in the female, the lining membrane of the vulva, vagina, and uterus, is most liable to suffer, the urethra often escaping entirely, even when the attack is of more than ordinary severity. In both sexes, the disease, in consequence of direct inoculation, occasionally attacks the anus, the nose, and the con- junctiva, frequently destroying the sight in less than twenty-four hours from the com- mencement of the morbid action. It is a well-known fact that a woman, not herself laboring under gonorrham, may com- municate the affection, more or less of the poison having been deposited in the vagina during a previous copulation with an unsound man. The fact is also well established that certain secretions, as the leucorrhceal and menstrual, may, under certain circumstances, cause a disease in the male closely simulating gonorrhoea; but yet, I conceive, not at all identical with it, notwithstanding what has been said to the contrary. The period of latency of the gonorrhoeal poison, or the interval which intervenes be- tween the impure connection and the development of the disease, probably does not ex- ceed a few hours, although from three to five days usually elapse before it exhibits any well-marked symptoms. Occasionally, however, the peculiar discharge shows itself as early as six, twelve, or fifteen hours, and, on the other hand, cases are seen where it does not appear before the expiration of a week or more. There is great diversity, in this respect, in diffei*ent individuals, some being extremely susceptible to the impression of the virus, while others are almost proof against its attacks in any event. Young men with a large orifice of the urethra, and a tender, delicate skin, with a predisposition to herpetic affections of the cutaneous and mucous tissues, are particularly liable to suffer. A long and narrow prepuce, entangling and retaining the virus, is another circumstance favoring the development of the disease. One attack of gonorrhoea is no protection against another. Some men literally labor habitually under the disease ; no matter what precaution they may employ, they cannot have intercourse without being inoculated. They contract the affection as easily as tinder catches fire. The smallest spark of virus is sufficient to kindle the disease. Dr. Le Fort, of the Midi Hospital of Paris, finds that of 2583 cases of gonorrhoea, the disease in 778 appeared within the first four days, in 869 from five to eight days, in 276 from nine to twelve days, in 112 from thirteen to sixteen days, and in 17 from seventeen to twenty days. The first signs in 50 cases of the disease were observed at the end of 842 DISEASES OF THE MALE GENITAL ORGANS. c H A P. XVII. twenty-four hours, in 149 after the second day, and in 327 after the third day. In only 35 of the entire number of cases did the incubation exceed the fifteenth day. Symptoms—Gonorrhoea may, practically considered, be regarded as consisting of three stages, each marked by a certain train of phenomena, giving it a sufficiently distinctive character. The first may be called the formative stage, the second the stage of maturity or full development, and the third the stage of decline. The first stage, comprising the initiatory steps of the disease, is announced, as its very first symptom, by a sense of titillation along the course of the urethra, especially at its an- terior extremity, and by a feeling of turgescence and weight in the penis. Shortly after this the orifice of the tube is observed to be red and pouting, and glued up with a thin, whitish secretion; the head of the penis has a swollen and phlogosed appearance; some degree of scalding is experienced in voiding urine; and, upon pressing the urethra, a small quantity of watery mucus may be squeezed out. The fluid is merely an increase of the natural secretion of the part; it is somewhat viscid, although hardly as much so as in health, and, if any of it fall upon the patient’s linen, it is very apt to leave a little darkish stain, the spot feeling slightly stiff. The first stage seldom lasts beyond a day or two, occasionally, indeed, not more than a few hours, when it is succeeded by the second. The fire, previously kindled, now bursts forth in a full flame, and the disease soon reaches its acme. Every symptom is declara- tive of inflammatory action. The discharge is now quite abundant, often amounting to several drachms in the twenty-four hours ; of a thick, ropy, cream-like consistence, and of light-yellowish color, generally bordering upon greenish. In case the morbid action runs very high, it is not uncommon for the pus to contain more or less lymph, thereby aug- menting its consistence, and also pure blood, the result, probably, of a rupture of some of the minute vessels of the mucous membrane. The whole penis is very much swollen, tender, and painful, its head being extremely red and congested, and the prepuce enlarged and oedematous; the scalding in voiding urine is violent, and the stream is often much di- minished in size ; there is a frequent disposition to erections; and the system, sympathiz- ing with the local disorder, is feverish and uncomfortable. When the inflammation is of extraordinary severity, there is apt to be serious involvement of the neighboring parts, along with soreness of the testicles, groins, and perineum, and tumefaction of the veins and lymphatics of the back of the penis. These symptoms may last for several weeks, and they will be very likely to do so unless combated by appropriate means. Sometimes they subside under very simple treatment; at other times, and more generally, active measures are required for their subjugation. As the inflammation abates, the discharge not only diminishes in quantity, but changes in quality, becoming scanty, thin, and pale, resembling weak whey, or a thin mixture of mucus, or mucus and pus, in water. Occasionally it is of a thin, turbid nature, or slightly sanguinolent, leaving a characteristic stain upon the patient’s linen. There is now com- paratively little scalding in micturition ; the stream of urine is also more bold; and there is less tendency to morbid erections. The disease, in fact, is in a subacute state; it has lost its severity, and is manifestly on the decline, subject, however, upon the slightest exposure, or from the most trifling irregularity, to a resumption of all its former intensity. In this way it may flow and ebb, now advancing and now receding, for weeks and even months, without any apparent indication as to a final cure. Having reached this point, the term chronic is applied to it, or, as expressive of the nature of the discharge, the word gleet, the fluid being of a thin, whitish character, small in quantity, and but little different from the natural secretion, unless it is temporarily changed by a reaction of inflammation. It is generally somewhat viscid, and hence it is apt to glue together the edges of the orifice of the urethra, particularly in the morning and after exercise. The quantity of fluid sometimes does not exceed a few drops in the twenty-four hours; at other times it is more consider- able, and then leaves, perhaps, several distinct marks upon the patient’s linen. Occa- sionally almost the only discharge is a whitish, flaky substance, looking very much like little fragments of soft-boiled rice, which is sure to cause the patient a great deal of anxiety, and the surgeon not a little annoyance. There is a form of gonorrhoea in both sexes, in which, instead of the usual discharge, the parts are remarkably free from moisture, constituting what the older writers were in the habit of calling gonorrhoea sicca, or dry clap. It is characterized by a high degree of scalding in micturition, excessive soreness and tenderness in the penis and circumjacent parts, and by a great tendency to morbid erections, the inflamed surface being uncommonly red and congested. The dryness rarely continues beyond a day or two, when it is generally suc- CHAP. XVII. GONORRHCEA. 843 ceeded by an abundant, greenish, muco-purulent discharge, not unfrequently intermixed with pure blood, indicative of the intensity of the morbid action. Pathology—Gonorrhoea is essentially, from first to last, an inflammation of the mucous tissue of the urethra, the intensity of its action varying in the several stages into which the disease is usually divided. The primary impression is generally made upon the ante- rior portion of the canal, not occupying, perhaps, more than a few lines of its surface, but as it advances it gradually and sometimes rapidly extends over the greater part of the lining membrane, reaching as far back as the neck of the bladder, and forwards to the head of the penis and even to the prepuce. Although few opportunities have been afforded of inspecting, after death, the urethra of persons affected with acute gonorrhoea, enough has been learned to show that, when in this condition, its mucous membrane is of a red, florid complexion, from the injection of its capillary vessels, most distinct about the navi- cular fossa and the bulb, and that there is marked enlargement of its follicles, especially of the lacunas of Morgagni, which, from their great size in the natural state, would often seem to be obliged to bear the chief burden of the disease, the morbid action frequently lingering here long after it has ceased in the other structures. A knowledge of this fact is of no inconsiderable practical importance, as it serves to explain the astonishing obsti- nacy which, in many cases, characterizes gonorrhoea, depending apparently upon the diffi- culty of medicating the interior of these follicles, their depth and peculiar position render- ing it frequently impossible to force injecting matter into them. In addition to the above appearances, it is usual to find considerable thickening of the mucous membrane, thus accounting for the diminished size of the stream of urine; and, in the more violent forms of the disease, there is always some inflammatory new formation in the cells of the spongy substance of the urethra, causing that peculiar incurvation of the penis which attends its morbid erections. When the gonorrhoea extends far back, the glands of Cowper are liable to be involved, and it is well known that the prostate gland, the neck of the bladder, and, in fact, the whole seminal apparatus, not unfrequently suffer, especially when the disease continues uncommonly long in a very active condition. Ulceration of the mucous membrane of the urethra rarely, if ever, follows upon acute gonorrhoea no matter how severe the attack; it is only when the disease is very protracted, or when it is associated with chancre or chancroid of this canal, that such an occurrence is at all likely to happen. In chronic gonorrhea, commonly called gleet, the mucous membrane, from the bulbous to the prostatic portion of the urethra, is often studded, as may be shown by endoscopic inspection, with numerous granulations, of a florid color, and of a soft, spongy consistence, similar to those so often observable in chronic inflammation upon the conjunctiva, larynx, fauces, vagina, and uterus. Not unfrequently, indeed, the granulations are spread over a large extent of surface. The discharge is generally thin and watery, and is most abundant in the morning, after protracted sexual excitement, and after the use of stimulating food and drink. Complications Gonorrhoea may exist in a very simple form, passing through its dif- ferent stages without infringing in the least upon any tissues save those primarily and necessarily implicated. In general, however, it encroaches more or less upon the sur- rounding structures, producing those more severe and distressing symptoms which so often characterize the lesion. These secondary affections, or complications, as they may be termed, coming on at a variable period during the progress of the inflammation, are bala- nitis, chordee, cystitis, retention of urine, stricture, epididymitis, bubo, hemorrhage, chan- cre, phlebitis of the penis, and abscess of the urethra, perineum, or prostate gland. Gonorrhoea of the urethra occasionally coexists with gonorrhea of the head of the penis and prepuce, known under the name of balanitis, from a Greek w'ord signifying gland. The two affections may arise simultaneously, or one may take precedence of the other, and they may go on together for an indefinite period, although the latter generally dis- appears long before the former, as it is much more amenable to medication than the disease of the urethra. The reason why the gland does not always participate in the in- flammation of the canal is simply because, from its constant exposure and consequent hard- ness, it loses, in great measure, its susceptibility to morbific impressions. What corrobo- rates this statement is that balanitis, spurious gonorrhoea, or preputial gonorrhoea as it is variously termed, is almost exclusively confined to young subjects with a long, narrow, and very sensitive foreskin. An infection of such a nature is almost unknown in the Israelite, who, in obedience to the requirements of the rites of his church, is compelled to part with this cutaneous appendage at the end of the first week after birth. The disease is usually well marked from its commencement, the prominent symptoms consisting of more or less pain and itching, along with a discolored and abraded appear- 844 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. ance of the inflamed surface, marked tumefaction of the prepuce, which is often quite (edematous, and an abundant puriform discharge, of a peculiarly fetid and irritating cha- racter, apparently from the admixture of sebaceous matter, which is always so copiously secreted in this disease. The morbid action is especially severe along the gutter behind the crown of the penis, at the point of reflection of the prepuce, depending upon the remarkably delicate, vascular, and glandular structure there. The diagnosis is always very easy when the patient is able to retract the foreskin, but when this covering is unusually narrow it is often very difficult, if not impossible, to deter- mine the precise source of the discharge, as it may then proceed entirely from the urethra, or partly from the urethra and partly from the head of the penis. The principal signs of distinction are, the smaller amount of pain and scalding in micturition in balanitis than in urethral gonorrhoea, the more profuse discharge, the more severe swelling, the slighter tendency to chordee, and the more tractable character of the malady. The discharge may proceed from a concealed sore, either chancroidal or chancrous; which, in the "former case, will not only be very copious but very thick, while, in the latter, it will be small and thin, and be accompanied by a circumscribed hardness, easily distinguishable by the touch. Separation of the lips of the orifice of the urethra often throws valuable light upon the subject, and may be effected either with the fingers, a small ear speculum, or a reflecting mirror, called a meatoscope. In case of doubt inoculation may be performed. Chordee is extremely common, and is generally a source of great distress; it is never absent during the height of the inflammation, and is always most severe at night, when the patient becomes warm in bed, or the mind is engaged upon a lascivious dream, an unchaste image, or an impure thought. Its attacks are variable ; it often comes and goes several times during the night, and, not unfrequently, it lasts for hours together, causing sleeplessness and excessive pain, the more so because it is entirely involuntary, the organ refusing to be controlled by any effort of the will. In the more violent forms of the dis- ease, it is attended.with a remarkable incurvation of the penis, the organ being bent back- wards towards the perineum, by the distention of the erectile structure of the urethra by inflammatory new formations, thus preventing the influx of blood necessary to the erection of the affected tissues. When the distention is unequal, the penis is sometimes drawn to one side. Occasionally the cavernous bodies suffer in a similar manner, although in a less degree, and then the organ is sometimes curved upwardly. Cystitis, as a complication of gonorrhoea, is caused by an extension of the inflammation from the urethra to the bladder, along the mucous membrane, affording thus an example of the propagation of disease by continuity of structure. It often supervenes at an early stage of the morbid action, and forms an exceedingly disagreaable concomitant, being characterized by an almost constant desire to urinate, by heat and pain deep down in the pelvis, and by a sense of burning or scalding in micturition, especially at the close of the operation. The inflammation is confined, in great measure, to the neck of the bladder. When very severe, it may be accompanied by a discharge of puriform matter, or even pure blood. Gonorrhoeal prostatitis is an uncommon occurrence. It seldom makes its appearance under ten or twelve days from the primary attack, and the symptoms characterizing it are very similar to those of cystitis. There is, however, in addition, more or less enlargement of the affected gland, with tenderness on pressure, and greater difficulty in micturition. Marked constitutional symptoms generally attend, and if the disease be not promptly checked it may end in the formation of abscesses. Cowper s glands are sometimes inflamed, and add to the urethral discharge; but there are no signs by which such an affection can be distinguished from prostatitis, cystitis, or urethritis. Retention of urine from an extension of the inflammation of the urethra to the neck of the bladder is an occasional occurrence in gonorrhoea. The affection is characterized, in addition to the symptoms ordinarily present in this condition, by excessive burning and smarting along the course of the urinary passages, and by a great deal of soreness and tenderness in the perineum and anus. The immediate cause of epididymitis generally is a repulsion of the gonorrhoeal inflam- mation, from exposure to cold, or the use of irritating injections, the period at which it supervenes being liable to much diversity. Thus, of 645 cases, observed by Dr. Le Fort, 24 occurred during the first week; 93 in the second week; 182 from the fifteenth to the thirtieth day; 150 between the first and second month; 42 between the second and third month ; 26 after the third month ; 14 after the fourth month ; and 25 after the sixth month. Although the disease commonly begins in the epididymis, it rapidly extends to the CHAP. XVII. GONORRHCEA. 845 body of the testicle, which, however, is seldom involved in an equal degree. The swell- ing and other symptoms are well marked, and the suffering is often intense, the system frequently deeply sympathizing with the local disorder. The original seat of the in- flammation is the mucous lining of the seminal passages, but it is generally limited to one testicle. Thus, of 138 cases, collected by Gaussail, D’Espine, and Curling, both organs were affected only in 11. Of the remaining cases, the right testicle was the seat of the disease in 78, and the left in 49. Le Fort found it double in 44 cases out of 540. The left testicle suffers more frequently than the right. Of 1342 cases observed by Sig- mund, of Vienna, this organ was affected in two-thirds. During the height of the inflam- mation, and sometimes even at an early period, there is almost always a suppression of the gonorrhoeal discharge. The spermatic cord sometimes suffers; never, however, as an affection independent of epididymitis. It is characterized by great hardness, by excessive tenderness, and by severe pain extending from the groin to the back, accompanied by more or less febrile excitement. The seminal vesicles are also liable to become involved when the disease affects the epi- didymis ; but in what degree, or in what proportion of cases, is not determinable. The disease is distinguishable by deep-seated pelvic pain, accompanied by a sense of weight in the bas-fond of the bladder, and by great tenderness under the pressure of the finger in the rectum. In severe attacks the inflammation may pass into suppuration. Bubo is an occasional sequence of gonorrhoea; it is most liable to form in young sub- jects, after exposure to cold, or severe fatigue, and is usually confined to one groin, the lymphatic glands of which become enlarged, tender, and painful, but rarely suppurate. The swelling may be seated above Poupart’s ligament, but, in a majority of instances, it will be found below, the number of glands concerned varying from one to three or four. Hemorrhage of the urethra, as an attendant upon gonorrhoea, is an uncommon occur- rence ; it generally takes place during a violent erection, from the rupture of some of the vessels of the mucous membrane, and may be so considerable as to require active measures for its suppression. There is nothing definite as to its seat, although generally it will be found to be located in front of the pubic portion of the canal. The coexistence of gonorrhcea and chancre of the urethra is probably more common than is generally imagined, and it was this circumstance, no doubt, which led to the notion, at one time so common among surgeons, of the identity of the two diseases. As this subject, however, has received due attention in the chapter on syphilis, all that is here necessary to state is that the chancre is usually situated in the anterior extremity of the canal, immediately within, or a little beyond, the meatus, where its presence is always indicated by a circumscribed hardness, and, not unfrequently, by all the visible signs of an ulcer. Phlebitis of the penis, as a complication of gonorrhoea, is very uncommon. It generally sets in within the first two or three weeks of the disease, and is characterized by the exist- ence of a hard, firm cord, situated in the course of the dorsal veins. The pain is usually considerable, and there is nearly always some degree of oedema. No constitutional symp- toms attend. Lymphangitis is another, but also a very infrequent, complication, characterized by swelling and tenderness of the penis, especially along its upper surface, and more or less discoloration. Occasionally considerable oedema attends, especially when it coexists with phlebitis. Finally, gonorrhoea is occasionally productive of periurethral abscesses commencing either in the submucous or in the subcutaneous connective tissue of the urethra, preceded by unusual hardness and other phenomena of inflammation, and pointing in various situa- tions, sometimes along the spongy portion of the tube, sometimes in the perineum, and sometimes, again, in the region of the prostate gland. Such an occurrence, which, for- tunately, is uncommon, is most liable to happen in persons in whom the specific disease is coincident with stricture of the urethra, leading to great difficulty in micturition. When the matter opens into the urethra a fistule necessarily results. Such is a brief account of the more common and more immediate consequences of gon- orrhoea ; to complete the history of this part of the inquiry, it is necessary to add that the disease often leads to stricture of the urethra, owing to the protracted inflammatory action of the mucous membrane, and the inevitable effusion of plastic matter into its sub- stance. There is reason to believe, as has been stated elsewhere, that this lesion is much more frequently produced by gonorrhoea than by all other causes combined. Besides the local effects of gonorrhcea now considered, there are others which are of a 846 DISEASES OF THE MALE GENITAL ORGANS. CHAP, xvi i. general character, and which may, therefore, be said to be constitutional. The affections which are usually described as belonging to this category are gonorrhoeal rheumatism, ophthalmia, and cutaneous eruptions, more especially some of the scaly forms. These affections are, it would seem, remarkably common in London, in consequence, as is sup- posed, of the damp, cold, and variable state of the atmosphere so prevalent in the British metropolis. In this country their occurrence is extremely infrequent, and I have myself seldom witnessed it either in hospital or in private practice. The question arises here, Are we to regard the supervention of these so-called secondary affections as a result of the direct action of the gonorrhoeal poison upon the system, or as a mere coincidence, taking its place in a constitution strongly predisposed, by hereditary influence, atmospheric vicissitudes, and the debility occasioned by the treatment of the original disease, to the development of rheumatism in various parts of the body, particularly the joints, muscles, and sclerotic coat of the eye ? I cannot, indeed, myself, conceive how the subject can be viewed in any other light. All pathologists are agreed that gonorrhoea is strictly a local malady, and that the poison produced by it, although it may be absorbed into the system, is incapable of contaminating the solids and fluids, in the sense in which this question is regarded when the poison of chancre has been conveyed into the body. If gonorrhoea be a constitutional disease in one case, it ought to be so, as a rule, in all, the same law hold- ing good here as in syphilis, and yet every one knows that this is not true. In warm cli- mates and intertropical regions nothing is ever heard of gonorrhoeal rheumatism, whereas, syphilis, in its secondary and tertiary forms, is unusually rife. The joints most liable to suffer, during the progress of gonorrhoea, are the knees, ankles, and elbows. The attack sometimes comes on at an early period in the local disease, is frequently very obstinate and protracted, and is liable at any time to occasional recurrences. In the case of a young man at the Jefferson College Hospital, every outbreak of gonorrhoea, three in number, had been followed by rheumatism of some of the larger joints. Men are more subject to this form of rheumatism than women. Scaly eruptions of the skin and soreness of the throat probably depend upon the ab- sorption of chancrous matter, and not upon any malign agency exerted by the poison of gonorrhoea. This view appears the more plausible, when it is remembered that these consecutive affections of the cutaneous and mucous tissues are well-known results of syphilis, especially of the milder form. It is only necessary to suppose, what, indeed, so often happens in venereal diseases, that the patient is simultaneously affected with gonorrhoea and chancre, or that the latter malady has somewhat preceded the former, and all the difficulty with which the subject is invested will at once vanish. Gonorrhoeal ophthalmia, described in a previous chapter, presents itself in two varieties of form, the conjunctival and the irido-sclerotic. The former, when the result of direct inoculation, is a most painful and destructive disease, generally speedily eventuating in gangrene of the cornea and loss of sight. Gonorrhoeal irido-sclerotitis is comparatively infrequent; it is a constitutional affection, which commonly coexists with rheumatism in other parts of the body, particularly of the joints, and is characterized by the usual phenomena. Pyemia, as a result of gonorrhoea, occurs chiefly, if not exclusively, in subjects of an anemic, broken-down constitution. The disease appears at a variable period after the commencement of the discharge, and is characterized by the ordinary phenomena, as rigors, followed by high fever, excessive prostration, aching of the limbs and back, elevation of temperature, and, at least in some cases, by an icterode condition of the skin. Dissection reveals congestion of the internal viscera, with metastatic abscesses, purulent deposits in and around some of the joints, especially the knee and ankle, and inflammation of the prostatic, vesical, and pelvic veins. A few cases of pericarditis and endocarditis have been noticed after gonorrhoea, occasionally as early as four or five weeks from the outbreak of the disease. Fournier has described a rare form of sciatica, attributable, as he supposes, to the effects of gonorrhoea. The disease usually commences quite suddenly, speedily reaches its maximum of intensity, and seldom lasts longer than five or six days. It differs from ordinary sciatica by the rapidity of its course, the sevei’ity of the pain, and the readiness with which it yields to cupping and veratria ointment. Treatment—In the treatment of gonorrhoea it is important not to lose sight of the several stages into which the disease is usually divided, as they must necessarily exert a modifying influence upon the employment of our therapeutic measures. There seems to be a general belief that an incipient gonorrhoea may, if properly managed, be cut short, or be made to abort. A course of treatment, known as the ectrotic, CHAP. XVII . GONORRHEA. 847 consisting principally of injections, aided by repose and light diet, is much insisted upon as almost, if not completely, infallible. The article, serving as the basis of this medi- cation, is nitrate of silver, in the proportion of a quarter of a grain to the ounce of water, and thrown up every four hours for two successive days, unless it be found that the dis- charge assumes a thin, sero-sanguinolent character, the natural etfect of the remedy, when it is at once discontinued. The intention of this treatment, which, we are told, should be conjoined with perfect rest, abstinence from animal food, and the use of diluent drinks, is to subvert the specific inflammation, before it is fully developed, by the substitution of one of an entirely simple character. Another plan, originally suggested, I believe, by Dr. Wallace, of Dublin, the very opposite of the above, so far as the local measure is concerned, proposes to attain the same end by the use of a strong solution of nitrate of silver, containing at least ten grains of the salt to the ounce of water, and introduced once a day, until there is unequi- vocal evidence of a complete change in the nature of the morbid action. I allude to these two modes of practice merely for the purpose of condemning them, being satisfied, from ample experience, that, although they may sometimes succeed in arresting the disease in its incipiency, yet, in general, they either completely fail, or, what is worse, only aggravate the existing troulde, increasing the discharge, pain, and scalding of the urethra, protracting the attack, and endangering the safety of the epi- didymis and testicle. A much more rational, because a much safer, plan is to treat the dis- ease in this stage with the mildest possible injections, consisting of a very weak solution of acetate of zinc or lead, in water, the quantity of the salt not exceeding the fourth or third of a grain to the ounce. This may be thrown up three, four, or even six times a day, and often exercises a remarkably controlling influence over tire disease. Or, instead of this, an injection of two grains of tannic acid to the ounce of water may be employed. Finally, I frequently use, with the happiest effect, as an injection in this stage of the disorder, simple tepid water, green table tea, or some mucilaginous fluid, mixed with a few drops of laudanum. I have always found that the more mild and soothing the treat- ment is during the incubative period the more likely it will be to prove beneficial in arresting the disease, and this is a point upon which it is impossible to insist too strongly with the young and inexperienced practitioner, who is too apt to commit the very serious mistake of employing harsh remedies when those of an opposite kind alone are admis- sible. Along with these means it is important that the patient should be kept perfectly quiet; that the bowels should be well opened with saline cathartics; that he should abstain from meat, condiments, and all stimulating articles of food and drink; that free use should be made of cooling drinks; and that the parts should be well fomented with cloths wrung out of warm water. In the second stage, when the disease is fully established, as denoted by the excessive discharge, the pain and scalding in passing water, and the phlogosed condition of the penis, the treatment must be essentially antiphlogistic, precisely as in any other severe inflammation. The practitioner must lose sight entirely of the specific character of the disease, and look upon it in the light solely of a common affection. If the patient is young and plethoric, blood may be freely taken from the perineum, groin, and thighs, followed by a brisk purgative, and afterwards by antimonial and saline preparations, to maintain slight nausea and a gentle action on the bowels; perfect repose of mind and body must be enjoined; the diet must be very mild and restricted; and the urine must be rendered as bland as possible by the liberal use of cooling drinks, simple or demulcent, with the addition of a small quantity of bicarbonate of sodium. Cbordee is controlled by a full anodyne given at bedtime. The local treatment is of the most gentle kind. The complaining organ is placed in an easy, elevated position, and frequently immersed, for half an hour at a time, in a tin- cupful of tepid water, containing a teaspoonful of common salt, the object being not only to soothe and relax the parts, but to promote cleanliness. If the pain and swelling be considerable, the genitals, together with the hypogastrium and perineum, are kept con- stantly wet with cloths wrung out of hot water, either simple or medicated with laudanum or hops, and covered with oiled silk. Under similar circumstances, leeches are often serviceable, from fifteen to twenty being applied to the groin, pubes, and perineum, the flow of blood being promoted by the ordinary means. Painting the under surface of the penis in the course of the urethra twice a day with tincture of iodine, diluted with three or four parts of alcohol, often proves highly beneficial in moderating the morbid action. The only direct medication during this period is an injection of warm water, repeated from six to ten times in the twenty-four hours. 848 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. This treatment need seldom be continued longer than three or four days, even in the most severe forms of the disease; at the end of this time the inflammation is generally sufficiently subdued to justify the employment of what are usually considered, and not without reason, as the specific remedies tor this disorder. Ihese are copaiba and cubebs, the efficacy of which in relieving gonorrhoea has long been thoroughly established. . Oil of sandal wood is also much used. Indeed, many practitioners employ these articles habitually, without any preparation whatever, either ot the part or system, in all stages of the affection, from its first inception to its final termination in gleet. That this treat- ment occasionally succeeds is indisputable, but more frequently, by far, it allows the dis- ease to go on unrestrained for an indefinite period. The dose and mode of administration of copaiba deserve consideration. Many persons readily bear a drachm, three times a day, but a smaller quantity than this generally makes nearly as strong an impression upon the disease, while it is much less liable to disturb the stomach and bowels, and to cause eruptions of the skin. Indeed, I have generally found that a third or fourth of a drachm will answer every purpose. The most eligible form of exhibition is that of emulsion, prepared by rubbing the balsam up in gum Arabic and extract of licorice, to which are afterwards added camphor water and spirit of nitrous ether, with a little tincture of opium. The camphor water is a valuable ingredient on account of its soothing effects upon the genito-urinary apparatus, and may be adminis- tered three times daily, in quantities varying from two to four drachms. The dose of nitrous ether should not exceed fifteen or twenty drops, as only the slightest possible impression upon the renal secretion is aimed at. A\ hen the copaiba causes acid eructa- tions, nausea, griping, or diarrhoea, a minute portion of morphia, or a few drops of ace- tated tincture of opium, may advantageously be combined with it. As camphor ’water is not always agreeable, a good substitute may generally be found in cinnamon, mint, or ginger water. When there is much scalding in voiding urine, or an unpleasant eruption of the skin, a few grains of bicarbonate of sodium may be added to each dose of the mixture, or, what is preferable, the free use of alkaline and demulcent drinks may be enjoined. The licorice is particularly valuable in disguising the taste of the copaiba. The oil of gaultheria, one drop to the ounce of emulsion, is often employed for the same purpose. When the copaiba emulsion disagrees with the digestive organs, it is occasionally administered by the rectum, as an injection, but such a mode ot medication is not only very inefficient, but extremely disgusting, and has, therefore, found little favor. Under similar circumstances, the copaiba capsule is often used, the balsam being thus conveyed, without coming in contact with the gustatory nerves, into the stomach, where, its envelop being dissolved by the gastric juice, it soon enters the circulation, producing an effect like that which results from the use of the emulsion, although less rapid, and, on the whole, also, less beneficial. It is for this reason, therefore, that the fluid preparation deserves a decided preference. The ordinary dose of capsules is two thrice a day. There is a pre- paration of copaiba, formerly much in vogue, but now very justly discarded, on account ot its inertness, consisting of a combination of this article with carbonate of magnesium, administered in pill form. When copaiba disagrees, it may sometimes be advantageously replaced by ciibebs, or the two articles may be combined, experience having shown that the modifying influence thus produced occasionally enhances their beneficial effects, at the same time that it renders the stomach more tolerant of their presence. The usual dose of powdered cubebs, the only form in which they are administered in gonorrhoea, is one drachm, three times daily, in a little milk, but twice and even thrice this quantity may be given without detriment. In fact, it generally requires rather a large dose to produce any marked effect at all. Oil of sandal wood, like copaiba, is best administered in the form of emulsion, prepared with cinnamon, peppermint, or ginger water, with the addition ot a little alcohol, the ordinary dose being from fifteen to thirty drops thrice a day. The medicine is usually well-borne by the stomach, and does not distress the bowels, or cause cutaneous eruptions. Another form of administration is that of capsules, of which two or three may be taken every eight or twelve hours. Of the three articles here mentioned as the great antigonorrliocal remedies, the advan- tages are, in every respect, greatly in favor of the balsam of copaiba, especially when per- fectly pure, and given in the form of camphor emulsion. What its mode of operation is, or how its remedial effects are produced, is solely a matter of conjecture. It is positively certain, however, that it makes a direct impression upon the affected surfaces, as the odor of the balsam is always very apparent in the urine, even if used only for a short time. CHAP. XVII. GONOERHfflA. 849 Cubebs and oil of sandal wood also exert a direct influence upon the genito-urinary mucous membrane, but their action is much less conspicuous than that of copaiba, and in many cases they totally disappoint expectation. Along with copaiba, or copaiba and cubebs, direct medication must be employed ; for the time lias now arrived when injections are not only useful, but, in some degree, indis- pensable in order to corroborate and confirm the cure. A numerous catalogue of articles is at the command of the surgeon, from which to make his selection. The most valuable are the different preparations of lead and zinc, sulphate of copper, nitrate of silver, iodide of iron, alum, bichloride of mercury, and tannic acid, dissolved in soft water, and employed, either alone or variously combined, to suit the exigencies of each particular case. The great rule with regard to their use is to begin with a very weak solution, the strength being gradually increased as the inflammation subsides, and the urethra becomes more tolerant to the effects of medication. Unfortunately, the opposite of this practice is too often adopted, and the consequence is that the foundation is thus but too frequently laid for organic stricture and other serious results, as troublesome to manage as they are dis- tressing and alarming to the patient. A little skill and judgment will usually enable us to avoid this error; for, after all, the proper regulation of injections in the treatment of gonorrhoea is as much a matter of common sense as of a chastened experience. Another excellent practical precept in relation to this class of remedies is to vary their employ- ment frequently, substituting one article for another as the former loses its effects, and also reducing or increasing their strength in proportion as they prove either too mild or too severe. I know of no branch of surgery where a practitioner may show his knowledge and judgment, in the treatment of disease, to more advantage, or in a more favorable light, than in that of gonorrhoea. Sometimes the very best injection, in this stage of the affection, is a grain each of acetate of lead and zinc to the ounce of water. Another article, from which I have derived great benefit, is the iodide of iron, from one-fourth of a grain to half a grain to the ounce of water. The proper strength of the solution of nitrate of silver is from the fourth of a grain to two grains to the ounce of water; of sulphate of copper one-eighth of a grain ; of tannic acid two to four grains; of alum from one to five grains. The success of an injection depends altogether upon the manner in which it is adminis- tered. In the first place, the syringe should be good; large enough to hold at least two ounces, with a well-working piston, and a long, smooth nozzle, well oiled. The patient having voided his urine in order to wash away any matter that may be in the urethra, and sitting on a chair or the edge of the bed, inserts the instrument, charged with the lotion, deep into the canal, the penis being held perpendicularly, and the edges of the meatus firmly pressed against the tube. The fluid is then sent back with some degree of force, so as to reach, if possible, the posterior extremity of the passage, in which it is retained for several minutes before it is allowed to escape. There is no danger of the injection passing into the bladder, or of its causing any harm, if it should do so, as its active ingredients would soon be neutralized by the urine. The frequency of the repetition of the injection must depend upon circumstances. In general, thrice a day will suffice, but occasionally it is necessary to perform the opera- tion four and even five times in the twenty-four hours; never, however, unless the fluid is very bland and unirritant. If it causes pain, smarting, or burning, beyond a few minutes, it should either be diluted, or used only twice a day. From neglect of this pre- caution the disease is often aggravated, and the cure protracted. If the injection is found to disagree, or to prove unavailing, it should promptly be replaced by a more suitable one. When the disease has reached its third stage, or has degenerated into gleet, it generally manifests a disposition to linger, or to remain stationary, with, perhaps, hardly any mate- rial variation in its character, for many weeks and even months together, especially if followed by stricture of the urethra. It has, as it were, become inlaid in the mucous membrane, and usually proves extremely difficult to dislodge. It is a case alike annoying to the patient and the surgeon, who often finds his best skill and judgment at fault in select- ing a suitable remedy. The best plan, in this condition, is for both parties to be patient. At all events, it is certain that the disease cannot be taken by storm; for, as it is chronic, so also must be the treatment. Very often success may be obtained by very mild and gentle means ; perhaps, simply, by attention to the diet and bowels, and by the use of some slightly astringent injection, as a grain each of acetate of lead and zinc, or the one-tenth of a grain of iodide of iron, to the ounce of water, aided by a few drops of balsam of copaiba, several times in the twenty-four hours. Plethora must be controlled by purgatives, and by the use of antimonial and saline medicines, either alone, or in union with a small dose of 850 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. balsam, or of sandal wood oil; the diet, too, must be properly restricted, and stimulants of every kind interdicted. In a word, the treatment must be partly antiphlogistic, partly specific. If, on the other hand, the patient is feeble or anemic, tonics, as quinine and iron, must be given. The tincture of chloride of iron is a very useful article, and one that has almost acquired the title of a specific in the treatment of gleet, although it really possesses no such property. Its chief value appears to be due rather to its effects as a tonic than to any particular influence which it exerts upon the genito-urinary organs. It is often advantageously combined, when there is no contraindication, on account of the state of the stomach, with copaiba, or cubebs; and I have repeatedly given it with marked benefit, especially when there was unusual atony of the urethra, in union with tincture of cantharides, the proper dose being about twenty-five drops of the former to ten, twelve, or fifteen of the latter, in a suitable quantity of water, every eight hours. The diet, in these anemic cases, must also be more nutritious; and material benefit often accrues from the liberal allowance of ale, porter, or Holland gin, the latter of which, besides invigorating the digestive organs, generally produces a direct, specific impression upon the urinary apparatus. Exercise in the open air must not be neglected, and a cool, or tepid shower-bath, followed by dry frictions, taken morning and evening. In short, no effort should be spared to improve the general health. Exercise on horseback is to be interdicted, as it tends to exert a pernicious influence upon the affected parts, and, for the same reason, sexual intercourse is to be scrupulously avoided. The use of cubebs has been highly extolled in the treatment of this class of cases, on the ground of their alleged invigorating effects both upon the part and system. In my own practice, however, 1 have seldom realized such a result, and I, therefore, long ago ceased to place any confidence in them. If given at all, they should be employed in much larger quantities than in the subacute form of the disease. When gleet proves very obstinate, resisting all the ordinary means, however judiciously or perseveringly employed, a speedy termination may often be put to its progress by the use of heroic injections, consisting of twenty to thirty grains of nitrate of silver to the ounce of water, and introduced into the urethra every twelve hours, until there is a free sanguinolent, discharge with severe scalding in micturition. In some cases one such opera- tion suffices to break up the specific disease, while in others it is obliged to be repeated two or three times before the desired object is attained. However this may be, the treat- ment is to be followed by injections of some mucilaginous fluid, w'arm applications to the parts, rest, a full anodyne, and light diet; otherwise the new inflammation might readily extend to the bladder and testes. Instead of the nitrate of silver, I have occasionally used with excellent effect tincture of iodine, in the proportion of twenty, twenty-five, or thirty drops to the ounce of water, employed in a similar manner. Now and then over- stretching the urethra with a full-sized conical steel bougie effects a cure when other remedies have failed. When the mucous membrane is thickly studded with granulations, the most effectual remedy is cauterization, conducted upon the same principle as in spermatorrhoea, or with a solution of nitrate of silver, from twenty to thirty grains to the ounce of water, applied by means of a rod armed with a sponge or wadding passed through a straight catheter open at the vesical extremity. The operation, in either case, must be performed with great care, and not repeated oftener than evei*y fourth or fifth day. Instead of nitrate of silver, I occasionally employed a medicated bougie in cases of this kind. The best article for this purpose is the ointment of nitrate of mercury diluted with ten, fifteen, or twenty parts of simple cerate. To this preparation a small quantity of iodoform may often be advantageously added. The only proper instrument for applying it is a fluted catheter, such as that represented in fig. 612. The contact should be maintained until the ointment is completely dissolved. The use of the instrument may be repeated every third or fourth day. Finally, whatever measures be adopted for the relief of gonorrhoea, considered in refer- ence to all its stages and grades of character, it is a matter of the first moment, in regard to the permanent cure of this disease, that the treatment should be continued, uninter- ruptedly for at least eight or ten days after all discharge has apparently ceased. If this precaution be neglected, there will always be great danger of a speedy return of the dis- order, thus compelling both patient and practitioner to go through a similar routine. The treatment of the local complications of gonorrhoea must be conducted upon general antiphlogistic principles, modified by the peculiar character of each affection. With the exception of chancre, they are to be viewed, not as independent lesions, but as maladies CHAP. XVII. GONORRHOEA. 851 owing their existence entirely to gonorrhoea, or to the specific inflammation of the mucous membrane, of which, in fact, most of them are merely a continuation. The chordee, which is often such a very troublesome symptom, generally disappears with the inflammation which causes it; hence, antiphlogistics are always the most suitable remedies for combating it radically. Immediate or temporary relief is best secured by antispasmodics, especially morphia administered hypodermically, or morphia and tartarized antimony, a third or a half grain of the former with one-sixth of a grain of the latter being given towards bedtime. Under the influence of this prescription the patient soon falls asleep, copious diaphoresis ensues, and a tranquil night is passed. The same object may gen- erally be readily attained by an opiate suppository, or by an enema of a drachm of lauda- num, or of this quantity of laudanum and fifteen grains of camphor, dissolved in alcohol, and mixed with some mucilaginous fluid. If the parts are hot and violently excited, the cold douche, or wrapping the genitals up in cloths wrung out of cold water, and frequently renewed, generally affords prompt relief. The induration of the spongy structure of the urethra, caused by inflammatory new formations, gradually disappears under the steady use of mercurial inunctions and sorbe- facient lotions, aided by the exhibition of an occasional dose of blue mass, or a minute quantity, thrice a day, of bichloride of mercury. Cystitis usually readily yields to the application of leeches to the perineum, the warm hip-bath, hot fomentations to the hypogastrium and genitals, and full anodynes with tar- tarized antimony, to allay spasm of the organ and promote relaxation of the system. In plethoric subjects the lancet may be required. If retention of urine take place, and anti- spasmodics fail to afford relief, the catheter must be used. Stricture of the urethra often forms a very troublesome complication. Its existence should always be suspected when the disease is vex-y protracted, or unusually rebellious. The treatment must be conducted in the usual manner. Phlebitis of the penis inquires saturnine and anodyne lotions, conjoined with rest and elevation of the parts. A brisk purgative and leeching may be necessai’y if the inflam- mation is severe. Prostatitis is treated upon the same principles as gonorrhoeal cystitis; by anodyne dia- phoretics, suppositories, leeches, and hot applications to the perineum, and, if plethora is conjoined with high excitement, by general bleeding. Epididymitis is best relieved by the lancet, leeches, a brisk cathartic, and the free use of saline and antimonial medicines, in slightly nauseating doses. Light diet and perfect rest are enjoined; and the affected organs, carefully suspended, are kept constantly wet with a strong solution of acetate of lead and tincture of opium, applied warm or cold, as may be most agreeable to the part and system. In the more sevex-e attacks leeches may be applied to the perineum, groins, and inside of the thighs, or blood may be taken directly from the inflamed parts by multiple punctures. Ice is often veiy suitable in the earlier stages of the disease. No attempt is made by direct medication to reinvite suppressed discharge ; as the inflammation subsides this will be sure to return of its own accord, with- out risk of bad consequences. Slight ptyalism may be necessary to rid the glandular structure of induration and swelling; and a careful supei’vision must for a long time be exercised over the general health by rest and light diet. Affections of the spermatic cord and seminal vesicles must be treated upon general antiphlogistic principles. Bubo is treated antiphlogistically; by rest in the recumbent postui’e, active purgation, and light diet, and by the application of iodine and emollient cataplasms, medicated with acetate of lead, and tinctui’e of opium. The hemorrhage which occasionally attends this disease is seldom so copious as to in- quire special interference; when it does, it will genexally be found to yield very promptly to applications of pounded ice in a bladder, aided by compression with the fingers or the catheter. Internally acetate of lead, ergot, and morphia may be used. The coexistence of urethral sores, whether chancroidal or chancrous, constitutes a serious complication, generally greatly retarding the cui-e. The most certain local remedies are frequent injections of hot water, or of weak solutions of acetate of lead, inflations of iodo- form, and, when the ulcers are within reach, pencilling them daily with a five-grain solu- tion of nitrate of silver. Tents smeared with very dilute ointment of nitrate of mei’cury are also highly beneficial. In chancrous sore the constitutional use of mercury is indicated. Abscesses, forming along the coui’se of the ui-ethra or perineum, are treated in the same manner as abscesses in other parts of the body; antiphlogistically in the first instance, and by free incision afterwards, sufficiently early to anticipate sei’ious destruction of tissue and the occurrence of urinary fistule. 852 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. For the cure of balanitis very simple treatment is generally sufficient. The patient is purged with some cooling medicine, and kept at rest on a restricted diet, while the parts are frequently bathed with cold or tepid water, and covered, in the interval, with an emol- lient poultice, or medicated dressings. If the foreskin is too narrow, or too much swollen, to admit of retraction, the use of the syringe will be necessary, simple hot water, or some gently astringent lotion, as a solution of acetate of lead, or Goulard’s extract, being fre- quently thrown into the preputial bag, to promote cleanliness and to stay inflammation. Harsh and irritating applications are carefully abstained from. In many cases prompt improvement follows the injection of a solution of tannic acid and opium in water and red wine. In the chronic form of the disease the use of a very dilute ointment of nitrate of mercury often rapidly conduces to a cure. Keeping the inflamed surfaces in a state of isolation by the interposition of a piece of soft, dry lint always exerts a salutary influence, and greatly expedites recovery. If symptoms of rheumatism arise the ordinary antiphlogistic means must be used, along with Dover’s powder, opium, and calomel, or morphia and colchicum at night. When the disease has reached the subacute stage, benefit will be derived from the exhibition of iodide of potassium, in union with bichloride of mercury, especially if there be evidence of deposits of plastic matter. Tonics and change of air will be necessary when the mal- ady is rebellious. Topically the usual remedies must be employed, as saturnine and ano- dyne lotions, leeches, iodine, and blisters, the latter being particularly valuable in cases of copious synovial secretion. No benefit will be likely to accrue from the exhibition of copaiba and cubebs. The treatment of gonorrhoeal ophthalmia is discussed at sufficient length in the chapter on the Diseases of the Eye. The conjunctival form of the affection generally proves destructive, despite the best directed efforts of the surgeon. For the sclerotic variety the most efficient remedies are bloodletting, local and general, calomel and opium, colchicum, sudorifics, blisters to the nape of the neck, and the application of atropia to the eyebrows, forehead, and temples. The treatment of pyemia must be conducted upon ordinary principles. The secretions must be promptly corrected, the condition of the blood improved, and the vital powers sustained. SECT. VIII NONSPECIFIC URETHRITIS. The male urethra is sometimes the seat of a nonspecific discharge, so closely simulating that of gonorrhoea as to render it very difficult, if not impossible, to distinguish between them, especially when it occurs in married men. It has been supposed that such a dis- ease might be contracted during intercourse with women laboring under leucorrhoea, and other ordinary utero-vaginal affections, and this is probably the fact, the occurrence being the more likely to happen when there exists an unusual proclivity in the urethra to inflammation. A muco-purulent discharge of this canal is occasionally met with in young men, independently of sexual intercourse. I am acquainted with a highly intelligent physician who seldom fails to suffer in this way whenever he labors under dyspepsia or an attack of hemorrhoids, to both of which he is rather subject. On several occasions the discharge has been coincident with an attack of rheumatism. Children are sometimes affected in a similar manner. In 1859 Dr. Bournonville sent to me a male infant, seven months old, from whose urethra there had been more or less of a muco-purulent discharge for upwards of a month.# The child had become affected, soon after its birth, with eczema, but this had long ago disappeared, and at the time I saw him he was very stout and robust. I recollect the case of a boy, between three and four years of age, in whom the disease existed in a marked degree for a number of weeks, and still another, nearly ten years old, in whom the discharge could not have been more thick and profuse, if he had labored under genuine gonorrhoea. Such attacks have their analogy in the vaginal profluvia of little girls. A rheumatic or gouty diathesis strongly predisposes to the occur- rence of urethral profluvia. Simple urethritis is most commonly met with in unhealthy, delicate children, predis- posed to cutaneous disease and disorder of the digestive apparatus. Occasionally, it can be traced to the irritation of worms in the alimentary canal, to stone in the bladder, or organic lesion of the anus and rectum, as ulceration and hemorrhoids. A strong injec- tion of nitrate of silver, if repeated several times, will cause a more or less copious dis- charge of pus from this canal; and the secretion accompanying a chronic stricture, the re- sult of an attack of gonorrhoea, often, especially under strong sexual excitement, as in newly CHAP. XVI I. SPERMATORRHCEA — MASTURBATION. 853 married men, gives rise to a similar phenomenon. Dr. William Kelly, of New York, has shown that a violent urethritis may be induced by injecting pus taken from the eye of a child laboring under acute ophthalmia. However induced, the symptoms do not differ essentially from those of gonorrhoea. The disease is generally ushered in by a peculiar itching, or stinging sensation, rapidly fol- lowed by heat in the part, unnatural redness of the meatus, and slight scalding in passing water. The discharge is at first thin andgleety, like the white of egg, but it soon becomes muco-purulent, thick, yellowish, and very abundant. When it supervenes upon sexual intercourse it generally sets in within the first twenty-four hours. The most reliable diagnostic circumstances are, the history of the case, the age of the patient, the suddenness of the attack, the comparative smallness of the discharge, and the facility with which the disease yields to treatment. When such an affection occurs in a married man, or in a man accused of rape, the surgeon cannot be too cautious in the ex- pression of his opinion respecting its true character. In some cases the disease is very obstinate ; in others, it either soon disappears of its own accord, or yields to very mild remedies. Diligent inquiry should always be made into the nature of the exciting cause. The general health must be amended, cooling laxatives given, and the utmost attention paid to cleanliness. If these means do not speedily effect a cure, copaiba and astringent injections should be employed in the same manner as in true gonorrhoea. When tonics are required the best articles are iron and quinine with nux vomica. Should the discharge be connected with a rheumatic or gouty state of the system, the exhibition of colchicum will be beneficial. SECT. IX SPERMATORRHOEA MASTURBATION. A loss of semen is one of the natural consequences of manhood ; it is a necessity of the system, and is, therefore, to be regarded as a disease only when it occurs too frequently, or when it is provoked by improper means. When this is the case it may be followed by the most deplorable results, both bodily and mental. Although, as a rule, the great cause of this disorder is masturbation, it may also be produced by excesive venery, gonorrhoea, stricture of the urethra, contraction, and elon- gation of the prepuce, stone in the bladder, hemorrhoids, fissure of the anus, ascarides in the rectum, and disease of the cerebellum and spinal cord. In certain states of the geni- tal organs, or of the brain, it may occur from the slightest cause, as riding in a carriage or railway car, friction of the head, as in the operation of shampooing, reading an exciting story, or listening to amatory conversation. Sometimes the mere presence of the opposite sex is capable of provoking it. Spermatorrhoea is a frequent attendant upon locomotor ataxia, especially in its earlier stages, at first with and afterwards without erection of the penis. The irritation on which it more directly depends is seated at the neck of the bladder, the ejaculatory ducts, and the seminal vesicles, although very frequently the entire mucous membrane of the urethra is in a state of exquisite sensibility similar to that occasionally witnessed in the eye, nose, fauces, and larynx. Masturbation is a common vice among youth, and, once established, is liable to be followed by the most serious con- sequences, both as it respects the health and the happiness of the individual. At first, the emissions are strictly voluntary; they take place under the influence of a lascivious dream, or an excited state of the brain, and are attended by the usual feeling. By and by, however, as the local irritation increases, they occur without sensation, and even without consciousness, either during sleep, or while the patient is at the water-closet. When the habit is fully established there may be five or six discharges a week, or even as many as two or three in the twenty-four hours. The disease may continue in this state for years without any decided abatement. The seminal fluid itself, although secreted in preternatural quantity, is without ropiness, very thin, and characterized by a strong odor. In protracted cases a not uncommon effect of masturbation is stricture of the urethra, which, when once established, keeps up reflex irritation for an indefinite period in all the associated organs, and is, therefore, generally a powerful cause of spermatorrhoea. It is hardly to be expected that an affection which keeps up such a constant drain upon the system should continue long without seriously disturbing the general health. Among the earlier symptoms denotive of this circumstance are, derangement of the digestive organs, attended with constipation of the bowels, occasional headache, and nervous tre- mors. At a more advanced period the patient is harassed with palpitation and dizziness, his sleep is disturbed at night, his extremities are cold and clammy, his body exhales a 854 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. peculiar seminal odor, he shuns society, and is a prey to gloom and despondency. In a word, he is completely hypochondrical. The erections are imperfect, the testes waste, and there is a feeling of numbness and coldness in the thighs, scrotum, and perineum. Impotence, more or less complete, is one of the most common effects of this disorder, if at all protracted. When the disease is fully established the gait is unsteady, the memory is impaired, there is no aptitude for business, and the patient is unable to look one in the face, his actions being those of a poltroon. In a word, he is mentally and physically emasculated. Epilepsy and insanity are occasional consequences of this vile practice. In the report of the Longview Asylum for 1863, masturbation is assigned in nearly one- sixteenth of the cases as the cause of the mental disorder ; and the statistics of some of our other insane institutions exhibit an equally frightful proportion. The diagnosis of spermatorrhoea is generally very easy. The only affection, in fact, for which it is liable to be mistaken is prostatorrhoea, a discharge of mucus from the prostate gland, especially when it occurs at the water-closet from severe straining in defecation, or during strong sexual excitement. Under such circumstances it is not uncommon for a few spermatozoa to be mixed with the mucus, but the number is too small to constitute the disease. Nor must the occasional presence of spermatozoa in the urine be looked upon as, in itself, an evidence of seminal disorder, inasmuch as bodies of this kind are not unfrequently seen in this fluid in young and middle-aged persons in perfect health. The treatment of spermatorrhoea must necessarily vary with many circumstances. Be- fore any rational plan of management can be adopted, it is obvious that every possible effort should be made to ascertain the nature of the exciting cause, the removal of which is often promptly followed by a cure, with little or no internal medication. Hence the urethra and genital organs should always be thoroughly explored, as a preliminary measure. An organic stricture, so often the result of masturbation in the young, or a contracted and elongated prepuce, is a frequent cause of all the trouble. The only bougie for making a satisfactory examination of the urethra is one with an acorn-shaped or bulbous extremity. The ordinary instrument is entirely unfit for such a purpose. Hypenesthesia of the urethra is always present when the disorder depends upon masturbation, even when there is no stricture, although such a disease may generally be looked for in all obstinate cases of the complaint. No headway can be made in the treatment of this affection with internal remedies so long as there is any stricture, or tight prepuce, or any other tangible cause in operation. The proper remedies for the cure of these complications need not be dwelt upon here. The excessive morbid sensibility which so generally attends them is usually soon dispersed by injections of acetate of lead and opium, and the daily passage of a large nickel-plated bougie, retained, as the treatment progresses, from ten to twenty minutes at a time. Weak injections of nitrate of silver, as two grains to the ounce of water, are often useful; and in many cases I have derived signal benefit from cauterization of the affected parts with the solid nitrate of silver, directed to the supersensitive spots with a porte-caustique, such as the one delineated at page 778. Sometimes a syringe catheter, fig. 669, may be employed Fig. 669. Syringe Catheter. with advantage for applying this salt in the form of a spray: and occasionally I have ob- tained good results from mopping the whole surface of the urethra with it, from one ex- tremity to the other, with a sponge attached to the style of a large silver catheter. This mode of medicating the tube is especially serviceable in cases of excessive hyperesthesia. Another plan which has often yielded me marked benefit, under such circumstances, is the application of a very weak ointment of nitrate of mercury conveyed by means of a fluted catheter, passed once a week, retained always for live to ten minutes. The CHAP. XVII. SPERMATORRHOEA — MASTURBATION. 855 instrument which I employ for this purpose is represented in fig. 612. One important rule respecting all such applications is that they shall not smart or offend by their contact, otherwise they will inevitably do harm. After the division of the stricture for the cure of spermatorrhoea, I have occasionally witnessed benefit from the use of a weak ointment of iodoform. Injections of acetate of lead, in the proportion of three to five grains to the ounce of water, are often highly beneficial, repeated twice or thrice a day, the fluid being thrown as far back as possible, and retained each time for five to ten minutes. In the male department of the Pennsylvania Hospital for the Insane, under the super- vision of Dr. Jones, one of the most effective remedies for the cure of masturbation is a decoction of dulcamara in the proportion of two ounces of the dried twigs to a pint of water boiled for twenty minutes. Of this one ounce and a half are given twice in the twenty- four hours, until the patient is deprived of all sexual desire and power of erection. In one remarkable case, in which masturbation had been practised for a long time twice every day, a complete cure with this medicine was effected in a few months. Dulcamara has long been known to possess antiphrodisiac properties, and is worthy of an extended trial in this class of cases. Cold bathing, general and local, is often highly beneficial. Dashing cold water against the perineum, scrotum, penis, and inside of the thighs is useful. Some persons, especially such as are of a nervous, irritable temperament, experience greater advantage from warm bathing than from cold. Occasionally marked relief arises from cold enemas, repeated twice in the twenty-four hours. When the patient is plethoric, as is sometimes the case in the early stage of the disease, leeches may be applied to the perineum, followed, if the local excitement is unusually great, by a blister, or a small issue. The morbid erections so often present in spermatorrhoea are generally easily controlled by anodyne enemas, or by opium, belladonna, and tartar emetic given by the mouth at bedtime. Great relief, sometimes followed by a rapid cure, is occasionally experienced from indi- rect pressure upon the prostate gland by means of an ivory pessary, worn in the rectum every night for several consecutive weeks. This mode of treatment, which was found highly advantageous by Trousseau, probably produces its beneficial effects by obtunding the morbid sensibility of the seminal vesicles and the ejaculatory ducts, always so exces- sively augmented in this condition of the sexual organs, and thus fitting them the better for their offices as a retentive apparatus. The pessary should be of an elongated olive shape, from the size of an almond to that of a pullet’s egg, and should be secured to a perineal band, fastened around the hips with a gum-elastic belt,. A total abandonment of masturbation, and temporary abstinence from sexual inter- course, are indispensable to a cure. The patient must sleep upon his back on a hard mattress, and everything stimulating, in the form of food and drink, must be carefully avoided. The bowels must be relieved by mild aperients. Exercise in the open air is an important auxiliary. Horseback and rough carriage exercise are injurious, as they have a tendency to create undue excitement in the genital apparatus. Sometimes an en- tire change of occupation affords more relief than anything else. When the patient, despite his utmost determination, finds it impossible to resist his bad habit, the whole skin of the penis should be frequently painted with dilute tincture of iodine ; or, this failing, vesicated with cantharidal collodion. Great prostration of the system, with restlessness and loss of sleep, indicates the use of tonics, as quinine and tincture of iron, with hyoscyamus or opium. Dilute phosphoric acid sometimes exerts a powerful restorative influence. In such cases a change of air, and the daily use of the shower-bath, greatly promote recovery. The diet should be light, but nutritious, and a glass of generous wine should be allowed at dinner. When there is reason to believe that the emissions are dependent upon cerebellar irritation, the chief reliance must be upon leeches and blisters to the nape of the neck, the warm shower-bath, and other soothing measures in conjunction with bromide of potassium and chloral, in the proportion of fifteen to twenty grains of the former to three or five of the latter, along with five drops of tincture of belladonna, thrice a day. Another very valuable medicine is the monobromide of camphor in the dose of five grains, given at or soon after each meal. If the patient be plethoric, I sometimes add to each dose of these articles, all of which are powerfully sedative, a few drops of tincture of the root of aconite. A full dose of either of these combinations, given at bedtime, often answers a better purpose than a small dose repeated several times a day. One-sixtieth of a grain of sulphate of atropia, as an aver- age dose, administered at bedtime, will frequently be found to be more beneficial than any other remedy. 856 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. When, by the above measures, the system has regained its natural tone, and the sexual apparatus its accustomed vigor, the best guarantee against relapse is marriage. Upon this point, however, it is impossible to be too cautious. The practice of masturbation generally engenders a want of confidence in young men, in regard to their ability to consummate the marriage contract. In fact, it often renders them temporarily impotent. I have repeatedly known this to be the case after marriage, much to the annoyance both of the patient and the surgeon. In general, however, the defect is rather mental than bodily, and may easily be corrected by entire abstinence for several weeks, and by the use of a little medicine, such, for instance, as a few drops, three times daily, of equal parts of tincture of nux vomica, chloride of iron, and catha- rides, with the assurance of speedy recovery. In this way confidence is restored, and the difficulty soon vanishes. Occasionally the obstacle is caused by too great eagerness, or by too frequent indulgence soon after marriage. At other times, again, the erections are imperfect, or the act is prevented by a premature emission. These effects frequently sub- side of their own accord ; when they do not, an attempt should be made to correct them by a judicious course of treatment, especially by the use of tonics, the shower-bath, galvanism, and attention to the bowels and secretions, conjoined, if the parts are mor- bidly sensitive, with cauterization of the urethra, and mildly astringent injections. SECT. X SATYRIASIS. Satyriasis is a peculiar condition of the brain and genital organs, characterized by incessant erections, an ungovernable desire for sexual indulgence, and an erotic state of the mind bordering upon delirium. It is, in fact, a species of insanity, essentially similar to nymphomania. Fortunately the desire, so revolting in its nature, and generally so deplorable in its consequences, is exceedingly uncommon, otherwise society might find it difficult to protect itself against the assaults of its subjects. Men of the most virtuous habits are not exempt from attacks of this kind. Priests and penitents who, in obedience to their vows, have all their lives scrupulously abstained from sexual intercourse, and practised, in all respects, the most perfect self-denial, have been known to suffer most frightfully from satyriasis, despite their best directed efforts to pre- vent and counteract it. In general, however, the subjects of satyriasis are men of disso- lute habits, debauchees, and masturbators, who in early youth abandoned themselves to practices of the grossest immorality. The causes of this complaint reside either in the brain, or brain and spinal cord, in the genito-urinary apparatus, or in a defective state of the general health. The disease may also be provoked by the inordinate use of cantharides, administered for medicinal pur- poses, or designedly to excite the sexual appetite. However induced, the mind is speedily involved in the venereal affection. The worst forms of satyriasis nearly always depend upon some disorder or other of the cerebellum. The intimate connection between this organ and the genital apparatus, de- monstrated long ago by Gall and Spurzheim, has been placed in a very satisfactory light by clinical observation. Numerous instances of injury have occurred tending to show that, when the cerebellum is seriously affected, the patient is often seized with the most desperate priapism, attended with an erotic state of the mind, and such a degree of salacity as to render it unsafe for any female, even a member of his own family, to be in the same apartment with him. Sometimes the effects are primary, coming on almost immediately after the receipt of the injury; at other times secondary, or more or less remote. Mere concussion of the cerebellum, from a blow on the occiput, or the upper and back part of the neck, is occasionally sufficient to provoke the disease. Mr. Robert Dunn, of England, has recorded a case in which satyriasis supervened upon an attack of apoplexy. The patient was a man, fifty-two years of age, who, along with many other singular vagaries, was afflicted with an almost uncontrollable desire for coition. After death a considerable portion of the right hemisphere of the cerebellum was found to be converted into a softened, pulpy mass, in the midst of which there was a clot of blood, of the size of a pullet’s egg. There are facts upon record which go to prove that mere congestion of the lesser brain, especially if at all severe, is capable of producing satyriasis. Satyriasis, dependent upon irritation, disease, or injury of the genito-urinary apparatus, is of constant occurrence, and does not require any special comments. Chancre of the penis, want of cleanliness of the prepuce, inflammation of the urethra, and irritation of the bladder, prostate gland, and seminal vesicles may be enumerated as so many causes CHAP. XVII. IMPOTENCE. 857 of the complant. It is seldom, however, that satyriasis thus induced is either so severe or obstinate as when it arises from injury or disease of the brain. Men and even boys in ill health are often troubled with morbid erections and an almost irresistible desire for connection, accompanied with frequent nocturnal pollutions. A similar effect is often experienced during the progress of serious, protracted, and exhaust- ing maladies. Many years ago I attended, along with Dr. Knight and Dr. Rogers, of Louisville, a young physician, who was slowly but, as we had reason to believe, safely convalescing from a severe attack of typhoid fever. Despite our remonstrance he in- dulged his passion, immediately grew worse, and died within a few days completely ex- hausted. Priapism and intense venereal desire are occasional symptoms of acute peri- tonitis. The abuse of aphrodisiacs is capable of exciting satyriasis. This is especially true of cantharides, occasionally resorted to by the jaded and worn-out debauchee to provoke erections and to prolong the gratification of his passions. The absorption of the active principle of cantharides stimulates the seminal vesicles and by reflex action irritates the cerebellum. When the disease is fully established, there is complete perversion of the intellectual and moral faculties. The sleep is disturbed by the wildest dreams, and the imagination is a prey to the most lascivious images. Sexual indulgence, instead of calming the feel- ings, only serves to augment the suffering. The erections are constant; the seminal emissions frequent. Fever is not always present, but there is generally great disorder of the digestive apparatus, with constipation of the bowels, a fiery expression of the eye, scintillations, buzzing of the ears, and an exhalation of a peculiarly offensive odor from the skin. If relief is not afforded, the patient, in the more severe cases, falls into a state of delirium, followed by convulsions, paralysis, and death. In the milder forms, the morbid excitement gradually wears off, and restoration eventually occurs. In regard to the treatment of this complaint no definite rules can be laid down. When it depends upon organic disease of the cerebellum, or of the brain and spinal cord, the merest palliation alone is to be hoped for. The most reliable means are leeches and blisters to the occipito-cervical region, tartar emetic and opium in full and frequent doses, efficient purgatives, anodyne enemas, shower-baths, cold lotions, a restricted, unirritant diet, and gentle exercise in the open air. Bromide of potassium, in doses of thirty to sixty grains three times a day, either alone or along with chloral and a small quantity of belladonna, is worthy of trial in the more simple forms of the disease, from its well- known soothing influence both upon the nervous system and the genito-urinary apparatus. The patient should exclude himself from female society, and avoid everything calculated to excite his imagination. The violence of the paroxysm might be controlled by chloro- form. In very obstinate cases, cauterization of the prostatic portion of the urethra should be employed. Castration, proposed by some of the older surgeons for the cure of this disease, is a cruel and useless remedy. SECT. XI IMPOTENCE. Impotence is not only of frequent occurrence, but, from the depressing influence which it invariably exercises both upon the mind and body, is worthy of the most serious con- sideration. Indeed, I know of no class of cases more likely to interest the feelings and sympathies of a conscientious practitioner. The term “impotence,” as I understand it, simply implies inability to copulate, in contradistinction to the term “sterility,” which signifies incapacity to procreate. An individual may be unable to propagate, and yet possess the faculty of sexual intercourse. The causes of impotence are of two kinds, physical or mental, real or imaginary, permanent or temporary. The first relates to various defective states of the body, more especially of the genito-urinary apparatus; the second, to the condition of the mind, or of the brain and its dependencies. Under the former head may be arranged impotence, 1st, from imperfections of the penis; 2dly, from absence, atrophy, and other defects of the testicles; 3dly, from disease of the bladder, urethra, or prostate gland; and, 4thly, from disorders of the seminal vesicles and their excretory ducts. 1st. Absence of the penis, whether congenital or accidental, is, of course, an absolute cause of impotence. Excessive brevity is also a disqualifying circumstance. Persons affected with exstrophy of the bladder are unable to copulate, from the defective condition of the penis. Extreme length might serve as an obstacle, but would only be a relative cause of impotence. Excessive volume, as that arising from elephantiasis, arterio-venous DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. formations, and other morbid growths, may effectually interfere with the intromission of the organ. Carcinoma and syphilitic warts, present in a high degree, also act obstruct- ingly. Wounds of the penis, tearing away portions of the cavernous bodies, occasion impotence by preventing erections. The permanent retention of a ball in the penis, as in a case previously referred to, might produce a similar effect. The presence, however, of a foreign substance in this organ does not necessarily interfere either with copulation or procreation. A case has been recorded by Liston in which a man performed with ability all his sexual functions, and ultimately became the father of a family, notwith- standing a brass curtain-ring, used to prevent incontinence of urine, had been buried in his penis ever since lie was eight years of age. Late in life, however, after the ring had become incrusted with calculous matter, the organ was very unserviceable, and an opera- tion was necessary for his relief. Authors refer to a bifid state of the penis, as a cause of impotence, but such a formation must be extremely uncommon. Inordinate bulk of the penis, rendering the organ utterly unfit for copulation, as well as procreation, may arise from the presence of a calculus in the urethra. Sabatier refers to a case where such a body weighed three ounces, and Dumeril saw one in which it was nearly three times as heavy. An instance is reported in a previous part of this work in which the prepuce of a man, converted into a large pouch, contained upwards of one hundred concretions. Sper, of Toulon, attended a patient who for thirty years was de- barred from sexual intercourse by the presence of a calculus in the foreskin. Excessive enlargement of the prepuce, from inflammatory deposits, may effectually interfere with copulation. Impotence, of a permanent character, may be caused by extravasation of blood into the cavernous bodies of the penis, as in a case observed by Mr. Callaway, of London. A man, in a state of inebriation, after having had connection with his wife three times in the same night, suffered from persistent priapism for sixteen days, notwithstanding the employment of appropriate remedies. An incision was now made into the penis, below the scrotum, and a large quantity of grumous blood, with a number of small coagula, pressed out, with the effect of the immediate return of the flaccidity of the organ. After recovery, however, he continued to be perfectly impotent, from inability to command erections, owing, as was supposed, to the distention and agglutination of the cells of the cavernous bodies with inflammatory new formations. A similar effect is sometimes pro- duced in chordee, consequent upon gonorrhoea and external injury. A vicious direction of the penis may effectually oppose copulation. The most common form is that in which the organ is inclined, more or less strongly, towards the perineum, from a defective condition of the urethra, as in hypospadias. The deformity is usually associated with remarkable brevity of the penis, thus seriously aggravating the difficulty. McClellan met with a case, in a man between fifty and sixty years of age, in which the curvature was caused by a cartilaginous and osseous degeneration of the pectiniform septum. The organ was almost entirely unserviceable, until relieved by operation. La- teral deviation is sometimes occasioned by a similar condition of the fibrous sheath of the cavernous bodies. I have seen a considerable number of cases, chiefly in elderly sub- jects, of imperfect erections growing out of the existence of numerous patch-like pieces of cartilage in these structures. Great incurvation of the penis, interfering with intro- mission, may be caused by a very short frenum. Finally, impotence may depend upon excessive enlargement of the scrotum, as in hydrocele, elephantiasis, and hernia, dragging the penis out of place, or even completely concealing it within the morbid growth. A stout, corpulent man, sixty-three years of age, a patient of mine, was tried for rape and bastardy, but was acquitted, because the entire penis, excepting a little of the head, was buried in an enormous, irreducible rup- ture, nearly twelve inches in length by twenty inches in circumference. Intromission in such a condition could hardly be possible. 2dly. Impotence often depends upon defective states of the testicles. These organs may be entirely absent, as a congenital vice, or they may be removed by accident, by self-castration, or by operations performed on account of disease. Sometimes they are unusually small, perhaps not larger than a small bean, and at the same time very soft and spongy. I have met with several such cases, in all of which the defect was congenital and implicated both organs. Atrophy, properly so called, of these organs, may arise from various causes, of which injury of the posterior part of the head is one of the most common. The intimate connec- tion which naturally exists between the testes and the cerebellum is well known, and it is, therefore, easy to perceive how violence inflicted upon the latter through the back part of CHAP. XVII. IMPOTENCE. 859 the skull should exert a prejudicial influence upon the former. The wasting thus induced is generally very gradual, although not unfrequentlv it proceeds until there is complete destruction of the tubular texture. Since Larrey first called attention to the subject, numerous cases of it have been reported by different observers, in most of which the atrophy was complete. The influence of the brain upon the development of the testes is well illustrated in idiots and cretins, in whom these structures are often remarkably diminutive, in consonance, apparently, with the imperfect condition of the cerebellum. Another cause of atrophy of the testicle, by no means uncommon, is inflammation. The disturbance created in the functions of the organ by plastic deposits often continues after the morbid action has lost its acute character, until the merest vestige of the paren- chymatous structure is left. Parotitis occasionally produces a similar effect, as I have witnessed in several cases, although it rarely involves both organs in the same degree. Among the more uncommon causes of atrophy of the testicle are the inordinate use of tobacco, neuralgia, paraplegia, masturbation, excessive venery, and the compression occa- sioned in hydrocele, varicocele, hematocele, elephantiasis, and scrotal hernia. A case has been related by Mr. Wardrop, in which both organs were completely wasted in consequence of the obliteration of the spermatic arteries by the compression of an aneurism of the aorta. The immediate cause of the atrophy in these and similar affections is defective nutrition from the want of blood and nervous fluid. Destruction of the testicle occasionally arises from the effects of tertiary syphilis, as I have witnessed in a considerable number of cases. When the disease involves both organs, terminating in the annihilation of the tubular structure, irremediable impotence must be the inevitable consequence. Both testes may be retained in the abdomen, or one may remain there and the other descend into the scrotum. In neither case will the person necessarily be impotent. Atrophy, more or less complete, may seize upon these organs when they are retained in the inguinal canal, from the severity of the pressure of the abdominal muscles. Curling describes the case of a married man, who, in consequence of severe neuralgia of one of his testicles, was unable to cohabit with his wife, from the excessive pain he suffered before and at the time. It was so violent as almost to cause syncope. Several similar examples have come under my own observation. A defective condition of the testicle, if congenital or produced prior to the age of pu- berty, is invariably characterized by an effeminate state of the voice, by the absence of beard and of hair upon the pubes, by an imperfect development of the penis, and by all the other features, physical and moral, of eunuchism. 3dly. Impotence from disease of the bladder and prostate gland is infrequent, although, perhaps, less so than is generally imagined. Chronic inflammation, calculous affections, and paralysis of the bladder always seriously impair, and often completely destroy, the apetency for sexual intercourse. The erections, if any, are transient and imperfect. Excessive hypertrophy of the prostate gland is followed by similar results. In stone of the bladder, projecting forwards into the prostatic portion of the urethra, the gland is sometimes completely excavated, or converted into a large cyst, attended with the de- struction of the ejaculatory ducts and the corresponding portion of the urethra. Occa- sionally this body is completely effaced by calculi originally formed in its own substance. Men affected with tight, callous strictures, or any serious obstruction in the urethra, are seldom capable of commanding full, healthy erections ; while hyperaesthesia of the urethra, particularly of its prostatic division, by diminishing or abolishing the reflex excitability of the genito-spina.1 centre, is a fruitful source of impotence. 4thly. Certain diseased conditions of the seminal vesicles may occasion impotence, or an incapacity to copulate. These organs are liable to inflammation, abscess, tubercular deposits, fibroid degeneration, and the development of earthy concretions, completely undermining structure and function, and proportionately weakening, if not thoroughly annihilating, sexual power. The baneful effects of onanism, masturbation, spermator- rhoea, and of all kinds of venereal excesses have already been described. Cerebral impotence may depend solely upon the condition of the mind, or upon various morbid states of the brain, spinal cord, and nerves. Various bodily states, not directly connected with the nervous system, may also give rise to it. The intimate connection between the mind and the genital organs is well known. A disagreeable idea, a suspicion of chastity, or any unpleasant emotion, no matter of what character, often instantaneously arrests the most voluptuous enjoyment, and renders any further effort fruitless. The young husband, in his eagerness to consummate his matri- monial engagements, not unfrequently finds himself completely baffled in his expecta- 860 DISEASES OF THE MALE GENITAL ORGANS. CHAP. XVII. tions. A want of confidence is a pregnant source of disappointment, sometimes for weeks, or even months, and is, perhaps, at last surmounted only by the favorable impres- sion made by our remedies upon the patient’s mind. In an instance under my own care, everything had signally failed for nearly half a year, until I recommended the use of a strong infusion of hypericum, with the assurance that it had often acted like magic in such complaints. Complete relief speedily followed, not from any specific effect of the medicine, but from the confidence inspired in its infallibility. The advice of Hunter to a gentleman who had lost his virility has frequently been quoted. The inability was wholly mental, and completely vanished after a resolute abstinence for six nights. Impotence is sometimes relative, that is, a man may be able to cohabit with one woman but not with another, owing, apparently, to disgust or aversion. The famous case of the Earl of Essex, in the reign of James I., is a memorable example of this nature. A man has occasionally been unable to consummate the act upon finding that the woman was not a virgin, and conversely. “An attack of apoplexy,” says Curling, “often permanently extinguishes all desire as well as capacity for coition.” Paraplegia weakens, but does not necessarily destroy, sex- ual power. Habitual inebriates are generally indifferent to the pleasures of Venus, and may even be entirely deprived of the faculty of erection. Hard study greatly diminishes the desire for copulation. The effects of injury upon the posterior part of the head in impairing virility have already been mentioned. Protracted and wasting maladies, as typhoid fever, albuminuria, diabetes, dropsy, dyspepsia, cardiac affections, aneurism of the aorta, pulmonary phthisis, and psoas abscess are among the recognized causes of impo- tence. Dr. Begbie has shown that the oxalic diathesis diminishes the sexual power, and occasionally entirely extinguishes it. The phosphatic diathesis acts similarly, but in a less degree. Nitrate of potassium, carbonate of sodium, and various other diuretics possess anaphrodisiac properties. The habitual use of opium and its different preparations destroys the sexual power, prevents erections, and arrests the secretion of semen. The inordinate use of tobacco and atropia causes similar effects. SECT. XII STERILITY. Sterility, infecundity, or inability to procreate depends essentially upon three causes: 1st, a defective condition of the spermatozoa; 2dly, inability to bring the seminal fluid in contact with the genital organs of the female ; and, 3dly, a want of congeniality in the two sexes. 1st. The semen is a vital fluid, and, therefore, like the blood from which it is derived, susceptible of important alterations. Its fecundating properties are directly due to the presence of innumerable little corpuscles, known as zoosperms or spermatozoa. Of a soft consistence, and of perfectly homogeneous appearance, they are of a peculiar filiform shape, with a large, flattened pyriform head. The body and tail are exceedingly slender, and terminate in flat, tapering points, hardly distinguishable even with a powerful magnifying glass. The zoosperms are naturally very active, capable of rapid and varied movements, and remarkably tenacious of life, retaining their power of motion often for hours after they have been expelled. They are developed in the testes, but acquire their greatest perfection in the deferent tubes and seminal vesicles. They are suspended in what is called the seminal liquor, a viscid, colorless fluid, very small in quantity, and intermixed with the secretions of the seminal vesicles and prostate gland, which always constitute the greatest bulk of an emission. The peculiar odor of this fluid is altogether adventi- tious, and has no connection whatever with the fructifying influence of the semen. Sper- matozoa may often be detected after emissions in which the generative fluid comes in contact with the person’s linen, even after the spots have been dried, provided they be remoistened with distilled water. It is probable that, as a rule, no zoosperms are formed until the age of fourteen to sixteen years, and, therefore, up to this period the power of procreation does not exist, although the testicles secrete more or less fluid. The age at which they cease to be produced is unde termined. It is not uncommon for men of seventy-five, and even eighty, to possess the faculty of procreation, as is clearly evinced by the resemblance of their offspring. The memorable example of Parr, at a far later period of life, is well known. Duplay found zoosperms in thirty-seven out of fifty-one men between sixty and eighty-six years of age who died of various acute and chronic diseases. In the other fourteen no traces of any existed. In twenty-seven of the cases, the zoosperms were perfectly normal, and similar CHAP. XVII. STERILITY. 861 in every respect to those of the adult. In the other ten cases, on the contrary, they had lost their tails, and were more or less deformed in the head. Aspermatism, that is complete absence of seminal liquor, always exists in persons in whom the testes are wanting or more or less defective, either congenitally or accidentally, as the result of operations, external injury, or wasting disease, attended with disturbance of nutrition, are rarely entirely absent in ordinary maladies. In organic affections of the testicles, as cystic degeneration, tubercle, and tertiary syphilis, they always gradually disappear with the morbid deposits, although, as only one organ is gen- erally involved, the individual is not necessarily impotent. Chronic double epididymitis, the result of gonorrhoea, is often a cause of sterility, espe- cially when it is followed by callosity of the organ. Of twenty cases of this disease, examined by Gosselin, no spermatozoa could be detected in fifteen, although the seminal fluid appeared to be normal and the sexual powers were not impaired. The other cases were of longer duration, and in all, except one, there was an absence of zoosperms. Masturbation and venereal excesses may effectually prevent the formation of sperma- tozoa, by depriving the testes of their secernent power. The seminal fluid, under such circumstances, is very thin, almost liquid, and composed of water and mucus with a minute quantity of albumen, in which the microscope fails to detect animalcules, or, if any be present, they are feeble and deformed. Injury of the back of the head and of the cere- bellum, the seat of the instinct of propagation, often effectually arrests the development of spermatozoa ; and similar effects have occasionally followed upon apoplexy, paralysis, and other maladies of the nervous centres. In some persons the seminal liquor is naturally destitute of fecundating properties. They are as completely sterile, or incapable of pro- creating, as if they were deprived of the testes and penis. The researches of Goubaux, Gosselin, Follin, Godard, and others show that a retained testicle is, as a rule, incapable of producing spermatozoa, and that, when both organs are in this condition, the individual is incapable of procreation. It is an interesting fact, especially in a medico-legal point of view, that persons who have been castrated, often, if, indeed, not generally, possess the power of erection a con- siderable period after the operation, and even the faculty of emission. The fluid, how- ever, that remains, in such cases, in the deferent tubes and seminal vesicles cannot long retain its fecundating properties, as it must, after a few losses, be entirely deprived of zoosperms. Dyspermatism, or inability to propel the semen, and thus bring it in contact with the vagina and uterus, may be caused, 1st, by mechanical obstruction to emission ; 2dly, by defective physical conditions of the penis; 3dly, by imperfect erections; 4thly, by want of power in the ejaculatory muscles; 5thly, by hypospadias and epispadias; and, Gtlily, by inconsentaneous action between erection and ejaculation. 1st. Under the first head of causes of dyspermatism may be enumerated stricture of the urethra, polypoid growths, and the presence of foreign bodies. Persons thus affected may copulate, but, if the obstacle is at all considerable, the semen remains in the canal behind the seat of the obstruction, or it flows back into the bladder, and thus fails to reach its destination. Sometimes the obstacle is seated in the deferent tubes, in the seminal vesicles, or in the ejaculatory ducts, occasioned by inflammation and its consequences, as in disease and injury of the testicles, bladder, prostate gland, and probably, also, of the rectum. Several cases of complete dyspermatism have come under my observation from injury inflicted upon the ejaculatory canals in the operation of lithotomy. The individ- uals were able to copulate, but unable to emit. An imperforate condition of the prepuce may effectually arrest the flow of semen. A similar effect may be produced by the presence of calculi, formed in a sac of this muco- cutaneous membrane attended with partial occlusion of its natural orifice. 2dly. Complete dyspermatism must necessarily exist in all cases of absence of the penis, whether congenital or accidental. Extreme brevity of the organ, vicious direction, and various morbid growths, may all more or less interfere with the successful propulsion of the seminal fluid. 3dly. Imperfect erections may depend upon various causes, physical as well as mental, and may exist in such a degree as to prevent thorough and efficient ejaculation. 4thly. Ejaculation is effected under the influence of a reflex action, and cannot be pro- perly performed unless the muscles which are concerned in its production are in a sound, vigorous condition. Whenever these muscles—the seminal, perineal, and urethral—are disabled, whether by disease of the parts themselves, or of the general system, as in apo- plexy, or paralysis, or by external injury, as a blow, fall, or kick upon the perineum, anus, 862 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XV 11 X . scrotum, penis, or hypogastrium, ejaculation will either be imperfect, or altogether im- practicable. 5thly. Hypospadias and epispadias are genei’ally considered as causes of dyspermatism only when the urethra opens vei'y far back. I am of opinion, however, that these mal- formations may occasionally interfere with ejaculations even when they are limited to the anterior extremity of the penis, especially as the organ, under such circumstances, is often not only remarkably short, but so greatly curved as seriously to impede copulation. Many years ago I saw an elderly colored man, the father of eight children, in whom the urethra opened immediately in front of the scrotum. Persons affected with exstrophy of the bladder are susceptible of erections and emissions, but are generally both impotent and sterile. Gthly. Dyspermatism may be occasioned by a want of consentaneous action between erections and emissions ; that is, ejaculation may not occur until after the penis has be- come perfectly flaccid, and, consequently, incapable of pi-ojecting the seminal fluid to the requisite distance. Such an effect may be produced by various causes, both mental and physical. On the other hand, the emission may occur pi-ematurely, from excessive mor bid sensibility of the penis the moment the oi-gan is brought in contact with the vulva. CHAPTER XVIII. DISEASES AND INJURIES OF THE FEMALE GENITAL ORGANS. SECT. I AFFECTIONS OF THE UTERUS. EXAMINATION AND MODE OF MEDICATION. When the object is to determine the position of the uterus, the exploration should be made with the finger, well oiled and introduced into the vagina, as the woman is stand- ing up before the surgeon, who supports himself upon his knee, or sits on a low stool. In this manner, the finger, moved about in different directions, readily detects any dis- placement, whether it affects its neck, body, or fundus. If the patient coughs while in this posture, the effect produced by the concussion of the diaphragm and abdominal mus- Fig. 670. Conjoined Manipulation. cles upon the dislocated viscus is easily appreciated, at the same time that any change in its bulk may be ascertained by the touch, as this variety of exploration is called, and also the extent and degree of any morbid sensibility that may exist. The examination will always be more satisfactory if the bowels be previously well opened and strong pressure CHAP. XVIII. EXAMINATION AND MODE OF MEDICATION. 863 be made with the other hand immediately above the pubes. In very thin subjects un- affected by enlargement of the womb the finger in the vagina may be brought almost in contact with those on the outside, as in fig. 670, from Sims. Or, instead of this, the ex- amination may be made in the recumbent posture. In some cases the best posture is that in which the woman lies on her belly, with her feet hanging over the foot of the table, and the buttocks well raised by a pillow. Very frequently important information may be acquired by the introduction of the finger into the rectum. Retroversion of the uterus, ovarian dropsy, and various pelvic tumors, are often better diagnosticated in this way than in any other. Or, instead of this, the whole hand may be inserted into the bowel, as the woman lies on her back with the thighs sharply flexed on the pelvis, as was originally suggested by the late Professor Simon, of Heidelberg. The exploration, how- ever, is fraught with great danger, unless the hand is unusually small, and the examination is conducted with the utmost care and gentleness, the great source of peril being over- stretching, if not actual laceration of the bowel and injury to the peritoneum. But for this, such a mode of exploration could often be rendered very useful, affording information which cannot be obtained in any other way. Palpation is another mode of exploration often of great value, made as the woman lies, first, on her back, and then successively as she lies on either side. It is especially effective in the examination of fibroid and other tumors of the uterus, as well as in ordinary hy- pertrophy of this organ, and may often be advantageously conjoined with the use of the sound, finger, and speculum. When the design is to inspect the mouth and neck of the uterus, or this organ and the vagina, with the speculum, the patient is placed upon her back, on a lounge, or across the bed, her feet resting upon its edge, where the breech should also be, the limbs being raised and widely separated from each other, and the head and shoulders rather low. A sheet, with a small hole in the centre, is thrown over the person, which must never be exposed in any case. Sometimes the patient lies on her side, close to the edge of the bed, with the limbs well flexed upon the pelvis, and the body well doubled up. Whatever posture be adopted, there should always be a clear light, that of the sun being superior to any other. The Fig. 671. Fig. 672. Trivalve Speculum. Fig. 673. Sims’s Speculum. Cylindrical Speculum. index and middle fingers of the left hand are placed against the orifice of the vagina, near its superior extremity, when the speculum, properly warmed and oiled, is gently and slowly passed along the tube as high up as the mouth of the uterus, which, if not too large, often projects directly into it, thus affording a complete view of its condition. The speculum which I have long been in the habit of using is the trivalve, fig. 671, about six 864 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. inches in length, slightly conical in shape, and provided with a wooden cylinder to facilitate its introduction. It is, in every particular, a most convenient and useful invention. The cylindrical speculum, fig. 672, is also an excellent contrivance; but, in displacements of the womb, in vesico-vaginal fistule, and in various operations requiring full exposure of the parts and protracted manipulation, the speculum of Dr. J. Marion Sims, fig. 678, de- serves a decided preference. Under similar circumstances the self-retaining instruments, of which there are so many before the profession, afford great facilities. The late Pro- fessor Miller, of Kentucky, preferred a cylindrical speculum, bevelled at each extremity, in opposite directions, so as to shorten one of its sides, which is turned towards the pubes during the introduction; an arrangement which not only admits more light, but affords easier access to the mouth of the organ. Whatever instrument be used, a proper probe should always be at hand. For ordinary purposes, as well as when the object is to explore the cavity of the uterus, or to replace this organ, Simpson’s sound, fig. 674, should be selected, or that recommended by Dr. Fig. 674. Simpson’s Sound. Miller, which is a good deal more curved than that of the Scotch obstetrician, and, there- fore, better adapted to the rectification of some of the malpositions of the viscus. Another contrivance, one that is indispensable, is a soft sponge mop, for wiping away the secretions, so as to afford a clearer view of the affected structures. The best syringe for washing out the vagina is that of Davidson, now found in every apothecary shop. For pulling down the uterus during operations, various kinds of sharp hooks, thrust deeply into the neck of the organ, are used. When the womb is much enlarged, and its cavity, in consequence, is rendered tortuous and irregular, a thorough exploration can be effected only with an elastic sound, consist- ing either of a common bougie, or a piece of whalebone ; or, what is better, a Jenison’s or Jenks’s graduated, metallic instrument, represented in fig. 675. Fig. 675. Leeches are applied to the uterus and to the upper portion of the vagina by placing the animals in a speculum, the parts having previously been well cleaned with water, the number varying according to the amount of the morbid action, and the condition of the general system. A good average is from three to five foreign leeches, which often cause a very copious flow, the bleeding frequently continuing for many hours after the animals have dropped off. When the flow is too abundant the use of Monsel’s salt may be required. In congested, inflamed, ulcerated, and enlarged conditions of the uterus, blood is often advantageously drawn by scarification. The operation is usually performed with an ordinary sharp-pointed bistoury with a long handle, passed lightly over the affected sur- face at several points of its extent. Or, instead of this, the interior of the cervix may be Jenks’s Elastic Sound. Fig. 676. Hard-rubber Cylinder for Drycupping the Neck of the Uterus. incised, the cuts, from two to six in number, being carried into the muscular substance. In hypertrophy of the neck of the organ, great and rapid relief frequently follows the use of CHAP. XVIII. EXAMINATION AND MODE OF MEDICATION. 865 punctures, tlie knife being thrust into the uterine tissues at numerous points to the depth of the eighth to the twelfth of an inch. The flow will be the more abundant, if, previously to the use of the knife, the cervix be dry-cupped with the hard rubber exhauster, sketched in fig. 676, introduced through the speculum. The most common caustic, or, rather, antiphlogistic applications that are made to the uterus are nitrate of silver, either in substance or solution, and acid nitrate of mercury, either pure or weakened. To insure the efficiency of these applications, they should be made with the aid of the speculum, directly to the affected surface, care being taken not to use them too freely, too often, or too strong. The lightest possible touch frequently answers the purpose of an antiphlogistic agent. When the actual cautery is employed, a wooden speculum is necessary, to protect the parts from the heat, and to prevent the fluids from coming in contact with the vagina. Cauterization of the cavity of the uterus may be effected with solid nitrate of silver, provided the disease for which it is practised is not situated very high up. When this is the case it will be safer to use this substance in solution, applied with a mop, the strength varying from ten to forty grains, according to circumstances. Injections of the cavity of this organ are not always free from danger, however cautiously used. Indeed, a con- siderable number of cases have been reported in which they proved fatal, from the en- trance of some of the fluid into the peritoneal cavity. It has been shown that even injec- tions of simple tepid water are liable to be followed by severe shock and inflammation. Inflammation of the uterus and vagina is often rapidly relieved by means of tampons of cotton, charpie, or lint, medicated with various kinds of fluids, as a solution of tannic acid in glycerine, Goulard’s extract, acetate of lead, alum, or subsulphate of iron. The proper plan is always to begin with a comparatively weak solution of these substancess their strength being gradually increased as the treatment proceeds. Employed too strong at first, they are liable to cause pain and to aggravate the disease. The dressing should be repeated at least twice in the twenty-four hours, especially if there be much discharge. Alum has, on the whole, always yielded me the best and most prompt results. In inserting a tampon the vagina must be expanded with the speculum, and the sub- stance of which it is composed must be pushed up against the womb so as to cover in every part of it as well as fill the vagina more or less completely. When the tampon is employed to arrest hemorrhage any blood or matter that may be present must be thoroughly wiped away as a preliminary step. Rolls of cotton or strips of patent lint wet with Monsel’s solution should be introduced one after another until the tube is completely distended, the first being carried high up, and arranged around the neck of the uterus in the form of a collar. In urgent cases, the plugging should embrace the canal of the uterus. A compress applied over the vulva and confined by a bandage completes the dressing, which should be replaced at the end of forty-eight hours, the vagina having first been thox-oughly cleansed with carbolized water. Dr. John J. Black, of New Castle, Delaware, has used with great advantage medicated suppositories in vaginal affections. From numerous experiments performed at the Phila- delphia Hospital, with various articles, he has been led to give a decided prefei-ence to subsulphate of iron, in satux-ated solution, incorporated with cocoa butter and simple cerate with the addition of a small quantity of morphia. Retention is effected, if need be, with the aid of a compress and T-bandage. Perfect cleanliness of the uterus and vagina, in disease, can only be secured by the use of the syringe, of which there are a great many before the profession ; few, however, that combine all the necessary qualities of such an apparatus. To answer the purpose properly, the instrument should be a globular gum one, with a nozzle four inches in length, perfectly straight, nearly half an inch in diameter, and perforated with numerous large foramina, after the fashion of the common watering spout. The injection may be administered by the patient herself, as she lies on her back, over a bed pan, or while she is sitting up, care being taken to dii’ect the nozzle upwards and backwards towards the coccyx, and to use considerable force, in order to bring the fluid, which may be either simple or medi- cated, in contact with every portion of the affected surface. The injection, of whatever character, should always be tepid, inasmuch as cold is often productive of great distress, both local and general, especially in nervous, anemic women. Anodyne injections are occasionally employed for relieving pain of the vagina and uterus; but, unless the pelvis is thoroughly elevated at the time, the fluid soon runs off, and no benefit is received. Besides, the proceeding is both awkward and incon- venient. I have, therefore, myself long since abandoned it, and used, instead of it, cotton or lint, rolled up into a ball, steeped in a sti-ong solution of morphia, or pure laudanum, 866 DISEASES OF THE FEMALE GENITAL ORGANS, chap, xviii. and introduced by means of the finger, probe, or forceps, in immediate contact with the mouth of the uterus. Injections of styptic fluids to arrest uterine hemorrhage should not be employed without the greatest caution, as numerous cases are upon record in which they have proved fatal either by penetrating the peritoneal cavity through the Fallopian tubes, or by passing directly into the uterine sinuses, and thence into the veins of the broad ligaments. Danger is particu- larly liable to arise from injections of the different preparations of iron, as the subsulphate and perchloride, in bleeding in abortions and early miscarriages, and also in hemorrhage of the womb at or near the full term. Caustic injections of all kinds are, as a rule, unsafe. Dilatation of the cavity of the uterus may be required to bring on premature labor, to relieve dysmenorrhoca, to facilitate the removal of morbid growths, and to promote im- pregnation, the substance generally employed being a compressed sponge tent, inserted Fig. 677. A Sponge-tent with Thread passing through it. with a long pair of forceps, with serrated blades. In this way the object may often be attained in a few hours, especially if a series of dilators be used in rapid succession. When it is designed to increase the size of the canal of the organ to promote conception, the sea- tangle tent answers every purpose, and is, in many respects, preferable to the sponge tent. Retention is favored by plugging the vagina with a mass of cotton, removal being effected through the speculum in from twelve to twenty-four hours. No force must be used in the operation, otherwise it may produce peritonitis, and even death. Of four cases in the hands of Professor Gaillard Thomas, death was caused in one by tetanus, in one by peritonitis, and in two by septicemia. Strict recumbency should always be ob- served, not only during the sojourn of the tent, but for a day or two after. The best form of sponge tent is that shown in fig. 677, in which the thread is passed through a canal in its interior, the ends being tied together previously to the insertion to facilitate removal. The uterine dilator, a special instrument, for expanding the orifice and neck of the uterus, possesses the advantage over most other contrivances of doing its work much more rapidly, a few minutes often sufficing for the purpose. The dilator generally preferred in Fig. 678. this city is that devised by Dr. Elhvood Wilson, sketched in fig. G78, and usually known in the shops by his name. When the contraction is very great a small incision consti- tutes an important preliminary step. Everything like violence must, of course, be care- fully avoided. The surgeon is sometimes obliged to remove a pessary from the vagina, owing to the Wilson’s Dilator. CHAP. XVIII. MALPOSITIONS OF THE UTERUS. 867 pain, inflammation, ulceration, and discharge which it so often provokes. The operation is by no means always an easy one, especially if the instrument is globular and of large size, when it may be exceedingly troublesome and embarrassing. The ordinary ring, flat, or horseshoe pessary may usually be extracted with the Anger. When unusual difficulty is experienced, recourse may be had to the lithotomy-forceps ; and a similar expedient will often be necessary in retention of the globular pessary. Cases have been witnessed where the suffering from attempts at extraction was so intense as to call imperatively for the use of an anaesthetic. It seems difficult to understand why there should still be such a fondness for the pessary, when it is so often productive of mischief, and when the very principles upon which its use is founded are so erroneous. I am sure that no one who has'ever witnessed the happy effects of a well-constructed abdominal supporter would exchange such an apparatus for the most unexceptionable pessary that could be devised. The one is clean and comforta- ble, the other filthy and painful; the one takes the weight of the viscera off the uterus and enables the female to walk and exercise without inconvenience ; the other, without sup- porting the uterus, compresses the vagina, bladder, and rectum, and renders progression often difficult, if not impossible. The number of pessaries before the profession, of every form and size, is legion, showing that they have a wide range of action, and that not a solitary one enjoys the full confidence of the gynecologist. That their indiscriminate employ- ment is attended with great suffering, and often with marked injury, no one acquainted with the subject can doubt. MALPOSITIONS. Of the various malpositions to which the uterus is liable, the most common are retro- version, anteversion, prolapse, and inversion. 1. In retroversion, fig. 679, the orifice of the uterus is tilted up against the pubic symphy- sis, the fundus being thrown downwards and backwards, so as to form a tumor between the vagina and the rectum. Thus the axis of the organ is totally reversed relatively to its natural situation within the pelvis. The displacement is very common in the unimpreg- nated state, and is also occasionally met with during pregnancy, especially between the third and fourth months. It generally occurs in consequence of the relaxation of the ligaments of the uterus, and of the engorged condition of this organ, rendering it, as it were, top-heavy, and thus favoring its descent against the rectum. For these reasons, the accident is often met with soon after delivery, at a time when the body of the uterus is unusually large and vascular, and, therefore, incapable of sustaining itself in its natural position. Retroversion of the womb is attended with a sense of weight and dragging in the pelvis and groins, pain in the sacrolumbar region, frequent desire to pass water, with almost constant uneasiness in the bladder, and difficulty in defecation. The general health is vari- ously affected, and there is usually more or less leucorrhoea. In the worst forms of the disease, the patient often suffers from retention of urine. The retroverted organ is always easily detected with the finger, its orifice lying immediately behind the pubic symphysis, while the body forms a hard, globular mass, resting upon the lower part of the rectum. The affection is liable to be confounded with abcess of the pelvis, polyp of the uterus, ovarian tumors pressing down the posterior wall of the vagina, and stricture of the lower bowel. The treatment is strictly antiphlogistic, consisting of rest in the recumbent posture, light diet, purgatives, astringent injections into the vagina, and the application of leeches to the uterus. Reposition is effected by the sound, carried into the cavity of the womb, aided by pressure against the body and fundus of the viscus with the finger in the vagina or rectum. In the milder cases of displacement, the reduction may often be readily effected through the agency of the colpeurynter, carried high up into the vagina, and then forcibly distended with air or water. When the uterus has become firmly adherent to the surrounding parts, the disease may be regarded as irremediable, although considerable relief may follow the use of a stem pessary. Fig. 679. Retroversion of the Uterus. 868 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. 2. Anteversion, fig. 680, is a displacement precisely the reverse of the preceding, the fundus of the womb being carried forwards on the urinary bladder, and the mouth back- wards towards the rectum and the hollow of the sacrum. It rarely occurs during pregnancy, and is almost always associated with hypertrophy of the uterus. Anteversion is sometimes produced by morbid adhesions between the organ and the peritoneum, which have the effect of forcing it out of its normal position. The patient ex- periences more or less distress, as a sense of weight and bearing down in the pelvis, and dull, heavy, aching pains in the lower part of the back. Leucorrhoea also usually exists, and there is often marked disorder of the general health, as shown by various nervous and anomalous phe- nomena. The bladder and rectum are frequently seri- ously incommoded by the pressure of the dislocated organ. The precise nature of the affection is always readily distinguished by digital examination. rlhe treat- ment is conducted upon the same general principles as in retroversion. When the ordinary means fail, elytror- raphy may be resorted to, the operation consisting in the removal of two horizontal strips of mucous membrane from the anterior wall of the vagina, separated about one inch and a half from each other, and united bv wire sutures, retained for a fortnight to three weeks. The object is to shorten the vagina, and thus drawr the neck of the uterus towards the pubic symphysis. In both of the above forms of displacement, the patient should observe recumbency for several weeks after the reduction, and, for a long time, pay great attention to her bowels and diet. Immediately after the operation is over, she should put on a uterine supporter, which should never be left off for a moment, when she is in the erect posture, until there is reason to believe that the parts have entirely regained their original situations. 3. Prolapse of the uterus occurs in two varieties of form, the partial and the complete. In the latter, known as procidentia, the organ projects beyond the vulva, forming a tumor between the thighs, attended with complete inversion of the vagina. In fact, the mass constitutes a genuine hernia, consisting of the uterus, either in whole or in part, of the anterior wall of the bladder, of the involved vagina, and often also of a portion of the small intestine. The affection may be produced by mere relaxation of the genital appa- ratus and the adjoining parts, with an engoi’ged condition of the uterus, thus materially increasing the weight of the organ, but the immediate cause is generally a severe strain during defecation,, micturition, or parturition. Serious prolapse is occasionally induced by the pressure of a pelvic tumor, by habitual distention of the bowels, and by the presence of a morbid growth of the uterus itself. The symptoms of prolapse vary. Even the more simple forms of the affection are always attended with more or less muco-purulent discharge, a feeling of wreight in the pelvis, dragging sensations in the groins and hypogastrium, pain in the sacrolumbar region, and disorder of the general health. The diagnosis is easily determined by a digital examination while the patient is in the erect posture. The neck of the uterus will generally be found towards the sacrum, immediately in front of the rectum, and there will be no difficulty in forming a pretty correct idea as to its distance from the vulva. The existence of procidentia is denoted by the peculiar shape and reducibility of the tumor, and by the central situation of the orifice of the uterus. For the more simple forms of prolapse, the most suitable treatment is the constant use of a well adjusted supporter, the pad, which should be rather broad, and of an ovoidal shape, resting upon the hypogastrium, so as to hold up the abdominal viscei’a, and thus prevent them from pressing too much upon the womb. The apparatus need not be worn at night, but it should always be put on in the morning before the patient gets out of bed. When the disease exists in a very aggravated degree, it may be necessary, in addition, to employ a stem pessary, made of silver or hard rubber with a perforated cup for the accommodation of the neck of the uterus. The pressure thus exerted lifts the organ out of its abnormal position, and enables it to regain its natural relations. Great benefit generally accrues from the steady use of astringent injections, a soluble condition of the bowels, a concentrated diet, and rest in the recumbent posture, with the frequent applica- tion of leeches to the neck of the uterus, to relieve engorgement and induration. The Fig. 680. Anteversion of the Uterus. CHAP. XVIII. MALPOSITIONS OF THE UTERUS. 869 ordinary pessary, of whatever shape or substance, is a filthy instrument, provoking pain and discharge, and generally doing more harm than good. The chief remedies in ordinary procidentia are leeches and scarification, astringent injections, protracted recumbency, and the use of a stem pessary with an abdominal supporter. When the neck of the uterus is greatly elongated, thickened, and indurated, the best plan is to excise it, in order to relieve the organ of a portion of its weight. In the more rebellious forms of the complaint, attended with inordinate dilata- tion of the vagina, elytrorraphy may sometimes be advantageously employed, the process of Sims, re- presented in the annexed cut, fig. 681, being the one usually adopted. This consists in removing with a tenaculum and curved scissors on each side of the vagina a strip of mucous membrane, from one-third to half an inch in width, commencing im- mediately above the neck of the bladder, and ex- tending nearly as high up as the uterus, the two raw surfaces exhibiting somewhat of a horseshoe configuration. The edges of the wound are tacked together with silk or wire sutures, retained until they are completely united. The object of the operation is to contract the canal of the vagina so that the uterus may afterwards be more easily kept in place. The adhesions, however, not unfrequently give way, thus frustrating its design. The pro- cedure has been modified by Emmet and Thomas ; and Laugier, Kennedy, and others, have attempted, but unsuccessfully, to produce a similar effect with the hot iron. I have reason to believe that this operation generally proves useless, even in a short time after its performance, especially in cases attended with hypertrophy of the uterus and an unusually capacious condition of the vagina. When the above treatment fails, the only resource is closure of the orifice of the vagina by paring the labia in the greater portion of their extent, and uniting the vivified surfaces with the interrupted suture. The operation, also frequently unsuccessful, con- stitutes what is called episiorraphy. 4. In inversion of the uterus, the viscus is turned inside out. It is generally attended with more or less prolapse of the body of the organ, and seldom happens except during delivery of the after-birth, from traction upon the cord, or the forcible removal of some growth from its interior, as a polyp or myomatous tumor. The lesion presents itself in three principal degrees. In the first, the fundus falls down nearly to the mouth of the womb, where it is arrested; in the second, it passes be- yond this point for half or more of its length; in the third, the whole organ escapes at the inferior orifice. In the second case it is obvious that the body and fundus may be compressed, or strangulated, by contraction of the neck. The complete form of inversion of this organ is well shown in the annexed drawing, fig. 682, from a specimen in the cabinet of the late Professor Meigs. The diagnosis of inversion is seldom difficult. The most important phenomena are the existence of a pyriform tumor larger below than above, and a constant sangui- nolent discharge, often so profuse as seriously to under- mine the general health, causing anemia, palpitation of the heart, and various other disorders denotive of loss of blood. The hemorrhage is often severe and copious. This occurred in 49 out of 102 cases analyzed by Dr. Charles A. Lee. The affection has occasionally been mistaken for a polyp, and, conversely, a polyp has been mistaken for an inverted uterus. Errors of this kind have occurred in the hands Fig. 681. Sims’s Operation of Elytrorraphy ; Sutures in Place. Fig. 682. Inversion of the Uterus. 870 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. of some of the ablest obstetricians, as Velpeau, Ley, and lligby, and cannot always be avoided even by the most careful and patient investigation, so closely do these tumors sometimes resemble each other. The reduction in the more simple forms of inversion of the uterus is often sufficiently easy, especially if attended to immediately after the occurrence of the accident. In chronic cases, on the contrary, it is very difficult and sometimes even impracticable. The efforts at replacement should always be made with the aid of an anaesthetic, while the patient is on her back, the bladder and bowels having previously been well emptied. In performing the operation the inverted organ should be firmly grasped with the hand in the vagina, and equably and thoroughly compressed, at the same time that it is pushed gently and steadily upwards. Care must be taken in this stage of the procedure not to put the vagina too forcibly on the stretch, otherwise it may be lacerated. The danger of such a mishap will be much diminished, and the reduction greatly facilitated, if counter- pressure be made with the hand applied immediately above the pubes. By these efforts, steadily and perseveringly continued, the body of the uterus is gradually unfolded, and the resistance at its neck progressively lessened, until, at length, after a period varying from a few minutes to several hours, the parts resume their natural position. The first instance in which this mode of reduction succeeded was that of Valentine, in 1847, one of sixteen months’ duration. This was followed successively by the cases of Barrier, Canney, and the late Dr. Quackenbusli, of Albany, who was the Hrst in this country to restore a chronically inverted uterus. The late Professor J. P. White of Buffalo, soon after had a successful case of fifteen years’ standing, and Dr. Tyler Smith, of London, one of nearly equal duration. Noeggerath, Sims, Emmet, and others have since been equally fortunate. Dr. Tyler Smith effected the replacement very slowly with the aid of an India-rubber air-ball, conjoined with manipulation for ten minutes at a time twice a day for upwards of a week. Professor White, who had quite a number of successful cases, and who believed that all cases of inversion can be reduced without qualification as to their duration, devised what he called a uterine repositor for facilitating replacement. The instrument, represented in fig. 683, is described at length in The American Journal of the Medical Sciences, for April, 1872. In this mode of reduction, direct pressure is Fig. 683. White’s Repositor. applied to the dislocated organ with the rubber cup, and the counterpressure with the hand above the pubes. Dr. T. Addis Emmet has in several instances succeeded—not, however, without great difficulty—by grasping the womb as near as possible at its neck, and then, by pressing steadily upwards, unrolling first that portion of the tumor which was inverted last, the extremities of the fingers acting as a wedge laterally. The ma- noeuvre was greatly facilitated by the application of the other hand to the lower part of the abdomen. In very obstinate cases the reduction, by manipulation, will generally require a relay of assistants, on account of the excessive fatigue experienced by the compressing CHAP. XVIII. MALPOSITIONS OF THE UTERUS. 871 hand, almost depriving it of power. Reduction may occasionally be effected by elastic pressure with the vaginal water-bag, as it is termed ; and Courty has devised an excellent and efficient method, which consists in inserting the index and middle fingers into the rectum, and dipping them into the cervical ring, so as to gain a point of resistance, while counterpressure is made in the vagina. In the first edition of this work I suggested the idea that the reduction in this affection, especially in cases of long standing, might be greatly facilitated by a slight vertical incision on each side of the neck of the tumor, where the chief obstacle ordinarily lies, the principle being the same as in the operation for paraphimosis. Since then several cases have been reported in which this plan, which I now find dates back to Millot, in 1773, was successfully employed. It is evident, from the great number of methods for replacing an inverted uterus now before the profession, that great liberty may be taken with this organ when in this con- dition, and that there is no single procedure applicable to all cases. Emmet has enumerated nearly a dozen methods, including an excellent one of his own, by so many different gynecologists. Of course, most of these, if not all, are based upon the same general prin- ciples. Great perseverance is often essential to success, and even then it is not always attainable. Thus we read of a case in the hands of Dr. Thomas and others in which signal failure followed fourteen attempts with the taxis. When the tumor is hopelessly irreducible, it is not only a source of mechanical incon- venience, but of almost incessant hemorrhage, and of muco-serous discharge, draining the system of blood, and keeping the woman constantly at death’s door. Under such circum- stances, she must either abandon herself to her fate, or submit to one of three expedients, all full of hazard : vaginal hysterectomy of the affected organ, abdominal hysterectomy, or an attempt at reduction through an opening in the wall of the abdomen large enough to admit the hand and a dilator to expand the ring of the cervix, the main cause of the diffi- culty ; an operation originally suggested by Sir James Y. Simpson, and twice carried into effect by Dr. T. Gaillard Thomas, once successfully, and once with an unfortunate result. Amputation of the inverted organ through the vagina is generally a fatal pro- cedure, the patient dying from shock, hemorrhage, peritonitis, or pyemia. In an instance in my hands, many years ago, death occurred in two days from inflammation, and in another, in which I assisted Professor Miller, the woman perished from hemorrhage in less than three hours. On the other hand, of 14 cases of excision analyzed by Dr. Lee, only 4 died. No doubt many fatal cases of this operation have occurred that have never been reported, and it is, therefore, impossible to form anything like a correct estimate of its mortality. Of 32 cases of inverted uterus removed by ligature, only 4, or 1 in 8, according to Dr. Lee, died. The operation would, therefore, seem to be much safer than excision. The danger of the procedure is materially lessened by tightening the cord gradually, and also occasionally relaxing it, if it cause much local and general disturbance. When the strangulation is completed, the necrosed portion of the organ should be removed with the knife and scissors, to prevent fetor and irritation. There are no statistics of the ablation of inverted uterus with the ecraseur; nor is it possible, in the existing state of the science, to institute a comparison in regard to the relative safety of the operation as performed by this instrument, and by the ligature. In a case of inverted uterus, complicated with an intramural myomatous tumor, reported in 1871, by Dr. Thomas Hay, of this city, removal was successfully effected with the ecraseur, the patient who was thirty-three years old, making a rapid recovery. Experience has shown that a woman laboring under this affection may sometimes live in comparative comfort, and ultimately die, after the lapse of many years, of some other disease. In a case observed by Dr. Lee, the nature of the complaint had remained unde- tected for a quarter of a century. The woman was then forty-five years of age; and, menstruation ceasing shortly afterwards, there was no further hemorrhage, and the general health improved so rapidly as to render surgical interference unnecessary. In cases in which there is habitual bleeding, the flow maybe greatly moderated by frequent injections of hot water, and the use of tampons wet with Monsel’s solution. Recumbency will also greatly contribute to the relief of the patient, and the use of ergot and iron must not be neglected. I ask the question whether, when the organ is hopelessly irreducible and the subject of frequent and exhausting hemorrhages, it would not be safer to remove the ovaries than the womb, as this would effectually prevent bleeding and cause atrophy of the inverted organ ? 872 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. WOUNDS. The unimpregnated uterus, from its small size and its concealed position in the pelvic cavity, is seldom the subject of wounds, but such accidents may readily happen in the gravid condition of this organ, especially after it has ascended above the pubes. The lesion is usually inflicted with a knife or sharp piece of wood, and instances are recorded in which it was caused by the horn of an infuriated cow. Gunshot injuries of the uterus are uncommon. The Cassarean section affords the best example of an incised wound of this organ. It would be difficult, if not impossible, to diagnosticate a wound of this organ in its empty state, but such a lesion may, in general, be easily detected during pregnancy, by the escape of the amniotic liquor and the profuseness of the hemorrhage; besides, the accident might be attended by such an amount of injury of the walls of the abdomen as to afford an opportunity for direct inspection, as, for example, when a woman has been gored by a cow, or the pelvis has been ripped open by machinery or by the teeth of an animal. The great sources of danger in wounds of the uterus are hemorrhage and peritonitis. The former, which may be immediate or secondary, may depend upon the injury sus- tained by the organ itself, or upon mischief inflicted upon the foetus, or the foetus and placenta. In a case related by Devaux, the woman speedily perished from copious hemorrhage caused by the knife having penetrated the child’s chest. Death from per- itonitis usually comes on at a period varying from three to five days. If it were not for these occurrences, the probability is that few patients would die from such wounds, as they often readily unite by the first intention, as is shown in the Cmsarean operation. The treatment is governed by the general principles of practice. If the gravid organ has been penetrated, its contents should be removed either through the abnormal open- ing or by the natural route, after which the fluids in the pelvic cavity should be carefully sponged up, and the rent in the abdomen approximated by the interrupted suture, in the same manner as in wounds of the intestines. The opening in the uterus promptly closes of its own accord. The after-treatment is strictly antiphlogistic. The urine is drawn off from time to time with the catheter. LACERATION OF THE CERVIX. Laceration of the neck of the womb, consequent upon parturition, is of frequent occur- rence, and from the malign influence which it exerts when neglected or improperly treated upon the part and system, is well calculated to enlist the sympathy of the surgeon. Although attention was first prominently directed to this lesion by Sir James Y. Simpson, it remained for Dr. Thomas Addis Emmet, to place the subject in its proper light before the profession, as he did in two elaborate papers, published, respectively, in 1869, and 1874. The substance of these contributions, strengthened by additional observations, was afterAvards reproduced in his very able treatise on gynecology. The accident is most common in primipara; Emmet, indeed, doubts whether a Avoman can give birth to her first child Avithout some laceration of the cervix, and judging from the statements of certain gynecologists that they have treated such cases, not by dozens, but by hundreds, one is forced to conclude that the lesion is of frightful frequency. In former times—thirty, or forty years ago—such an occurrence was very uncommon, and it Avould probably still be so, if women during their pregnancy Avere treated as they Avere in those days. A stout, hale Avoman, especially if pregnant with her first child, Avas sure to be bled during the early stage of labor. The loss of a pint of blood, folloAved by a full anodyne, usually so thoroughly relaxed the parts as to prevent any accident of this kind. Nothing Avas heard or seen of lacerated wombs, perineums, or vesico-vaginal septums, so common at the present day. Now, no is bled, and every fourth, fifth, or sixth case of midwifery is subjected to the use of the forceps. Is it any wonder that, as Emmet affirms, hardly any woman gives birth to her first child Avithout some laceration of the cervix? That such accidents are occasionally unavoidable is unquestionable; but I must express my conviction that they would be incomparably less common if women Avere more frequently bled, and the forceps less frequently applied. Ignorance and haste too fre- quently do this direful work Apart from injury inflicted Avith the maladroit use of the forceps, manual delivery and precipitate labor, are undoubtedly the most common causes of laceration of the cervix. Nothing is more easy, especially in a first labor, than for the cervix to give way Avhen the CHAP. XVIII. LACERATION OF THE CERVIX. 873 os is in a rigid, unyielding condition, and the body of the organ in a state of violent con- traction. Premature evacuation of the amniotic liquor, carcinoma of the cervix, the presence of cicatricial tissue, and softening from long continued ulceration, may be enumerated as so many predisposing causes of the occurrence. The form and extent of the injury are subject to much diversity. Thus, the laceration may be partial or complete, affect one side or the other, be bilateral or antero-posterior. Emmet finds that laceration is most common in the middle line, and that the anterior lip suffers more frequently than the posterior. The rent, which is sometimes multiple, stellate, or very irregular, may extend through the entire length of the cervix, and even into the bladder, terminating, in this event, above in a cul-de-sac, admitting of an escape of urine. The existence of such a lesion may be suspected, when, after the safe removal of the placenta, and the thorough contraction of the uterus, there is unusual, troublesome, or persistent hemorrhage from injury of the vessels, and the diagnosis will be confirmed, if, upon the introduction of the finger, the cervix be found to be in a flap-like, knobby, or tuberculated condition. The most certain means, however, of removing all doubt upon the subject is to place the patient in the prone position, and to expose the parts with the duck-bill speculum. Mere ocular inspection with the aid of the ordinary instrument seldom answers the purpose. In the milder forms of such an accident the parts frequently heal spontaneously, or with the merest attention to cleanliness, during the time which is usually allotted to rest after confinement, or before the patient resumes her accustomed occupation. When the lace- ration is more severe, or of a really aggravated nature, great suffering, local and consti- tutional, is experienced, and, unless the case be properly treated, the woman is sure to become a permanent invalid. Conception may, it is true, sometimes occur, and the full term be reached ; still, the health always remains more or less disordered. In the chronic forms of the affection, the cervix is in a state of habitual engorgement and irritation; the Nabothian glands are greatly enlarged and cystiform, or enlarged and indurated, feeling like so many shot; the mucous membrane is of a deep red or purple color, and more or less everted ; the parts are exquisitely sensitive to the touch; and the neck of the womb is not unfrequently larger and heavier than the body. Leucorrhoea, neuralgic pains, and pelvic cellulitis are, under such circumstances, common consequences, along with difficulty in walking, pains in the back and loins, and more or less constitutional disturbance, the symptoms often betraying an hysterical tendency. Insomnia, dyspepsia, and excessive nervousness are common occurrences. If, in such a condition, a superficial examination be made, the observer will, probably, conclude that the case is one simply of ulceration, hypertrophy, or excessive engorgement of the cervix. To determine the true nature of the case, the exploration must be thorough. The operation for the cure of this lesion, technically called trachelorraphy, is generally sufficiently simple; but it should not, as a rule, be undertaken without some preliminary treatment. The general health should be seen to, and an attempt made to relieve the engorged, inflamed, and hypertrophied condition of the cervix by repeated punctures and scarifications, and by the application, in the intervals, of astringent remedies, as strong solutions of acetate of lead, tannic acid, or sulphate of alum, kept constantly in contact with the parts on lint or cotton. Hot water injections often afford great relief. Fig. 684. Hawk-bill Scissors. The operation consists in paring the affected surfaces with the knife and scissors, a convenient form of the latter instrument being that of Skene, fig. 684, and in approxi- mating them with wire, silk, or catgut sutures, passed with short, sharp-pointed needles, DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII, held in appropriate forceps, from three to five being generally suffici- ent, as seen in fig. 685, modified from Thomas. The mucous membrane corresponding with the canal of the cervix must be left intact. The ope- ration will be greatly facilitated if, the woman being in the prone posture, the parts be dilated with the duck- bill speculum, and the womb well drawn down with a volsella, stout tenaculum, or tenaculum-forceps, fig. 686; or, as practised by Dr. Ellwood Wilson, the cervical canal may be transfixed with a stout, double liga- ture, which, being drawn down by a blunt hook and divided, leaves a loop on each side, by which the anterior and posterior lips of the rent are effec- tually brought under the control of the surgeon. The free use of hot water, or Pagliari’s styptic, will assist in arrest- ing hemorrhage. When the bleed- ing is troublesome, it will be well to pass the first suture through the vaginal tissue a short distance below the point of lacera- tion, so as to compress the circular artery, or its main branch. The after-treatment involves nothing peculiar. The sutures should not be removed before the ninth day, and the patient should not be allowed, as a rule, to rise under a fortnight. The urine is drawn off. if necessary, with the catheter, the bowels are relieved Fig. 685. Sutures passed after Denudation of Cervix. Fig. G86. Tenaculum Forceps. with enemas, and the vagina is frequently syringed with weak carbolized water, or chlori- nated sodium. The diet, for the first week, should be rather light. Peritonitis and cellulitis occasionally, although rarely, follow the operation. A pessary may sometimes be advantageously worn after recovery from the immediate effects of the operation. INFLAMMATION AND ULCERATION. The uterus is liable to inflammation, both in the married and in the single female, but much more frequently in the former than in the latter. The disease may attack any por- tion of the organ, or it may be limited to the lining membrane, the parenchymatous sub- stance, or the peritoneal covering, or all these structures may be involved simultaneously, together with the venous and absorbent trunks. Inflammation of the lining membrane—the endometritis of authors—occurs in two varieties of form, the acute and the chronic, and may be limited either to the neck or the body of the organ, although in many cases it is diffused over both. It is characterized by the same phenomena as inflammation of the mucous textures in other situations. The redness, which is of a deep shade, is often spread over a large extent of surface, and may, in violent cases, be accompanied by small ecchymoses, with an escape of blood on pressure. The mucous follicles, especially those about the mouth of the uterus, are more or less enlarged, and there is usually a very notable increase of the natural secretion. In some instances pus is deposited, and continues to be discharged for a considerable period. An CHAP. XVIII. INFLAMMATION AND ULCERATION OF THE UTERUS. 875 effusion of plastic matter is also occasionally observed, but chiefly when the disease invades the lining membrane of the body of the organ. Abscess of the uterus, a very rare disease, may arise from various causes, of which the most common, perhaps, is injury inflicted during parturition. It is characterized by severe pain, of a throbbing, pulsatile character, and the ordinary phenomena of inflammation, local and constitutional, in an aggravated degree. The diagnosis can only be determined with the speculum. Relief is afforded by early and efficient evacuation, if the matter is within reach. Dr. Graily Hewitt has reported a unique example of abscess of the womb, complicated with a traumatic aneurism of the uterine artery, which freely communicated with the abnormal pouch, one of large size, and thus gave rise to several severe attacks of hemor- rhage, in one of which the woman died. Ulceration of the uterus is most common between the ages of thirty and forty, in mar- ried women. It usually attacks the lips and neck of the organ, in every variety of form, from the slightest abrasion, merely involving the mucous lining, to a cavity several lines in depth. The resulting sore may be of a circular, oval, or linear shape ; or it may occur as a crack, chap, or fissure. Its edges are sometimes very abrupt, as if a depression had been made into it with a punch. The bottom of the ulcer is smeared with unhealthy pus, incrusted with lymph, or studded with granulations. The surrounding structures are red, tender, and often quite indurated. In cases of long standing, or of unusual severity, the lower extremity of the uterus is excessively engorged, considerably enlarged, and greatly altered in its figure, often exhibiting a knobbed, clubbed, or pouting appearance. Occasionally the affected structures, instead of being indurated, are abnormally soft, or hard at one point and soft at another. In the more aggravated forms of ulceration, the organ increases in weight, and thus becomes a cause of its own prolapse, by the dragging effects upon its ligaments. The concomitant discharge is subject to the greatest possible variety, both as it respects its quality and quantity. Thus it may be thick and yellow, thin and sanious, bland or irritating, scanty or abundant, mixed with mucus, free from odor or more or less fetid. Ulcers of the uterus may be acute or chronic, simple or specific. The simple sore usu- ally arises without any assignable cause, and often continues for months and years, mak- ing, perhaps, in the mean time very little progress. The syphilitic ulcer is distinguished by its excavated form, its hardness, and the copper-colored appearance of the adjacent parts; the chancroidal, by its multiple character, abundant discharge, and autoinocutable ten- dencies. Inflammation and ulceration of the uterus often coexist with vaginitis. The most com- mon symptoms are, a discharge of thick, yellow, purulent, or muco-purulent matter, a feel- ing of w’eight and fullness in the lower part of the pelvis, tenderness on pressure of the hypogastrium, pain and aching in the sacrolumbar region, and dragging, sickening sensa- tions in the groins and back, especially during exercise. The general health, at first unaffected, is sure to suffer as the disease progresses. The menstrual function is apt to be disordered; and, although conception is not impossible, even when there is considerable ulceration, yet a female thus affected is extremely liable to abort or miscarry. The diag- nosis can only be satisfactorily determined by a thorough exploration with the speculum. The treatment of inflammation of the mucous membrane of the uterus, in its milder forms, is generally very simple, the disease usually promptly yielding to the ordinary antiphlogistic remedies, as light diet, an active purge, recumbency for a short time, and injections of acetate of lead, Goulard’s extract, tannic acid, alum, or zinc. If the disease is obstinate, or complicated with ulceration, a few leeches may be necessary, followed by the application of solid nitrate of silver, or, what I prefer, dilute acid nitrate of mer- cury, repeated every fourth or fifth day, the parts being frequently syringed with cool or tepid water, medicated with some astringent substance. Tampons of cotton, cliarpie, or lint, wet with tannic acid and glycerine, in the proportion of two drachms to the ounce, and retained in immediate contact with the inflamed surface, often rapidly reduce the morbid action. Solutions of alum, similarly used, are often highly serviceable. They should be changed at first every twelve hours, and afterwards once a day. When leeches cannot be obtained scarification should take their place. If caustic be used too often or too freely, harm instead of benefit will result, and the case be much longer in getting well. The patient should be rigidly recumbent during the treatment. If the inflamma- tion extends into the cavity of the uterus, gentle cauterization will be required, followed, after the violence of the morbid action is subdued, by the use of small tents, medicated with iodoform, or some astringent lotion, and inserted once every four-and-twenty hours. A granular condition of the neck and mouth of the uterus occasionally exists, the. 876 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVI II . mucous membrane being thickly studded with bodies similar to those so frequently found on the eyelids. The disease, which is often associated with ulceration, laceration, or both, is generally a consequence of chronic inflammation, and is always attended with more or less muco-purulent discharge. The best local remedy is chromic acid, used in the same cautious manner as when applied to warty excrescences of the penis and vulva, repetition being effected every fourth or fifth day, and the affected surface kept constantly covered in the intervals with cotton wet with a strong solution of tannic acid, lead, or alum, the latter generally yielding the best results. When the granulations are very large and dense they may be removed, as a preliminary step, with the knife or scissors, seared with the hot iron, or freely cauterized with solid nitrate of silver. In the milder cases applications of perchloride of iron, powdered alum, and compound tincture of iodine generally do good service. Strong injections of alum, lead, or tannic acid must be used at least thrice daily if there should be much leucorrhoea. When the parts are much congested a cure can seldom be effected without repeated punctures and scarifications. Another effect of chronic inflammation of the uterus is an extraordinary development of its mucous follicles, particularly conspicuous about the mouth and lips of the organ, where the Nabothian glands are sometimes as large as a hemp-seed, or even a small pea, dense, almost gristly, and of a white, grayish color. The intervening struc- tures are generally tumid, red, morbidly sensitive, and disposed to bleed. Occasionally the enlarged glands are transformed into cysts of considerable size, filled with a pale, tremulous substance, easily re- moved by pressure. The appearance of these en- larged follicles, in the different stages of their pro- gress, is well shown in fig. 687. The disease is always attended with induration and thickening of the neck and lips of the uterus and a tolerably pro- fuse discharge of muco-purulent matter. The most effectual treatment is repeated and thorough scarifica- tion of the affected structures, along with leeching and the application of solid nitrate of silver ; or, what I have generally found more beneficial, the pure tinc- ture of iodine. Inflammation of the body and serous covering of the uterus is most common in females during the first eight or ten days after parturition. It sometimes betrays an epidemic tendency, and rapidly passes into suppuration, softening, or even gangrene. The pus that is poured out, in such cases, may be situated in the parenchymatous struc- ture, in the uterine cavity, the subserous connective substance, between the folds of the broad ligaments, or, finally, in the venous and absorbent trunks, or simultaneously in all these parts. In most of these localities it occurs in the form of isolated corpuscles; but cases are observed in which it is collected into little abscesses, which, sooner or later, burst into the vagina, rectum, pelvis, or urinary bladder. The pus is generally blended with a good deal of lymph, and is sometimes highly offensive. The lesion may originate in, and be limited to, the veins, constituting what is called uterine phlebitis; in the great majority of cases, however, the parenchymatous structure participates in the inflammation,"assuming a dark, livid aspect, at the same time that it loses its natural consistence. Serum and pus may also be found in the subserous connec- tive tissue ; while the peritoneal investment is sometimes covered with thick patches of lymph. The veins themselves are always much enlarged, and filled with pus, clots of blood, or plugs of plasma. The disease often extends along the venous trunks of the pelvis to those of the abdomen, or even to those of the inferior extremities ; and very frequently the absorbent vessels are similarly circumstanced, being greatly augmented in volume, and infiltrated with enormous quantities of purulent matter. The causes of uterine phlebitis are not always very evident. In some cases it appears to result from violence done in the extinction of the placenta, while in others it may be traced to the effects of cold and moisture, to the absorption of septic matter, or to some peculiar noxious condition of the atmosphere. In general, the disease exhibits all the evidences of erysipelas, or pyemia, both as it respects its pathology and symptoms. Ushered in by rigors, or chills, alternating with flushes of heat, it soon assumes a typhoid character, the pulse becoming small and frequent, the tongue dry and parched, and the surface covered with profuse, clammy sweats. The abdomen is exquisitely tender on pressure, the stom- Fig. 687. Follicular Disease of the Uterus. CHAP. XVIII. HYPERTROPHY OF THE UTERUS. 877 ach is irritable, the mind wanders, the milk is suppressed, and the lochial discharge is excessively fetid. The treatment must be conducted upon the same principles as in pyemia and erysipelas. Great attention is paid to cleanliness and ventilation ; free use is made of deodorants ; the syringe is employed three or four times a day; leeches and fomentations are applied to the abdomen ; the bowels are locked up with opium, to prevent irritation of the peri- toneum ; and support is afforded with quinine, iron, milk punch, and nutritious broths and soups. HYPERTROPHY. Hypertrophy of the uterus occurs in two varieties of form, the general and the partial. In the first, the affection is usually most conspicuous in association with myomatous tu- mors, in which it is sometimes enormous. Thus in a specimen in my possession, the walls of the organ are nearly two inches in thickness, and of a firm, dense consistence, grating under the knife. Its cavity is of extraordinary size, and several small tumors are seen projecting from its outer surface. The hypertrophy is sometimes confined to the lips of the uterus, which, especially the anterior, become thick, dense, and stumpy. The immediate cause of hypertrophy of the uterus, is, evidently, in most cases chronic in- flammation attended with interstitial new formations. How far passive congestion may aid in its production it would be difficult to decide. My conviction is, that congestion in any form or degree cannot exist long without running into inflammation. Among the more common exciting causes may be mentioned displacement of the uterus, sexual abuses, disorder of the ovaries, habitual constipation, straining from obstruction of the blad- der or rectum, malarial diseases, and derangement of the digestive apparatus. The affec- tion often continues for a long time without apparently any disposition either materially to advance or to recede. The diagnosis is readily ascertained by touch and inspection. If the organ is unusually large, it may be distinctly felt in the hypogastric region, and may occasion serious inconvenience by its weight and pressure. The affection, which is almost invariably attended with more or less prolapse, must not be confounded with carcinoma. The treatment must be conducted antiphlogistically; by leeches, scarification, and cau- terization of the neck and mouth of the organ, and by strict attention to the diet, bowels, and recumbency. The exhibition of mercury will be of no particular avail, except in so far as it may assist in improving the general health ; but advantage will be derived from the internal use of iodide of potassium, and of chloride of ammonium, in doses of five to ten grains, three times a day. In partial hypertrophy the disorder, affecting chiefly, if not exclusively, the neck of the organ, consists essentially in elongation and thickening of its free extremity. The enlargement, which is sometimes congenital, is attended with more or less induration, and usually occurs as a conical body, not unlike a cow’s nipple, with the base uppermost. When the neck is uncommonly long and thick it fills the entire vagina, extending as low down as its mouth, and forming a tumor which can be easily felt and pushed about with the finger. The angle which it forms with the body of the uterus is variable; in most cases it is more or less oblique, and in some very acute. The body of the uterus generally oc- cupies its normal position, and retains its normal size and shape. Cases, however, occur in which the affection is associated with prolapse, or prolapse and retroversion, and gen- eral hypertrophy. The more aggravated cases are always attended with pain in the pel- vic and sacrolumbar region, bearing down or dragging sensations, leucorrhcea, and disor- der of the general health. Dysmenorrhoea and monorrhagia are not uncommon. Sterility is a frequent consequence. The immediate cause of hypertrophic elongation of the cervix is hyperemia or conges- tion, followed, at first, by subacute, and gradually by chronic inflammation. Under the influence of the irritation thus engendered, the muciparous glands gradually enlarge, an unnatural secretion, generally of a muco-purulent character, is set up, the mucous mem- brane of the cervical canal undergoes eversion, and the cervix, red, vascular, and sensi- tive, by degrees, assumes the characteristic condition above ascribed to it. A prominent exciting cause of the complaint is injury sustained in parturition. What is known as cicatricial hypertrophy of the cervix generally arises in this manner. The treatment of this variety of hypertrophy, in its earlier stages, is by leeching, scarification, and cauterization with nitrate of silver, conjoined with recumbency and as- tringent injections, of which alum, tannic acid, acetate of lead, and oak bark are the very best, repeated twice a day ; or, what is more effective, the fluid may be kept constantly 878 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. in contact with the affected parts by means of cotton or lint. Tincture of iodine, espe- cially that known as Churchill’s, may also be employed with advantage. Local depletion can seldom be dispensed with. The general health, if at fault, must be rectified. When these means fail, or the case is hopeless, excision is the only chance of relief. The operation, although comparatively simple, so far as its execution is concerned, is not without risk, and, should, therefore, never be undertaken without due consideration and proper preparation of the system. Not a few cases have been recorded in which it ter- minated fatally. Two reasons may justify operative interference, an urgent desire for offspring, and constant, or increasing suffering, sadly interfering with the woman’s happi- ness and marital relations. The chief source of danger from the operation, whether performed with the knife, the scissors, the ecraseur, or the galvano-cautery, are shock, hemorrhage, primary and secondary, injury of Douglas’s cul-de-sac, followed by peritonitis, pelvic cellulitis, ery- sipelas, and pyemia. The bladder may also be damaged, if great care be not taken. Tetanus has been known to be caused by the operation. The easiest and safest operation is excision with the knife and curved scissors, the woman lying on her abdomen, with the vagina well expanded, and the uterus drawn down in the usual manner. The elongated and deformed cervix being steadied with a stout volsella, the mucous membrane is peeled off for some distance below the point where the separa- tion is to be effected, a bistoury or small scalpel being the best instrument for this purpose. The parts are divided as high up as may be deemed necessary, an inch to an inch and a half generally sufficing. Any bleeding vessels should at once be secured by torsion, or the ligature. When the cervix is much engorged and enlarged, the hemorrhage will be sure to be more or less copious, and cannot then always be easily controlled. To ren- der the operation as bloodless as possible, an Emmet uterine tourniquet maybe applied, or a stout, gum-elastic, ligature may be thrown around the upper portion of the cervix, pre- viously transfixed with two short, thick pins, passed at right angles. The operation being completed, the mucous flap is carefully stretched over the extremity of the stump, and confined, as the case may be, with six, eight, or ten sutures, passed in such a manner as to keep the surfaces in accurate apposition. This procedure, originally practised by Sims, as delineated in fig. 688, from Emmet, is a vast improvement over the Fig. 689. Fig. 688, Ellwood Wilson’s Needle for Sewing up the Wound after Excision of the Cervix. Fig. 690. Stump after Amputation of the Cervix. Flaps Secured by Sutures. old method of treatment, as it prevents much annoyance and inconvenience, and greatly expedites the healing of the wound. For inserting the sutures, which may be of silk or silver, the best contrivance with which I am acquainted, is Dr. Ellwood Wilson’s curved needle, fig. 689 ; nothing, indeed, could be more convenient, or better adapted to the object. Fig. 690, also from Emmet, illustrates the appearance of the parts after the flaps are approximated by sutures. CHAP. XVIII. STRICTURE AND OCCLUSION OF THE UTERUS. 879 Removal of tlie altered cervix may be effected with the ecraseur ; but the operation, while it is often followed by more or less copious hemorrhage, is objectionable because of its liability to inflict serious injury upon Douglas’s cul-de-sac and the urinary bladder, on which account it is often followed by peritonitis, cellulitis, and other grievous effects. Besides, it is more difficult to remove just the precise amount of substance; and, worse perhaps than all, it is impossible to form a covering for the stump, which is, consequently, obliged to heal by granulation. Amputation of cervix is sometimes performed with the galvano-cautery ; it is said that the operation is attended with less risk than when it is performed with the knife, scissors, or ecraseur, that the shock is not so great, that the bleeding is more easily controlled, and that the wound always heals very kindly. My experience is too limited to justify me in expressing any opinion on its merits. The treatment after these operations is conducted upon general antiphlogistic principles. Recumbency must be observed for a long time after the primary effects have been sur- mounted ; the utmost attention is bestowed upon cleanliness, and any untoward symp- toms are met as they arise. Special care is taken to preserve the new os in a patent condition, and to prevent the ingress of irritating fluids into the uterine canal. For this purpose a linen tent should always be inserted before using injections. The sutures must not be removed under eight or ten days. STRICTURE AND OCCLUSION—RETENTION OF THE MENSTRUAL FLUID. The mouth of the uterus is sometimes the seat of stricture, being preternaturally small, or so much contracted as scarcely to admit a silver probe, or even a hog’s bristle. The lesion is often congenital, but in most cases it is brought about by inflammatory irri- tation, in the same manner as stricture of the urethra. A similar condition is sometimes observed in the cavity of the neck of the uterus. The canal, in one of my specimens, represented in fig. 691, is com- pletely occluded, for the distance of nearly an inch, by the adhesion of its two walls. A stricture in either of these situations would be a cause of sterility and of painful menstruation, as well as of retention of the menstrual fluid. Stricture of the uterus must be managed upon the same general principles as stricture of the urethra and other mucous outlets, by a series of gradually enlarging bougies of compressed sponge, sea-tangle, or elm bark, or the dilator of Wilson, fig. 678, p. 866, aided, in obstinate cases, by free incisions with a lithotome cache, and Atlee’s liystero- tome, or a narrow, probe-pointed bistoury. Any hemorrhage that may follow the opera- tion may always be promptly arrested with a tampon of cotton wet with Pagliari’s styp- tic or a solution of subsulphate of iron. The'treatment is usually tedious and troublesome, especially when the contraction is very tight. Danger, too, often attends, and, in many cases, can be averted only by the greatest care. A woman with a stricture of the uterus, injudiciously treated, may easily fall a prey to peritonitis. Occlusion of the mouth of the uterus is always the result of inflammation and of an effusion of plastic matter gluing together the lips of the organ. The accident commonly occurs soon after delivery, and is very liable to be eventually followed by retention of the menstrual fluid, causing the womb to expand in every direction, so as to form a large, globu- lar, or ovoidal tumor, extending above the umbilicus, fluctuating distinctly under pressure, smooth on the surface, free from pain, and of a uniform consistence throughout. The general health commonly remains for a long time nearly natural, although ultimately it is very prone to suffer. Severe uterine pains, of an expulsive and bearing down character, are usually experienced at every return of the menstrual period. This circumstance, to- gether with the absence of menstrual fluid, and the peculiar nature of the abdominal tumor, constitutes the most important and reliable diagnostic feature of the complaint. In doubtful cases the exploring needle is used. The treatment consists in evacuating the pent-up fluid,—which is generally black and grumous, like treacle, or partly liquid and partly solid,—with a small trocar or bistoury, introduced at the natural site of the orifice of the womb, or, if this cannot be found, as near to it as possible. The contents should be allowed to drain off gradually, so as to Fig. 691. Stricture of the Uterus. 880 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. afford the uterus an opportunity of contracting, and thus preventing the evil consequences that might arise from the ingress of the air, or from the escape of some of the san- guineous fluid into the abdominal cavity along the Fallopian tubes, which, under such circumstances, are often more or less dilated. A number of cases of death from perito- nitis have occurred from neglect of this precaution, although in four in my own hands in which the opposite course was pursued no inconvenience whatever ensued, lieclosure of the puncture is prevented by the judicious use of the tent and bougie. Contraction of the uterus, after such an operation, should be encouraged by the free use of ergot. The same cautious procedure, in regard to the evacuation of the menstrual fluid, should be adopted when the retention depends upon the existence of an imperforate hymen, or upon the presence of a fibroma or of some other morbid growth. DYSMENORRHCEA. Dysmenorrlioea, or painful menstruation, is a very common affection, both in single and in married women, but especially the former. It may depend upon various causes, some of them of a mechanical and others of an ordinary character, as a narrow and contracted state of the uterus, the presence of a polyp or myomatous tumor, the effects of cold, ova- rian disease, anemia and disorder of the general health, however induced. In many of the cases that have come under my observation, I have been led to believe that it was of a rheumatic character; a view supported by the agonizing lumbago which so generally attends it, and the relief afforded by antirheumatic remedies. However this may be, the disease is commonly of an inflammatory character, and is frequently, if not invariably, attended with a discharge of plastic matter and coagulated blood, the proper menstrual secretion itself being very sparing. The diphtheritic membrane, which is seldom thick or firm, generally moulds itself to the inner surface of the uterus, and is expelled either piecemeal or entire, the period required for its extrusion varying from a few hours to a number of days. The treatment is palliative and radical. The former, which has reference to what should be done during the menstrual attack, consists in the free use of anodynes, either by the mouth, hypodermically, or by the rectum, with the application of strong veratria ointment to the sacrolumbar region. If plethora exist blood is taken from the arm, and the system is relaxed by tartar emetic and morphia, aconite, Dover’s powder, and the hip- bath. To prevent a recurrence of the suffering, and afford, if possible, permanent relief, I have found nothing so effectual as the use of the wine of colchicum, in the dose of one drachm in union with a fourth of a grain of morphia, every evening at bedtime, com- menced about seven days before the expected period, and perseveringly continued for several consecutive weeks. If the patient is anemic the treatment should be associated with the administration of tonics, as iron and quinine. Great relief generally follows from the application of a large opium and aconite plaster to the sacrolumbar region, frequently renewed. When the affection is dependent upon an unusually tight orifice of the uterus, interfering with the discharge of the menstrual fluid, coagula, or deciduous membrane, the most effectual and speedy remedy is the free division of the stricture, dilatation being afterwards maintained with a suitable tent, inserted from time to time to prevent reclosure, to which there is always a remarkable tendency. The fact that this operation, no matter how thoroughly performed, or frequently repeated, often fails to afford permanent relief, is an indubitable evidence that dysmenorrlioea is not, as some have contended, always due to mechanical obstruction of the womb. NEURALGIA. Neuralgia of the uterus is not uncommon, and is occasionally met with very soon after the age of puberty, especially in nervous girls, in connection with dysmenorrlioea. Mar- ried women, however, are most subject to it; and it is liable to occur both in the empty and gravid state of the organ, although much more frequently in the former. Sometimes it takes place soon after delivery. Being generally associated with neuralgia in other parts of the body, it is either strictly periodical in its attacks, like the paroxysms of an intermittent fever, or, as is more commonly the case, it shows itself as a persistent affec- tion, liable to frequent exacerbations. The exciting causes are not always appre- ciable, although usually it is dependent upon disordered menstruation, organic disease of the uterus, vagina, ovary, bladder, or rectum, derangement of the digestive apparatus, or lesion of the cerebro-spinal axis. In many instances it is directly traceable to the in- CHAP. XVIII. DROPSY OF THE UTERUS. 881 fluence of malaria, and in that event its attacks are nearly always distinctly paroxysmal, recurring with considerable regularity once .or twice a day, or once every other day. The most prominent symptoms are sharp, darting, or shooting pains in the uterus and pelvic region, extending into the limbs, the back, hip, groin, and abdomen, which, to- gether with the uterus, is often exquisitely tender and sore on pressure. Not unfrequently the pain is of a dull, heavy, aching, gnawing, or burning nature. However this may be, it is always aggravated by fatigue, exposure to cold, disorder of the digestive organs, mental trouble and irregularity of the menses. In most cases it is attended with a bear- ing-down sensation, as if the organ were about to be expelled from the pelvis. I have repeatedly seen cases where the patient was unable, for weeks together, to maintain the erect posture, or even to walk across the floor, on account of the exquisite morbid sensi- bility of the affected structures. In the treatment of this affection, which is often exceedingly obstinate, and even in- tractable, one of the first and most important objects is to remove, if possible, the exciting cause, when the pain will often disappear of its own accord. The diet, bowels, and se- cretions should claim special attention in every case. In the malarial form of the malady, quinine in liberal doses, either alone or in union with arsenic and strychnia, constitutes the most valuable remedy, and the same articles are frequently of great benefit in the more ordinary attacks. Colehicum, in drachm doses at bed-time, with a third or half a grain of morphia, is also a remedy of much efficacy. During the violence of the paroxysm relief is sought in recumbency, the hot sitz-bath, hot fomentations to the abdomen and genitals, anodyne injections or suppositories, and the hypodermic use of morphia. A cotton tampon saturated with a strong solution of morphia and tincture of aconite in glycerine, and placed in close contact with the neck of the womb, often acts like a charm. COLLECTIONS OF GAS. Air now and then collects within the cavity of this viscus, constituting the disease which has been described by pathologists under the name of emphysema, physometra, and tympanites. How the air is formed is still a disputed point. In many cases it may be distinctly traced to the decomposition of effused fluids, as blood, serum, or pus ; in others, it is apparently a product of secretion, brought about by some morbid condition, the precise nature of which is unknown. These accumulations may take place at any period of life, in married females, and is generally an evidence of previous conception. They may also occur in single women, as a result of organic disease. When considerable, they cause the womb to expand and rise up in the abdomen, as in pregnancy, with which it may easily be confounded. After the flatus has existed for several months, the uterus commonly makes an effort to dislodge it, expelling it with a noise somewhat similar to that occasioned in eructation. The diagnosis is readily established by the pecular elasticity and resonance of the tumor, the absence of fluctuation, and the occasional escape of flatus from the vagina. The treatment consists in evacuating the air with a trocar, and injecting afterwards some stimulating fluid, as a very weak solution of nitrate of silver, iodine, or chlorinated sodium, for the purpose of changing the condition of the mucous membrane of the uterus. If putrid matter be present, it must be removed. Any interference for the relief of such an affection must be conducted with the greatest care and judgment, otherwise serious injury may be inflicted. DROPSY. Large quantities of water—-ten, fifteen, and even twenty quarts—have been known to accumulate in the cavity of the womb, chiefly in young and middle-aged married women. The affection, however, is extremely uncommon, and is always connected with closure of the mouth of the organ, caused by previous inflammation, malignant disease, or some morbid growth. The fluid is generally clear and limpid like the serum of the blood, which it also resembles in its chemical properties. In some cases it is thick and turbid; it has also been found of the color and consistence of coffee grounds, probably from the admix- ture of sanguineous matter. The tumor thus formed often similates pregnancy, is painful on pressure, and slightly fluctuates under the fingers. The disease, technically called hydrometra, is occasionally connected with utero-gestation, of which it then forms one of the most distressing complications. Its true pathology is is still involved in obscurity. 882 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. In all probability it is dependent upon chronic inflammation of the lining membrane of the womb, the character of which is changed into a kind of adventitious serous structure. The affection, which is always slow in its progress, is characterized by the existence of a tumor, of a rounded shape, which, commencing lowr down in the pelvis, gradually as- cends towards the umbilicus, occupying the middle line. It is soft and fluctuating, dull on percussion, of uniform consistence, and unaffected by position. Its identity with the uterus is easily established by vaginal examination, the neck of the organ being effaced, and the part distinctly fluctuating. When the uterus is not completely occluded, there is occasionally a partial escape of serous fluid. Menstruation is arrested, and the general health, although, perhaps, unaffected in the earlier stages of the disease, always seriously suffers in the end. The only remedy for this complaint is tapping, the operation being performed at the natural site of the orifice of the uterus, or, if this cannot he found, at the most protuberant part of the swelling. The fluid being evacuated, patency of the opening is maintained with a canula, or an elastic bougie. If reaccumulation occur, the fluid is again evacuated, and an attempt made to destroy the secreting surface of the organ by the injection ol a small quantity of a weak solution of tincture of iodine. Tapping above the pubes, in this complaint, except with the aspirator, is objectionable, as it might he productive of fatal peritonitis. HEMORRHAGE. Of hemorrhage of the uterus I shall speak only as it affects the organ in the unimpreg- nated state. The occurrence is most common in married females, about the cessation of the menstrual function, and it is observed in every state of the constitution, in the strong and plethoric, as well as in the feeble and relaxed. A great variety of causes may give rise to it; hut by far the most frequent is that peculiar state of the system which accom- panies the disappearance of the menses, together with ulceration of the mouth of the womb, or the presence of some adventitious growth. Disease of the ovary also powerfully predisposes to this lesion ; and there are some females who are naturally, or from habit, so prone to it that the most trifling exertion is sufficient to bring on an attack. The dura- tion of the hemorrhage varies from a few days to several weeks. When dependent upon structural disease, or the presence of a polyp, adenoma, or fibroma, the blood often comes away suddenly, in a gush, which continues, at intervals, for a few hours, and then ceases. The existence of hemorrhage of the uterus, in the unimpregnated state, especially if it be chronic, should always induce a careful exploration of this organ, with a view of ascer- taining the nature of the exciting cause, which, unless the woman has reached the change of life, will generally be found to depend upon the presence of some tumor, the removal of which promptly arrests the disease. When the hemorrhage depends upon atony of the uterus, associated with an anemic state of the system, a course of chalybeate tonics, in union with quinine and ergot, and the cool shower-bath are indicated. The bowels are properly attended to, and the diet should be nourishing, but nonstimulating. Strict recumbency must be observed, as the erect posture never fails to aggravate the complaint. If the flow is at all active, acetate of lead, ergot, and opium, or ergot and tincture of iron, are employed, and ice is applied to the hypogastric region. If the organ is deficient in proper contractile power, ergot is freely administered. If a good deal of blood has been already lost, prompt re- course is had to the tampon, consisting of a mass of raw cotton or a piece of sponge wet with a strong solution of alum, Churchill’s tincture of iodine, or, what is much better, of subsulphate of iron, and carefully inserted into the vagina, in contact with the orifice of the womb, retention being aided by a broad compress upon the vulva and a ”|“-ba.ndage- The most unobjectionable plug of all is the colpeurynter, a rubber bag, introduced into the vagina, and distended with air or water. If the ordinary materials are employed, substitution must be affected at least every twenty-four hours. In chronic uterine hemor- rhage, a large blister to the sacrolumbar region often proves beneficial. When the patient is very anemic, extirpation of the ovaries, or of the ovaries and Fallopian tubes, holds out the only hope of relief. Hemorrhage of the uterus, dependent upon the presence of a morbid growth, does not admit of cure without the removal of the exciting cause. MYOMATOUS AND FIBROMYOMATOUS TUMORS. Muscular and fibromuscular tumors of the womb are most common in married, elderly females, and they may occur in its substance, as intramural formations, in its cavity, or CHAP. XVI II. MYOMATOUS TUMORS OF THE UTERUS. 883 on its outer surface beneath its serous covering, as submucous or subserous projections or polyps, or in all these situations either simultaneously or successively, as in fig. 692. Of 74 cases, analyzed by Mr. Thomas Lee, 4 affected the neck of the organ, 22 were seated in the anterior or posterior wall, 18 projected at the exterior and 6 at the interior of the fundus, and 19 ex- tended into its cavity. Their shape is usually spherical; their diameter from the size of a hickory nut to that of a large melon ; their weight from a few ounces to upwards of a hundred pounds, as in the remarkable case reported by the late Dr. Francis, of New York. Formerly described as fibrous or fibroid tumors, these neoplasms, whether of ex- tramural or intramural origin, contain, as was first pointed out by Vogel, smooth muscular fibres in varying pro- portions. When the muscular elements predominate, and are disposed in more or less regular parallel bundles, which may be readily separated, while the in- terstitial connective tissue is soft, loose, sparse, and vascular, imparting to the growth a comparatively soft, elastic con- sistence, a rather uniform fibrous ap- pearance, and a whitish or reddish-white color, on section, the growth may be considered as a myoma. When, on the other hand, the tumor is rich in thick, dense, indurated connective tissue, and the vessels and muscular fibres are poorly developed, it should be classed, histologically, as a fibromyoma. On section, such a growth is found to be composed of strong, closely interlacing, irregularly disposed, or concen- tric fibres, which have a shining white, ten- dinous, or grayish appearance, intermixed with muscular fibres, the color of which is rosaceous or reddish-white. The older the growth, and the more it has the detached or polypoid form, the more does it lose the characteristics of myoma, and assume those of fibromyoma, the purer forms of myoma being of more recent development and hav- ing closer connections with the uterus. The microscopic appearances of the fibromyo- matous tumor are well shown in fig. 693, from Billroth. These growths are liable to certain de- generations, as the fatty, naevoid, cystoid, calcareous, sarcomatous, or carcinomatous. The softer varieties, or myomas, are par- ticularly apt to be the seat of naevoid and cystic changes, the former manifesting itself by great enlargement of its vessels, particu- larly of its veins, through which its struc- ture is rendered similar to that of the caver- nous bodies of the penis, and is endowed with a certain degree of erectility. Under these circumstances the tumor is termed telangiectoid or cavernous myoma. In a case reported by Dr. C. E. Wing, of Boston, a true aneurism existed on the surface of the Fig. 692. Myomatous Tumors of the Uterus, both Internal and External. Fig. 693. Fibromyomatous Tumor of the Uterus. 884 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVI II. tumor, and a false one in its interior. In a tumor of the uterus, observed by Caesar Haw- kins, there was a huge cyst which contained nearly two gallons of tiuid. Analogous cases have been reported by Ilewett, Schuh, Lee, Kiwisch, and others, the cystic myoma thus formed being described by some authors as a distinct neoplasm, under the name of fibrocystic tumor of the uterus. This metamorphosis is not due to the formation of true cysts, lined by a distinct membrane, but to mucoid softening of the interstitial connective tissue, through which spaces or cavities are created in certain portions of the growth, sometimes traversed by bands of tissue, and resembling the cavities of the heart. In some instances it is possible that they may arise from enormously dilated lymph spaces. The younger and smaller spaces are filled with a clear, or straw-colored, sero-albuminous fluid, not unlike normal synovia, while the contents of the older and larger varieties are discolored by blood, and vary in tint from bright red to blackish-brown. The calcareous transfor- mation is by no means rare. Most frequent in the subserous fibrous forms of the affec- tion, it usually manifests itself as an infiltration of the connective tissue of the deeper portions of the tumor, or as a complete petrification of the entire mass. In some instances it almost encases these morbid growths, in the form of a thin, brittle shell, not unlike that of an egg. The deposit consists chiefly of phosphate and carbonate of lime, together with a minute quantity of animal matter. A tumor of this kind is occasionally spontaneously expelled. The carcinomatous and sarcomatous degenerations are uncommon. Only one such tumor may exist in the uterus ; or there may be a considerable number, perhaps as many as six, eight, ten, or a dozen. When large they are usually lobulated, or divided by deep fissures. When seated under the serous covering of the uterus, these tumors often hang by a very slender neck, and they then assume a pyriform shape. They possess very little sensibility, and so long as they remain small, they produce no material change in the form of the uterus, or any particular local inconvenience ; but, when they attain a large bulk, they not only incommode by their weight, but may cause great displacement of the organ, and, by the pressure which they exert upon the bladder and the rectum, seriously interfere with the expulsion of the urine and feces. When they are imbedded in the walls of the womb, or spring from its inner surface, the subjects of them are commonly barren ; or, if they conceive, the uterine tissue is unable to undergo the necessary expansion, and abortion results. More or less copious hemorrhage frequently attends the submucous variety of the myomatous growth, especially when it has an unusually broad attachment. Sometimes a tumor of this kind springs from the base of the womb, whence it ascends into the abdomen, where it may be moved about from side to side, and so simulate pregnancy, or ovarian disease. A case of fibrocalcare- ous tumor communicating with the bladder has been recorded by Dr. Fleming. A good idea of the situation, shape, and mode of attachment of the myomatous tumor of the uterus may be formed by a reference to fig. 692, from a preparation in the Meigs Collection in the Jefferson Medical College Museum. The diagnosis of the myomatous growth of the womb is uncertain, except when it occu- pies the cavity of the organ, and projects down into the vagina, or beyond the vulva, when a careful examination will generally serve at once to reveal its true character. When the tumor is extrauterine, the proper mode of proceeding is to get, if possible, the body of the womb between the left index-finger in the vagina and the right hand upon the hypogastrium. This may generally be readily accomplished, provided the abdominal muscles be previously thoroughly relaxed and the bladder and bowels well emptied. Sometimes valuable information may be elicited by the finger in the rectum. The intra- mural tumor may usually be detected in the same manner as the outer. If pressure be made upon it, it invariably moves in unison with the womb, and a sound, probe, or catheter introduced into the cavity of the uterus will be found to pass over a much wider space than naturally; often, indeed, over a distance of many inches both in length and diameter. Whatever may be the original site of the tumor, whether anterior, lateral, or posterior, its tendency generally is, as it ascends into the abdomen, to assume a more or less central position ; a circumstance of no little importance in regard to the distinction between such a growth and an enlarged ovary. A myomatous tumor seated within the cavity of the uterus is not easily diagnosticated so long as it is small. This is especially the case when it is sessile, or attached by a very broad base. Under such circumstances, in fact, it might easily be mistaken for the gravid uterus. The discrimination is much easier when the adhesion is by a narrow pedicle. In all cases of doubt the most certain plan is to use the sound, or, what is often far preferable, a common medium-sized catheter with a stylet, passed gently into the uterus over the morbid mass. If, in doing this, the CHAP. X V 111 . MYOMATOUS TUMORS OF THE UTERUS. 885 instrument, as it is moved about, can be felt by the band resting upon the hypogastrium through the thin walls of the womb, it may I'easonably be assumed that the morbid growth is intrauterine. The affections with which the myomatous growth of the uterus is most liable to be con- founded are tumors of the ovaries, the Fallopian tubes, and the pelvic cavity. A careless observer might possibly mistake it for pregnancy, especially when, situated in the direc- tion of the middle line, it is of large size, of rapid development, and of a rounded, convex shape. When the growth is extramural, the neck and mouth of the uterus seldom undergo any material change, but the body is generally, if not invariably, more or less hypertro- phied, and, as a necessary consequence, the canal is proportionately increased in length and diameter, the former often amounting to four, five, and even six inches. As no such alterations occur in ovarian disease, they constitute facts of great diagnostic value. When, on the contrary, the growth occupies the cavity of the womb, the canal is either very much contracted, or totally obliterated, and the cervix is also eventually effaced, pre- cisely as in the latter stages.of pregnancy. In the mural variety of fibrous tumor there is commonly no morbid uterine discharge, not perhaps even any interruption in the menstrual function, whereas there always is when the tumor occupies the cavity of the organ. When a myoma of the uterus is of a cystic nature, the distinction between it and an ovarian tumor is very difficult, if not impracticable. The enlargement thus occasioned may be very great, and, if accompanied by fluctuation, as it will be almost sure to be, could scarcely fail to lead to the suspicion of the existence of ovarian dropsy. The safest guide, in such an event, would be the condition of the mouth, neck, and canal of the uterus, which are seldom altered in ovarian disease, but nearly always more or less in myomatous growths of the uterus. The treatment of the myomatous or fibromyomatous tumor of the uterus was, until recently, very unsatisfactory. When the growth is situated within the cavity of the organ, it is occasionally expelled spontaneously, and the woman either recovers or perishes from the effects of hemorrhage. As yet, no internal remedies have been found to be of any material benefit in dispersing it, or in arresting its development. I have often tried inunctions with dilute ointment of biniodide of mercury, and the internal use of iodine in various forms and combinations, iodideof iron, mercury, and chloride of ammonium with- out the slightest effect. When a tumor of this kind is partially detached, its expulsion may sometimes be expedited by the use of ergot. When the growth occupies the cavity of the organ, and has a comparatively narrow pedicle, removal may sometimes be readily effected with the forceps, knife, scissors, ligature, or ecraseur, as in an ordinary polyp. Even when the growth has a very broad base, portions of it may sometimes be tolerably easily removed in this wise, although in general it will be best, under such circumstances, when interference is indispensable, to attempt relief by enucleation by means of the fingers, scissors, gouge, bistoury, and other instruments, as practised by Atlee, Davis, Grimsdale, Brown, and many others. Dr. Sims has used with great advantage what he calls the uterine enucleator, with which the growth, previously firmly grasped with a stout hook, is generally easily pared off from the surface of the womb. The first thing to be done in such an operation is to dilate the mouth and neck of the uterus with sponge tents, either alone or with the aid of a metallic dilator. When this end has been attained, the capsule of the tumor is freely opened with the finger or knife, when the process of removal by enucleation and traction is at once begun, and persevered in until the object is accom- plished. If the tumor is very large it may be necessary to incise the neck of the uterus bilaterally, or even at four different points down to the vagina. Should it be too bulky for extraction, which, however, is seldom the case, it should be removed piecemeal. The bleeding which attends and follows the operation, and which is often very copious, should be promptly arrested by turning out the clots and inserting tampons of cotton or patent lint, fastened to strong cords and wet with a strong solution of subsulphate of iron. Ice applied to the hypogastrium and introduced into the vagina will also prove serviceable. The uterus generally contracts more or less firmly after the removal of its contents, and hence secondary hemorrhage is of rare occurrence. The tampons should be withdrawn at the end of thirty-six hours, after which the cavity of the uterus should be well washed out with a full-sized catheter attached to a syringe, at least from three to five times a day, with a weak solution of carbolic acid, chlorinated sodium, or permanganate of potassium. The immediate danger in this operation is from shock and hemorrhage; the remote from peritonitis, cellulitis, and pyemia. 886 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. The danger of this operation is vastly increased when the patient has been the victim of frequent and exhausting hemorrhages, or when, as occasionally happens, the tumor has been invaded by gangrene and thus been converted into a foul, putrid mass, causing septicemia, and excessive prostration of the system; under such circumstances no time is to be lost. By the speedy removal of the tumor life may still be saved, although the chances are then certainly much diminished. In the more ordinary cases, delay is often essential to safety, the health being gradually brought up under the use of tonics, stimulants, styptics, and deodorizing injections. When the tumor is of a cystic structure, its removal will be facilitated by the previous withdrawal of some of its fluid contents. Temporary relief may occasionally be procured by the use of the trocar inserted through the wall of the vagina. Removal of the intramural tumor, even if of large size, may be effected with compara- tive safety by the plan pursued by Professor Thomas. The first step of the operation consists, after the womb has been pulled down as far as possible, in cutting out, as a start- ing point, a piece from its inferior wall with a pair of narrow, sharp-pointed scissors ; and the second, in enucleating the morbid growth with the finger and the spoon-saw, fig. 694, or with the modification of that instrument represented in fig. 695. When the tumor Fig. 694, Fig. 695. Yarrow’s Enucleator. Fig. 696. Thomas’s Spoon-saw or Serrated Scraper. Emmet’s Enucleator. is very bulky it may be necessary to remove it piece-meal; and, under such circumstances > and even in ordinary cases, important aid may be derived from the use of an Emmet’s finger-stall, tig. G96, which, as it is composed of steel, and is serrated at the extremity, may be employed both as a saw and as a scraper. The hemorrhage, which, however, is seldom very copious, is controlled in the usual manner. The method of effecting the enucleation is well illustrated in tig. 697 from Thomas. In cases ineligible for enucleation, the only hope ot relief is from laparohysterectomy, a most dangerous operation, first performed, if I mistake not, in 1843, by Mr. Charles Clay, of England, and since repeated in numer- ous instances in different parts of the world. In November, 1881, Professor C. D. Palmer, of Cincinnati, published a table of 165 cases of laparohysterectomy derived from various sources, of which 84 recovered, and 81 perished, thus showing a mortality of 49 per cent. Ot the 165 cases, 127 were performed for partial and complete removal of the uterus for interstitial, broad-based, pedunculated, and fibrocystic tumors, with 62 recoveries and 65 CHAP. .XVIII. POLYPS OF THE UTERUS 887 deaths, or a mortality of 51 per cent. Of 38 cases, in which the tumors were peduncu- lated, and the uterus remained undisturbed, there were 22 recoveries and 16 deaths, or a mortality of 42 per cent. It is worthy of note that there has been a marked increase in the success in both of these operations as per- formed within the last few years, owing, doubtless, to the greater care exercised in the early detection of the cases, the operative pro- cedure, and the after-treatment. The hemorrhage, which so often attends upon fibroid tumors of the uterus, has recently been treated by spaying, or, in other words, by the removal of the ovaries, and cases have been reported in which the operation has afforded most satisfactory results. Instead of removing the ovaries alone for the cure of this form of hemorrhage, Mr. Lawson Tait excises these organs along with the Fallopian tubes, and he has advanced very specious arguments, as well as a number of clinical cases deifived from his own practice, in favor of the operation. POLYPS. There are, so far at least as my observation extends, not less than four varieties of ute- rine polyps, the fibromyomatous, vascular, mucous, and glandular, of which the first is by far the most common. This fibromyomatous variety is nothing more than a submucous fibromyomatous tumor of the womb, which, having originated as a small, round nodule, in the internal layer of its muscular structure, during its further growth, has advanced into its cavity, and become invested with its mucous membrane. Of a fleshy consistence, firm, yet compressible, smooth, elastic, of a pale grayish color, and composed of dense filaments, which are so intimately interwoven with each other, as to render it impossible to unravel them, this variety of polyp usually springs from the anterior and posterior walls or fundus of the ute- rus, and is made up of fibromuscular tissue, although the muscular element may predomi- nate in young growths. When, however, it has attained considerable volume, and when it arises from the neck of the womb, which is rather of a fibrous than of a muscular con- stitution, it should be classed, histologically, among the fibrous myomas. In its shape it is commonly globular or pyriform. Its pedicle may be thick and muscular, or narrow and fibrous, the muscular tissue disappearing as the tumor increases and becomes more depend- ent, the size of the pedicle being proportionate with that of the growth. It has few ves- sels, and is, therefore, little disposed to bleed or- to be attended with pain. Tumors of this kind have often a very rough surface, and they sometimes contain considerable cavities filled with mucus, pus, or earthy matter. The vascular polyp is composed essentially of hypertrophied and highly vascular papillse, the fibrous element being either entirely wanting, or existing only in a very limited degree. This species is extremely rare, occurring only in the neck of the uterus, and seldom attain- ing a large size ; it is of a red, florid color, of a soft, spongy consistence, sensitive on pres- sure, erectile, and exceedingly prone to hemorrhage. In respect to shape, it presents the same diversities as the other species. The vesicular, mucous, or gelatinoid polyp holds a kind of intermediate rank between the two preceding, being softer than the fibrous and harder than the vascular. It is semi- transparent, of a peculiar grayish complexion, compressible, glistening on the surface, and attached by a delicate pedicle, which renders it pendulous. Carefully examined, it is found to exhibit a shreddy, tremulous structure, interspersed with a few vessels, which are generally too small to emit much blood. The mucous polyp may acquire a large bulk, and is influenced by atmospheric vicissitudes, increasing in size when the weather is moist, and diminishing when it is dry. The glandular or adenoid polyp consists in an enlargement of one or more of the mucous follicles, situated in the neck and at the mouth of the womb, which are not only elongated, Fig. 697. Diagram representing the Tumor imbedded in the Posterior Wall of the Uterus. 1 shows the Project- ing Posterior Wall; 2, the Uterine Cavity; 3, the Tumor; 4, Anterior Uterine Wall at the Point of Attachment of the Anterior Vaginal Wall. 888 DISEASES OF THE FEMALE GENITAL ORGANS. chap, xviii. dilated, and lined by enlarged cylindrical epithelium, but partly converted into cysts. The stroma is made up of succulent fibrous tissue, and sometimes of smooth muscular fibres, containing numerous vessels. Hence, its similarity to certain soft polyps of the nose is very striking. It almost always occurs in clusters, of a reddish, whitish, or gray- ish color, commonly about the size of currants or small grapes, suspended by long, slender pedicles, and strongly resembling, in their general appearance, the surface of a cauliflower. Occasionally the granular matter bears a striking resemblance to fish-spawn, as in a case recently under my treatment in a married lady, thirty-seven years of age. AVhen there is only one such tumor, it may attain the volume of a walnut, or of a hen’s egg. It is invested by a smooth, delicate, vascular membrane, possesses little sensibility, and often contains a yellowish, curdy matter, which is apparently nothing but altered mucus and epi- thelium. Its connection with the uterus is very slight, and its growth generally very tardy. Uterine polyps are found of all sizes, from that of a bean up to that of a gourd. Their volume, and, in some cases, weight, are immense, ranging from ten to nearly forty pounds. They occasionally extend far down into the vagina; and cases have been witnessed in which they reached more than ten inches below the vulva. The shape of these morbid growths is mostly pear-like ; and, although they may originate in any portion of the cavity of the uterus, they are mbst frequently attached to its neck. Many of them have a nar- row, slender pedicle ; and, in such as are of great size, it is not uncommon to see deep fis- sures, which give them a lobulated arrangement. They are all invested by a thin mucous membrane, which is more or less vascular, and merely a prolongation of that of the womb, immediately beneath which the morbid growth is developed. Large cavities, filled with various substances, are sometimes seen in them. Polyps of the uterus are most common in elderly women, especially in such as have borne children. Their progress, which is usually very tardy, is characterized by vague, irregular pains, and by more or less hemorrhage, with a sense of weight and fullness in the pelvic region, vesical trouble, and a thin, sanious, fetid, or leucorrhoeal discharge. The menstrual function is either entirely arrested or extremely irregular. The diagnosis can only be determined by a careful examination. If the tumor is of considerable bulk, it will be very apt, in time, to protrude at the vulva. Care must be taken not to confound a polyp of the womb with a recto-vaginal hernia, a prolapsed vagina or bladder, or an aborted ovum retained in the neck of the uterus. The termination of this disease is uncertain. In some cases, the patient lives in com- parative comfort for years, while in others life is rapidly worn out by the constant hemor- rhages that are so liable to attend it. I have seen a number of women perish from this cause. Now and then an instance of spontaneous expulsion occurs, followed by speedy recovery. The only treatment that is of any avail in uterine polyps is removal, and the earlier this is effected the more likely will the woman be to make a good recovery. The operation may be performed by evulsion, ligation, or excision, precisely as in polyps of the nose. When the tumor is comparatively small, with a narrow pedicle, I always give the prefer- ence to the first of these methods, as being both safe, easy, and expeditious. The proper instrument is a large lithotomy-forceps, with rough, serrated blades, to insure a firm grasp. Or, instead of this, a Museux’s forceps, or stout volsella, may be used. AYhen the tumor is not too large, removal may be effected with the ecraseur, the most convenient and effec- tive of which is that of Sims, the chain of which, instead of being flexible, as in the ordi- nary contrivance, is rendered stiff by the addition of a pair of dilating forceps, so that it may be passed into the vagina, and even into the cavity of the uterus, as easily as a probe. Heywood Smith’s wire-rope ecraseur, fig. 698, is also a good contrivance for the purpose. The patient, during the operation, lies on her abdomen, as in the operation for vesico- vaginal fistule, or on the back, with the limbs elevated and well retracted ; and care is taken not to cause undue displacement of the organ. The vagina is expanded with the duck-bill speculum. A very ingenious instrument, called a polyptome, for the removal of uterine polyps, ope- rating upon the principle of the ecraseur, has been devised by Dr. Aveling. It consists, as seen in fig. 699, of two branches, one of which is bent at the extremity for seizing the morbid growth, while the other, which slides within the former, is designed to crush it. Ligation may be necessary when the tumor does not yield to evulsion, or when it has an unusually large base. The wire may be applied by means of a long double canula, and should be drawn with great firmness, so as to cause speedy strangulation. Great care is, of course, taken not to include any portion of the uterus. CHAP. XVIII. POLYPS OF THE UTERUS. 889 Occasionally, the object may readily be effected with a stout, well-waxed ligature, passed around the tumor, and tied with the ingenious instrument of Dr. A. L. Carrol, delineated in fig. 700. The blunt hooks are at a right angle with the blades, which operate upon the principle ot a glove-stretcher, and the knots are secured almost with as much ease and rapidity as when the parts are accessible to the fingers. Fig. 698. Fig. 700. Fig. 699. Aveling’s Polyptoxne. Heywood Smith’s Wire-rope kcraseur. Carroll’s Knot-tier. Although ligation may occasionally be required, experience has shown that it is often a hazardous procedure, and for this reason is now seldom employed. Of 10 cases collected by Dr. McClintock, of Dublin, 3 died, while of 24 treated with the knife, scissors, or ecraseur, not one proved fatal. The operation in the hands of Dr. Lee, of London, was almost equally disastrous; for of 59 cases reported by this distinguished accoucheur, there were 9 deaths, two of the women having perished before the removal of the tumor was effected. The same author refers to 35 other cases in which uterine polyps were removed by torsion or excision without one fatal result. When the ligature is employed, the vagina and uterus should be frequently and thoroughly washed out with weak antiseptic lotions ; otherwise, the foul secretions being retained, there will be great danger of septicemia. Excision is applicable only, or mainly, to small polyps with a narrow pedicle. When the growth is large, there is danger of profuse hemorrhage. The most suitable instru- ment is a pair of scissors with short, narrow, crooked blades, or a long probe-pointed bis- 890 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. toury, slightly curved towards the extremity, which is carefully insinuated around the neck of the polyp, the womb being previously drawn down with a volsella. Sometimes a small polyp may readily be scraped off with a gouge. The operation, however, requires care; for, if the parenchymatous structure of the womb be injured, fatal inflammation may ensue. Most of the above procedures will be greatly facilitated by drawing the morbid growth previously down into the vagina, or even beyond the vulva, and separating it from the walls of the uterus by the interposition of sponge tents. Occasionally partial detachment may be brought about by the internal use of ergot, given for a few days before the opera- tion. Any hemorrhage that may follow these operations, may usually be promptly checked by astringents, as powdered alum, or subsulphate of iron, and a full anodyne, with ice to the hypogastrium. If these means fail, or the case is urgent, the tampon must be employed. CARCINOMA. Carcinoma of the womb presents itself in two varieties of form, the epithelial and the eneephaloid, of which the first is by far the more common. A number of diseases, ap- parently of the most heterogeneous character, but in reality very similar, if not identical, have been described by authors under the several denominations of scirrhus, fungus hema- todes, cauliflower excrescences, and corroding ulcer. Scarcely any one of these appella- tions seems to me to be well chosen, as they have reference rather to certain states or appearances of the parts than to their true nature and constant anatomical characters. Not unfrequently, all the conditions expressed by these terms are blended together, and, even when they exist separately, they have invariably the same distinctive tendency. Carcinoma, of whatever nature, generally begins at the neck and lips of the organ, from which it gradually ascends to the other parts. So common is this mode of attack that it was once supposed to be invariable. Observation, however, has proved that there are numerous exceptions to this rule, the disease in many cases commencing at the base or body of the viscus, and thence spreading downwards towai’ds its inferior extremity. In epithelioma, the mouth of the womb is usually extremely hard, thick, and irregular, the lips being everted, painful on pressure, and liable to bleed on the slightest touch. After some time ulceration takes place, a thin, sanious fluid, abundant in quantity, and highly irritating and offensive in quality, oozes from the vagina, and all the textures of the affected parts are completely destroyed. The base and the body of the uterus, which are often much enlarged, also change their appearance; they become hard and firm, like fibro- cartilage, and are intersected by dense, grayish filaments, running in a radiating direc- tion. There is a soft, papillary form of epithelioma of the uterus, first accurately described by Dr. John Clarke, of London, under the name of cauliflower excrescence, occasionally, although rarely, met with in this country. Its general features are well illustrated in the annexed cut, fig. 701, from Simpson. It is most common after the age of forty, springs invariably from the mouth and neck of the uterus, is rapid in its growth, and is always attended with a profuse watery or sero-sanguinolent discharge, highly fetid and exhaust- ing. The morbid structure is of a soft, fungoid nature, deeply fissured, granulated, of a pale flesh color, very vascular, and prone to bleed on the slightest touch. As the mass increases it dilates the vagina, and sometimes protrudes at the vulva. Death finally occurs, after a period varying from fifteen to eighteen months, from constitutional irrita- tion, or from the effects of putrid and hemorrhagic discharges. The cauliflower excrescence is simply epithelioma with excessive outgrowth and carci- nomatous infiltration of the normal papillae or villi of the mucous membrane. In this respect it resembles the so-called “villous carcinoma” of other mucous surfaces. In general it is undoubtedly highly malignant, but instances occur where the action is, apparently, altogether of a benign character. In the case from which the engraving, fig. 701, was taken, the patient remained well at the end of eighteen years after the removal of the neck of the uterus. She made a very rapid recovery, and became afterwards the mother of five children. In the majority of instances of extirpation of the so-called cauliflower excrescence with- out relapse, it is highly probable that the surgeon has had to deal merely with a simple, exuberant papillary tumor of the mouth of the uterus, a form of disease not unfrequently met with in this situation, and very similar in its general appearance to papillary epithe- lioma. CARCINOMA OF THE UTERUS. 891 CHAP. XVIII. The encephaloid or glandular carcinoma generally occurs in the body of the uterus, con- verting its walls into soft masses, which vary in color according to the degree of their vascularity, being at one time uniformly white, at another, of a deep red tint, and in other cases, again, of a dark brownish complexion, caused by interstitial hemorrhage from Fig. 701. Cauliflower Excrescence of the Posterior Lip. d. Healthy Anterior Lip. c, c. Base of Anterior Lip. d, d, d. Portion of healthy Vaginal Mucous Membrane Removed along with the Cervix. rupture of the enormously enlarged vessels. Their size seldom exceeds that of an orange, but sometimes they are as large as a foetal head, of an irregularly globular figure, filling the pelvic cavity and displacing the neighboring viscera. As carcinoma of the womb, of whatever form, progresses, various morbid growths spring from the ulcerated surface, and fill up the vagina. These, at length, fall off' by sloughing, and are either speedily succeeded by others, or they leave a deep, excavated sore, with hard, irregular edges. In this stage of the complaint, there are generally copious discharges from the vagina, consisting of a thin, corroding sanies, serum, pus, or sero-purulent matter, almost insupportably offensive. Epithelioma of the uterus is most common in married females that have borne children, soon after the decline of the menses. Mr. S. W. Sibley, of London, finds that of 135 women affected with carcinoma of the uterus, 123 had borne children, and 12 had not; making thus a difference of 86 per cent. The majority of cases occur after the age of forty. Of 409 cases examined by Boivin and Duges, 95 appeared prior to the thirtieth year. The symptoms of carcinoma of the uterus are usually unequivocal, even at an early period of its existence. One of its very first effects is hemorrhage, not slight, but severe, long continued, and recurring, with more or less frequency, throughout its entire progress, and becoming gradually more and more profuse. It is, therefore, a phenomenon of great diagnostic value, particularly in the incipient stages of the affection. The pain is vari- able. Usually it is sharp and lancinating, darting about through the neighboring parts, and coming on at an early period. The general health seldom suffers much for several months; it then begins to decline, the patient losing appetite, flesh, and strength, and the countenance ultimately assuming that peculiar, sallow, cadaverous aspect, so character- istic of the carcinomatous cachexia. The discharges are now also very profuse, and generally so excessively fetid as to be almost of themselves denotive of the nature of the malady. As the disease progresses, the morbid action gradually extends to the neighboring organs, as the vagina, rectum, and bladder, the two latter of which, as exhibited in fig. 702, are frequently laid open, thus adding greatly to the suffering. The body of the uterus usually retains its integrity longer than any other portion of the organ. After death, the pelvic viscera are generally found to be more or less matted together, and the pelvic and lumbar lymphatic glands more or less enlarged. The period at which carcinoma of the uterus proves fatal varies. Of 120 cases, analyzed by Dr. J. C. W. Lever, of London, 107 died at an average of twenty months and a quarter from the invasion of the malady. The shortest duration was three months; the longest five and a half years. Marriage and the previous state of the health did not appear to have exercised any particular influence upon the progress of the disease. The diagnosis of carcinoma of the uterus is not always so easily determined as might at first sight appear, owing to the fact that the disease is liable to be confounded with other affections, as various kinds of ulcers, myoma- tous tumors, polyps, and pregnancy. The most important considerations are the history of the case, the occurrence of hemorrhage, the character of the discharges, the peculiar nature of the pain, and the obstinacy of the disease. Carcinoma generally begins at the neck of the organ, from which it gradually extends to the body and fundus. Once fairly begun, the disease is persistently progressive until the patient is worn out by her suffering. The hemorrhage usually begins soon after the establishment of ulceration, and is nearly always most profuse in the earlier stages of the disease. It is frequently the first symp- tom that attracts attention, and, if the woman still menstruates, or has only lately ceased to be unwell, is very liable to be mistaken for menorrhagia. The bleeding, whether slight or copious, intermittent or almost constant, is invariably accompanied by clots. The discharge, prior to ulceration, is mucous or muco-purulent, and free from fetor; subsequently, it is ichorous, sero-sanguinolent, dark, greenish, or brown, more or less pro- fuse, irritating, and highly offensive. In some cases it closely resembles the washings of flesh, and occasionally it is quite red from the admixture of blood. Its quantity, fetor, and acrimony are greatly increased in the latter stages of the complaint. The pain in carcinoma of the womb is sharp and lancinating, as if a knife were thrust into the body; occasionally it is dull, heavy, aching, burning, or grinding. It is seated deep in the pelvis, and increases with the disease. In some cases it is most distressing in the .loins, rectum, anus, or thighs, in the course of the sciatic nerves ; and, under such circumstances, it not unf'requently manifests a neuralgic disposition. The common ulcer of the uterus is generally superficial, and readily amenable to treatment; it is not attended by hemorrhage, and the discharge, never very profuse, is usually muco- purulent, and free from fetor. The syphilitic sore is recognized by its hardness, by the his- tory of the case, and by the existence of syphilitic disease of the vagina, vulva, and other parts ; the chancroidal, by its multiple character, profuse discharge, and tendency to spread. A myomatous growth, or polyp, is usually distinguished by its peculiar appearance, by the repeated hemorrhages which so often accompany it, and by the absence of sero-purulent, ichorous, or sero-sanguinolent discharge. Pregnancy may be diagnosticated from carcinoma by the gradual enlargement of the womb, the absence of hemorrhage and fetid discharge, and by the existence of the morn- ing sickness. Finally, the diagnosis can, after all, only be clearly established by a thorough examina- tion with the finger and the speculum. No matter how distinctly the signs may point to the existence of carcinoma, such an exploration should never be omitted. The greatest difficulty is generally experienced when the disease is located in the cavity of the organ : when it attacks the inferior extremity the discrimination is usually sufficiently easy. In the former case it is sometimes necessary to dilate the neck with the tent before a satis- factory conclusion can be reached. Treatment The treatment of carcinoma of the uterus is, for the most part, merely palliative; resolving itself, as a rule, into the adoption of measures for assuaging pain, arresting hemorrhage, promoting cleanliness, and supporting strength. Recumbency 892 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. Fig. 702. Carcinoma of the Neck of the Uterus, ending in the production of Recto-vesico-vaginal Fistule. CHAP. XVIII. CARCINOMA OF THE UTERUS. 893 always contributes materially to comfort. Anodyne suppositories are among the best means for relieving pain and inducing sleep. Hydrate of chloral and bromide of potassium are of great service when the patient is very nervous, or troubled with insomnia, and should be administered in full doses at least once a day. Hypodermic injections of morphia will be indispensable during the latter stages of the disease to assuage the agonizing suffering so common at these periods. Hemorrhage is most effectually controlled witli cotton tents wet with a moderately strong solution of Monsel’s salt. Ergot may also be given with advantage. Cleanliness, a matter of paramount importance, is best secured with weak injections of chlorinated sodium, chlorolalum, or permanganate of potassium, repeated not less than three, four, or five times in the twenty-four hours. Monsel’s salt is itself a powerful antiseptic, and, when used to check hemorrhage, may advantageously supersede the articles just mentioned. Carbolic acid is offensive, and possesses no special virtue as a detergent. The food must be regulated according to the necessities of the case. As a rule, it should be given in as nutritious and concentrated a form as possible. An almost purely milk diet is often of great benefit, and milk punch can seldom be dispensed with during the latter stages of the disease. Among the most valuable internal remedies for imparting tone to the system, improving the appetite, and increasing the plasticity of the blood are quinine and iron, especially in the form of the tincture of chloride. The use of arsenic has been greatly extolled in the treatment of carcinoma of the uterus. It was a favorite remedy with the late Dr. W. L. Atlee, of this city. His plan was to give two or three drops, thrice daily, of Fowler’s solution, combined with the local use of a very strong solution of iodine. His formula consisted of one drachm each of iodine and iodide of potassium, dissolved in an equal quantity of glycerine, and applied either on cotton or with a brush, several times a week. Remarkable improvement is said to have followed in many cases this treatment in the hands of the great gynecologist. In my own prac- tice I have utterly failed to realize any benefit from the arsenic, but have witnessed good effects from the local remedy as a hemostatic, especially in the earlier stages of the disease. As it respects operative interference, most cases of carcinoma of this organ unfortu- nately fall too late into the hands of the surgeon to be benefited by it. If the diagnosis could always be certainly determined in the earliest stages of the disease, or while the morbid action is limited to one of the lips of the organ, or a small portion of its neck, there is every reason to believe that, in not a few instances, a permanent cure could be effected, or, at all events, that life could often be prolonged for a number of years, the woman in the mean time enjoying comparative freedom from suffering. Removal of portions of the uterus, or even of the entire organ, through the vagina, on account of malignant and other diseases, is a procedure which has long been familiar to the profession. Its removal by the abdominal section, for carcinoma, appears to have been originally proposed by Wrisberg, in 1787 ; but was first carried into effect by Pro- fessor Langenbeck, of Gottingen, early in the present century. The excision of portions of the uterus is a comparatively simple affair, not, however, always free from danger, whereas the extirpation of the whole organ, whether by the vaginal or abdominal section, is always a most hazardous operation, although, as far as immediate results are concerned, less so than was formerly supposed. Indeed, it may be said that the recent statistics of hysterectomy for the cure of carcinoma are rather flattering than otherwise. In this country a vaginal hysterectomy was first performed in 1880, by the late Dr. J. M. Briggs, of Bowling Green, Kentucky. Removal of the Cervix Riddance of the neck of the uterus affected with carcinoma may be achieved with the ecraseur, the knife, or the scissors. The patient is placed upon her back, as in the operation for vesico-vaginal fistule, the vagina well washed out with chlorinated water as a preliminary step, is thoroughly dilated with a duck-bill specu- lum, and the womb drawn down with a stout volsella, fig. 703, so as to bring it com- pletely under control. The mode of applying the ecraseur is well seen in fig. 704, from Chassaignac. Every precaution being taken to include the whole of the diseased struc- tures with, if possible, a portion of healthy tissue, the chain of the instrument is set in motion, and severance affected in as gradual a manner as possible, the patient being all the while well anaesthetized. Little hemorrhage is to be looked for in this procedure, and any that may occur is readily checked with the hot iron, or the cotton tampon saturated with Monsel’s solution. Instead of the ecraseur the knife, or knife and scissors, may be used for removing the diseased structures; and this, as a rule, is the safer plan, as the surgeon can better see what he is about, or, in other words, more readily determine the boundaries between the 894 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVII i. diseased and sound parts. Two bistouries, one sharp and the other probe-pointed, are always required; a pair of long forceps with large teeth must be at hand; and there should also be two pairs of long scissors, one of them with very short blades, slightly curved on the fiat. The uterus is well studied with a stout volsella, and the dissection is conducted in such a manner as to embrace every particle of diseased tissue without expos- ing the peritoneal cavity, an accident which would seriously complicate the case, if not imperil life. Moreover, great care must be taken not to wound the bladder or rectum. More active bleeding attends the use of the knife, or knife and scissors, in this operation, and the surgeon should, therefore, be fully prepared to meet any such contingency. Fig. 703. Fig. 704. Volsella for Pulling down the Uterus. Amputation of the Neck of the Uterus hy means of the Straight flcraseur. a. Shows the Neck of the Organ dragged down to the Vulva hy means of Museux’s Forceps, c, d. The Chain of the Instrument passed around the part to its Base. Dr. W. H. Baker recently suggested a modification of the more common method of dis- posing of the morbid structures, which he claims possesses certain advantages, among others, greater simplicity and ease of execution, less danger from relapse, greater facility for effecting clearance, and less trouble in conducting tiie after-treatment. The operation is thus performed. The uterus being pulled down in the usual manner, the vaginal por- tion is opened anteriorly with the scissors, and the cervix separated from the bladder, the forefinger being used to aid in tearing the tissues. A similar incision is made behind, and the cervix liberated from the peritoneum up to the level of the internal os. Finally, the lateral edges are separated by connecting the incisions with those previously made in front and behind, when the uterotome is substituted for the scissors and a funnel-shaped mass of the body of the organ is cut out. The blood being sponged away the operation is completed by applying the actual cautery at a red heat to the whole of the denuded surface. Due care must be taken not to open the bladder and peritoneum. The danger will be lessened if a catheter be previously inserted into the bladder. When the morbid mass presents itself in the form of numerous excrescences, as when it has made hopeless progress, portions of it may often be advantageously stripped off’ with the scissors, or destroyed with the galvano-cautery, introduced through a wooden specu- lum, or through the ingenious shield devised by Dr. Wilson, of Baltimore; or the object CHAP. XVIII. CARCINOMA OF THE UTERUS. 895 may be accomplished, especially when the diseased structures are very much softened and disintegrated, by means of a Simon’s scoop, represented in fig. 705. The hemorrhage, which is often very alarming by its profuseness, is in general easily arrested by plugging the vagina with lint or cotton wet with Monsel’s solution. It is hardly necessary to add that all these expedients serve the purpose mainly of palliatives. Fig. 705. Simon’s Scoop. The actual cautery heated to a red heat has sometimes afforded me good results as a temporary expedient. The instrument should be introduced through a wooden speculum, the diseased structures having been previously well dried. The treatment is more espe- cially adapted to the incipient forms of carcinoma. Removal of the cervix for carcinoma cannot be regarded as a very promising expedient so far as a permanent cure is concerned. However it may be effected, it is sure, sooner or later, to be followed by recurrence of the malady. This is unquestionably its general, if not invariable, tendency. In very many cases, indeed, the operation is only partially per- formed, that is, more or less of the morbid matter is left behind, and often, in consequence, spreads with increased vigor and rapidity. I have certainly witnessed great benefit from the operation in the way of relief from pain, hemorrhage, and foul, offensive discharge; but cure in not one solitary instance, and this statement may, I think, be safely accepted as tallying with the results of general experience. Lisfranc, who performed amputation of the cervix very frequently, reported 97 cases with only two deaths; a result entirely at variance with the assertion of his pupil Pauly, who, to use the language of one of his contemporaries “ brutally revealed the truth.” Unfortunately there are no reliable modern statistics of the operation. So far as the immediate danger of excision of the cer- vix is concerned, it is comparatively slight in the hands of an adroit and cautious surgeon. Amputation of the cervix for malignant disease was originally suggested by Ambrose Pare; and, although it was occasionally performed toward the close of the eighteenth century, it remained for Osiander, of Gottingen, to systematize it in the early part of the present. The operation was for a long time almost entirely in the hands of the French surgeons. Removal of the Entire Uterus For excision of the entire uterus for carcinoma two methods present themselves; in one the organ is removed through the vagina, constitut- ing what is called vaginal hysterectomy; in the other by cutting through the wall of the abdomen, or what is known as the abdominal section, or laparohysterectomy. The relative merits of these two procedures are still unsettled, although the preponderance would seem to be in favor of the latter. The danger from both operations is great; often immediate, from shock and hemorrhage, and remote or secondary from peritonitis, cellu- litis, pyemia, and septicemia. Another point that must not be forgotten in considering the propriety of such an operation is the fact that serious disease not unfrequently exists in the surrounding structures, more especially in the broad ligaments, and the lymphatic glands of the pelvis, before the surgeon has made up his mind to perform it. When such involvement is present, very little, if any, ulterior benefit can accrue from the use of the knife, and hence it is not surprising that the operation has thus far failed to secure the general acceptance of the profession. Neither of these operations should be undertaken without proper preparation of the system and previous disinfection of the diseased structures with carbolized water, or some other antiseptic lotion. If the peritoneal cavity be opened without such precaution, sep- ticemia and other bad effects will inevitably ensue. a. Vaginal Hysterectomy Extirpation of the uterus by the vaginal section was first performed, if we may credit the statement of Colombat De L’lsere, in 1822, by Dr. Sauter, of Constance. The operation was soon afterwards repeated by Iloelscher, Siebold, Langenbeck, Lizars, Bauner, Recamier, Blundell, Delpech, Roux, and others, death fol- lowing, in every instance, either within a few hours, days, weeks, or months, sometimes from shock or loss of blood, and occasionally from a return of the disease, which was always of a carcinomatous character. Siebold, II. M. Langenbeck, and Recamier each had two, and Blundell four, cases of this kind. One of the patients of the latter, a woman, fifty years of age, the subject of carcinoma, was doing well five months after the operation. 896 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. All these cases occurred before the close of the first third of the present century. In 1850 the late Dr. Paul F. Eve extirpated, by the vaginal section, for carcinoma, the entire uterus along with its appendages, death occurring from a return of the disease three months after the operation. From this time on nothing further was heard of the operation until 1879, when Pro- fessor Czerny, of Heidelberg, had a successful case, followed soon after by a second and a third, with the effect of arousing general attention to it. Dr. C. Fenger, of Chicago, is entitled to the credit of introducing it to the notice of the profession of this country and of setting forth its claims to favorable consideration, as he did in an elaborate paper, accom- panied by the particulars of a successful case in his own practice, in the American Jour- nal of the Medical Sciences for January, 1882. The woman during this operation lies either upon her back, as in lithotomy, or, what is preferable, upon her abdomen, as in the operation for vesico-vaginal fistule. The vagina being widely expanded, the uterus is drawn forcibly down with a volsella, and separated with great care from the surrounding structures, in such a manner as not to inflict any injury upon the bladder, the rectum, or the small bowel, which, if necessary, must be pressed out of the way by an assistant. The dissection must be conducted with the knife and scissors, mostly with the latter; and any vessels that may require it, are at once secured with the carbolized catgut ligature. The ovaries and Fallopian tubes, if sound and strongly adherent, may be left intact, their pedicles being treated in the usual manner. The edges of the wound in the peritoneum are closed with sutures, retained until complete union has taken place. Unless this be done, there will be danger of an escape of the bowel, although the gap is generally filled up by the enlarging bladder. When the parts cannot be stitched together, a cotton tampon, wet with carbolized oil, must be used. One of the difficulties experienced in vaginal hysterectomy is the ligation and separa- tion of the broad ligament on the side first assailed in the operation. Where this has been effected, the management of the other ligament is sufficiently easy, because there is then no longer any tension. To facilitate this step of the operation, Dr. P. Mueller re- cently—1882—suggested the propriety of the previous splitting of the uterus, longitudi- nally, along the middle line, so as to enlarge the field for the necessary manipulations. During the after treatment the strictest recumbency is observed for at least a fortnight; special attention is paid to the diet, and the bowels must be confined for a week with opium. The cotton tampon is removed at the end of forty-eight hours, or even sooner, especially in hot weather. When this has been effected, the vagina should be well syringed with car- bolized water, or some other antiseptic lotion, the operation being afterwards repeated at least thrice daily. If the wound has been left uncovered, its cicatrization may be pro- moted by the frequent application of glycerine or simple cerate combined with tannic acid, nitrate of lead, or some other slightly stimulating substance. The rectum, if distended with gas, may be relieved from time to time with the silver canula, or a turpentine and assafoetida enema. The principal sources of danger after all operations involving excision of the uterus, whether partial or entire, are shock, hemorrhage, peritonitis, cellutitis, and septicemia. Vaginal Hysterectomy for other Affections than Carcinoma A number of cases are upon record in which the uterus, either alone, or jointly writh its appendages, was re- moved by the vaginal section for inversion or prolapse. Dr. Eli Geddings, of Charles- ton, in 1854, removed the entire organ on account of inversion, a strong ligature having previously been thrown around the upper portion of the mass to guard against protrusion of the boAvel. Excision w7as then effected with a bistoury. The operation was followed by rapid recovery. A case, in which the wdiole of this organ along with the left Fallopian tube and left ovary w'as successfully removed by the late Professor Choppin, of New Or- leans, on account of procidentia, in a woman, thirty-eight years of age, is recorded in the Southern Journal of the Medical Sciences for February, 1867. In connection with this variety of the operation, it may be stated that there are at least twro well authenticated instances upon record in which the entire uterus along with the ovaries was forcibly pulled away after delivery, under the belief on the part of the midwife that the organ was the placenta, and yet both women made an excellent recov- ery. One of these cases occurred in Kentucky under the observation of Dr. Ballard, and is circumstantially detailed in the second volume of the Western Journal of Medi- cine and Surgery. The other has been described by Dr. Martin, of Bavaria. A number of similar examples are recorded in the annals of midwifery. A case in which the whole organ sloughed away after a lingering labor, and the woman finally recovered, oc- curred in the practice of Mr. Darville, of England, in 1839. CHAP. XVIII. ABDOMINAL HYSTERECTOMY. 897 b. Abdominal Hysterectomy Professor William A. Freund, of Strasburg, in 1878, performed what is now known as his operation, for the total removal of the uterus, on account of carcinoma. The operation, as originally practised by this distinguished gyne- cologist, was conducted under antiseptic precautions, the patient’s system having pre- viously been placed in as good a condition as possible, with the strictest regard to hygienic surroundings. The bladder and rectum being emptied, and the vagina thoroughly washed out with a ten per cent, solution of carbolic acid, an incision is made along the linea alba, extending from near the pubic symphysis to within two inches of the umbilicus, into the peritoneal cavity. The bowels are held up with a warm, wet napkin ; the fundus of the uterus is transfixed and drawn up with a stout cord; and ligatures are passed, first through the Fallopian tubes and broad ligaments, then through the ovarian and the round ligaments, and, finally, through the walls of the vagina, near the cervix. The ligatures being tied firmly, with their ends left long, the uterus, previously put upon the stretch, is separated from its connections and removed. The ends of the ligatures are now dropped into the vagina, and drawn upon in such a manner as to invert the raw edges in the wound and force them down into the canal. By this procedure the sound peritoneal surfaces are made to meet above in a line across the pelvis, between the bladder and the rectum, and are stitched closely and firmly together. The peritoneal cavity being thoroughly cleansed, the wound in the abdomen is closed in the usual manner, and covered with several layers of wadding confined by a broad bandage. Finally, a tampon soaked in a ten per cent, carbolized oil is inserted into the vagina. One of the great points, requiring special attention in this operation, is to guard against hemorrhage. To meet this contingency, Professor Martin, of Berlin, has suggested that the principal arteries should be ligated previously to their division, while Mr. T. Spencer Wells favors, as more simple, the ap- plication of suitable clamps, which might be left hanging in the vagina until they drop off spontaneously, or until all danger of bleeding is over. In a remarkable, and, I believe, hitherto unique case, of epithelioma of the uterus, con- joined with pregnancy, Mr. Wells, in 1881, extirpated the whole of that organ along with its appendages and all the diseased structures around, and succeeded in saving his patient, a woman, thirty-seven years of age, six months advanced in gestation with her sixth child. The operation was performed in the same manner as in ovariotomy. The bleed- ing vessels were secured with carbolized silk, and the opening in the vagina and the edges of the divided broad ligaments were united with silk sutures. The foetus weighed twenty-two and a half ounces, a little over two ounces less than the uterus and its ap- pendages. Symptoms similar to those so frequently witnessed after ovariotomy followed the operation, but the temperature never rose above 101.2° Fahr., and the most rapid pulse was one hundred and twenty-eight. At the end of a month, the woman was so well that she was sent home. The relative merits of these two operations are not fully determined, although it may, I think, be stated in general terms, that, inasmuch as the abdominal section affords a wider and more open field for the manipulations of the surgeon, it deserves the preference. Hemorrhage is more easily prevented, and more readily controlled, if it occur; the bladder, ureters, and rectum, are less liable to be wounded ; and any disease that may exist in the adjacent structures is more fully under the eye of the operator. Vaginal hysterectomy presents great difficulties when the uterus is very large, or the vagina disproportionately small, and should, when this is the case, yield to the abdominal section. The subjoined statistics will serve to show how often, and with what results, these operations have been performed up to the present time. Olshausen, in 1881, reported 41 cases, in which the organ was removed by the vaginal method, of which 29 recovered and 12 died. Fenger, in the paper previously referred to, published last January, gives the statistics of 45 cases from the practice of different gynecologists, with 31 recoveries, 11 deaths, and 3 un- finished operations. Of these cases, Billroth had 7 with 3 deaths; Schroeder 8 with 7 re- coveries; Martin 12 with 6 recoveries, 3 deaths, and 3 unfinished operations; and Ols- hausen G with 6 recoveries. Schwartz, last June, collected 55 cases, of which 20 died and 35 recovered, the disease having recurred in 6 of the latter. Ahlfeld, in 1880, published a table of 66 cases of hysterectomy by the abdominal sec- tion, performed for malignant disease, of which 49 proved fatal; in 4 the operation was not completed, and of the 13 said to have recovered, there were 9 relapses. Kleinwach- ter’s more recent cases, 94 in number, show 24 recoveries; while Kaltenbacli’s 88 cases, collected about the same time, claim 30 successes. 898 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP, x v 1 11. SARCOMA. The sarcomatous tumor of the uterus, whether occurring as a soft, round-celled infiltra- tion of the mucous membrane, or as a firm, spindle-celled outgrowth of the interstitial connective tissue, either pure, or combined with the soft, oedematous variety of myoma, is very rare. A myomatous or fibromyomatous polyp does not recur after extirpation ; but certain polypoid formations are observed which are characterized by a constant tendency to return. Such growths, which resemble ordinary polyps in their external features, but differ from them in the appearances presented by their cut surfaces, are found on minute examination to consist principally of closely aggregated spindle cells and fine nuclei imbedded in a dimly granular intercellular substance, thus showing the charac- teristic features of fasciculated sarcoma. The sarcomatous, fibroplastic, or recurring fibroid polyp so closely resembles the ordi- nary uterine polyp that its distinction without the aid of the microscope is almost impossi- ble. Its presence, however, may be suspected by its more rapid development, its larger volume, its softer consistence, its occurrence at a comparatively early age, its liability to ulceration and repeated hemorrhages, its persistent recurrence after removal, and, possibly, the infection of distant organs during its latter stages. With regard to the treatment little need be said. Unless the growth is thoroughly extirpated, which is scarcely possible on account of its intimate connection with the parent tissues, recurrence is inevitable, and partial operations are always followed by rapid repullulation in a softer form. In a few cases surgical interference has apparently pro- longed life; but it should not be undertaken unless the mass is productive of annoyance by its weight, exhausting discharges, or displacement of the womb. CAESAREAN HYSTERECTOMY. Various circumstances may render it necessary to open the uterus and extract the child, among which the more important are, deformity of the pelvis, rupture of the womb and the escape of the child into the abdomen, and the sudden death of the mother from accident or disease. The Cmsarean operation, performed for a long time for this pur- pose, has, in consequence of its great fatality, been entirely superseded in cases necessi- tated by deformity of the pelvis, by what is known as the Porro-Miiller method, a pro- cedure which involves the removal not only of the child and of the placenta, but also of the uterus and its appendages, and is, as has been shown, recent as it is, by ample expe- rience, to be incomparably safer than the ancient operation. The main difference be- tween Porro’s operation and the operation of Muller consists in the fact that, whereas, in both the uterus is sacrificed, in the former the organ is opened and the child extracted as it lies within the abdomen, while in the latter it is removed intact along with its contents, the woman being thus protected from hemorrhage and the peritoneal cavity from effusion of blood. In all other respects the methods are essentially alike. In the Porro-Miiller operation, so called in honor of Professor Porro, of Pavia, and of Professor Miiller, of Berne, the abdomen is opened in the same manner as in the removal of the uterus for malignant disease or of a morbid growth. The bladder having been emptied and the woman lying on her back with her feet resting on a chair and the uterus w'ell supported on each side, an incision from eight to ten inches in length is carried through the integument along the linea alba, commencing just above the pubes and ter- minating at or near the umbilicus. The tendinous structure is then cautiously divided down to the peritoneum, which is next opened to the requisite extent with a probe-pointed bistoury. The wound should be ample to afford room for the subsequent manipulations. The gravid womb being now lifted from its bed through the wound, a stout ligature is thrown firmly around the cervix, which is next severed along with the uterine appendages and the whole mass removed, the child having been previously liberated. The stump is either seared with the hot iron and dropped into the pelvis, or it is fastened in the lower angle of the abdominal wound, which is closed in the usual manner. A drainage tube should be inserted into Douglas’s cul-de-sac. Porro, in his first operation, performed in May, 1876, surrounded the cervix with a strong wire tightened with the aid of a serre- noeud. Differing hardly any, if indeed at all, from the Porro operation, is that of Dr. Horatio R. Storer, of Newport, performed in July, 1869, upon a parturient woman, who, having reached the full term, could not be delivered by the natural route by reason of a large fibrocystic tumor which almost completely filled the pelvic cavity and did not admit of CHAP. XVIII. CiESAREAN HYSTERECTOMY. 899 entire removal. After the child was liberated the uterus was ligated at its neck and sepa- rated with the ecraseur, when the stump was cauterized and secured by means of a clamp in the lower part of the abdominal wound. Death occurred from exhaustion at the end of sixty-eight hours. The results of this case were reported soon after in the American Journal of the Medical Sciences, and, although unfortunate, clearly foreshadowed the Porro-Miiller operation, now so widely celebrated. One of the great advantages of the Porro-Miiller operation is that not one drop of blood need to be spilt into the peritoneal cavity, as the uterus is not opened until it has been drawn through the abdominal wound. While maintained in this position a warm, wet, carbolized cloth is held behind the tumor to catch and absorb any blood that may escape from the external opening, and at the same time protect the bowels. For a similar reason a soft, wet, carbolized sponge is retained in the abdominal cavity during the introduction of the sutures. The dressing and after-treatment are conducted precisely in the same manner as in ovariotomy. When this operation is demanded on account of pregnancy associated with a narrow, contracted, or deformed pelvis, rendering parturition at the full term impracticable, it can- not be performed too early, as the chances of recovery will then be proportionately in favor of the mother. Another advantage, and one of no trifling importance, in such a condition, is that the surgeon has a much better opportunity of preparing the woman for the operation. The statistics of these operations have been kindly furnished me by Dr. Robert P. Harris, whose labors in this direction are so well known and so very valuable. The Porro-Caesarean operation had, it seems, up to July, 1882, been performed 91 times; four times in this country, once in Great Britain, thirty-six times in Italy, and fifty times in the rest of Continental Europe, with a saving of thirty-eight living women and sixty-nine living children. The Porro-Miiller method was employed in fifteen cases, of which seven were successful in saving the mother. In comparing the old and the new processes, the results are found to be most striking. In the Krankenhaus of Vienna, in which the old Caesarean operation did not furnish one successful example in a hundred years, the Porro modification has saved eight women out of eleven—the last six in succession—with all the children. In the Santa Caterina Hospital, at Milan, where but seven women were saved out of sixty-two by the old operation, six out of eight women with all the children have been saved by the new. In the Paris Hospitals three women out of six have been saved, and all the children were delivered alive, “against,” says Dr. Harris, “an unin- terrupted series of fatal operations by the classic method, covering a period of eighty years.” Freund’s and Porro’s operations have, according to the statement of the British Medical Journal, been repeatedly performed in England within the last three months— April, 1882—but, with the exception of the cases of Kelly and MacCormac, all termi- nated fatally. Oniy three operations according to the Porro-Miiller plan have been performed in the United States. One of these occurred in the practice of Dr. Elliot Richardson, of this city, in September, 1880. It was necessitated by a deformed pelvis in a dwarf, twenty-five years of age, who with her child made an excellent recovery. The abdominal wound was ten inches in length, and after the womb wras lifted out of its bed, but before it was opened and emptied, its neck was constricted by the loop of the ecraseur with sufficient firmness to arrest the circulation, when it was transfixed, as seen in fig. 706, by two stout pins, and firmly tied with a strong silk cord previously soaked in carbolized oil, and passed twice around the parts exactly in the line of the temporary wire loop. The stump was confined at the lower angle of the abdominal wound which was closed with twelve inter- rupted silver sutures, of which four were superficial and eight deep, the latter being inserted at the distance of half an inch from the line of the inci- sion with a view of securing a firm hold. It is worthy of note that in Muller’s operation, the child is usually in a condition of partial dyspnoea. Of the other two American Porro- Fig. 706. 900 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII . Muller operations, one was performed by Professor Isaac E. Taylor, in 1880, and the other in the same year by Professor D. Ilayes Agnew. The patient of the former died on the twenty-sixth day from cardiac thrombosis, but the child was saved; that of the latter, who was the subject of numerous uterine fibroids, perished at the end of the third day, appa- rently from exhaustion brought on by vomiting, under which she had labored for some time before the operation. The pedicle in Taylor’s case was dropped into the pelvis. The old or classical Cassarean operation, as Dr. Harris terms it, has been per- formed, up to the present date, one hundred and twenty-four times in this country, once in Mexico, and seven times in the West Indies, with a saving of sixty women. In eight of the cases the operation was performed twice, and in one instance three times, one of the latter and two of the former terminating fatally, furnishing thus three deaths in nineteen operations. Of the nineteen children fourteen were saved. Early operations show, as might be supposed, a much higher percentage of recoveries, both of the mother and child, than those performed after the strength of the patient began to fail. Of this class of cases, twenty-one out of twenty-eight of the United States cases have been res- cued, with a saving of nineteen children out of twenty-three born alive. British statistics show a record of one hundred and thirty-four operations, with a sav- ing of twenty-four women and seventy-eight children. Only one of the women under- went a second operation, and she died soon after the last. In thirty-nine of the cases, the operation was performed within the first twenty-four hours of the labor, with a rescue of eleven women and twenty-eight children. Italy equals in the number of its operations those of America and Great Britain combined, but in its results it is little, if any, in ad- vance of the latter. Uterine sutures, composed of silver wire or of uncolored silk, were employed in twenty-four cases, and proved of great service in preventing the escape of fluids from the womb into the abdominal cavity. The antiseptic treatment has not been sufficiently tested to enable us to form a correct estimate of its merits. Anaesthetics, while they lessen the shock of the operation, increase the risk by exciting emesis, which sometimes persists to a dangerous degree. Local anaesthesia, Dr. Harris thinks, is preferable to inhalation, but care must be taken not to let the spray fall upon the uterus, as it always causes vio- lent contraction in that organ. Of the frightful mortality of the old Caesarean operation a faint idea may be formed when it is stated that of 424 cases analyzed by a foreign writer, 210, or nearly one-half, perished. Bauden, in 1873, stated that not one successful example had occurred in Paris during a period of eighty years, although the operation had probably been performed as many as fifty times during the present century; and in Great Britain and Continental Europe generally the result was nearly equally lamentable. The dangers from this ope- ration, now fortunately obsolete, were shock, hemorrhage, peritonitis, metritis, cellulitis, and pyemia. Of 147 fatal cases tabulated by Dr. Charles West, of London, 33 died from shock, 13 from hemorrhage, and 56 from inflammation of the peritoneum, or of this mem- brane and of the uterus. The late Dr. Fleetwood Churchill, of Dublin, collected the particulars of 28 cases in which the Ca;sarean section was performed more than once with the result of 4 deaths, 3 having occurred after the second operation, and 1 after the third. In 20 of the cases the children perished. In one instance the operation was performed five times, in another six times, and in a third seven times, upon the same woman with entire safety to the offspring. The late Professor William Gibson, of this city, succeeded twice in saving both mother and child in the same patient, the operation having been required on account of malformation of the pelvis. RUPTURE OF THE UTERUS. The most common cause of rupture of the womb is the violence of its own contraction during labor, the organ giving way under its inordinate action. It may also be occasioned by external injury, as a fall or blow upon the abdomen, by forcible attempts to turn the child, and by the maladroit use of instruments in the hands of ignorant, rash, or careless practitioners. When the viscus yields under its own expulsive efforts, it may usually be assumed that it has either become softened from inflammatory irritation, or that its walls have become weakened and atrophied by fatty degeneration. Such an occurrence is nearly always fatal, the patient rapidly sinking from the effects of shock and loss of blood. Unless delivery is speedily accomplished, death occurs within a few hours of the accident. When the child cannot be brought away by the vagina— CHAP. XVIII. AFP'ECTIONS OF THE OVARY. 901 and an attempt to do this is only, as a general rule, to be thought of when the feet are still in the uterus—not a moment should be lost in performing gastrotomy. The incisions should be carried along the linea alba, in the same cautious manner as in the Cfesarean section, the child extracted, the placenta removed, and the blood carefully cleared away from the cavity of the abdomen. Every effort should be made to induce prompt uterine contractions, as upon the success of this the safety of the patient will mainly depend. The wound, which can seldom be less than ten inches in length, should be closed with a suitable number of twisted sutures, conveyed through the peritoneum as in ovariotomy, and the after-treatment should be conducted upon general principles. Lambron, in a case of this kind, saved both mother and child. SECT. II AFFECTIONS OF THE OVARY. The most important diseases of the ovary, surgically considered, are inflammation and various kinds of tumors, both of an innocent and malignant character. INFLAMMATION. Inflammation of this organ, technically called ovaritis, is probably a much more com- mon disease than is generally imagined. It is most liable to occur after difficult parturi- tion, provoked abortion, and suppression of the catemenia in consequence of cold. In lying-in females it is generally complicated with inflammation of the uterus, Fallopian tubes, and pelvic veins, and it is then very liable to extend to the peritoneum. The symptoms of ovaritis are usually extremely obscure, a circumstance which readily accounts for the fact that the disease is so often overlooked. In general, the existence of the lesion may be inferred when there is excessive pain in the pelvic cavity, deep-seated, circumscribed, of a burning nature, and aggravated by pressure, motion, coughing, and the erect posture. As the inflammation spreads, the pain and tenderness become more diffused, and the patient generally lies with the limbs well retracted, to take off the tension from the abdominal muscles. High fever is always present; and, if the finger is introduced into the rectum, the ovary may often readily be detected by its large and globular feel. When the diseases passes into suppuration, the occurrence is denoted by rigors, alter- nating with flushes of heat, and accompanied by throbbing pains and an increased sense of weight in the pelvic cavity. If the quantity of pus be considerable, its existence may generally be discovered by a digital exploration of the lower bowel. The abscess may burst into the peritoneal cavity, causing fatal inflammation; or it may send its contents into the rectum, vagina, or bladder. Occasionally, again, especially when the inflamma- tion is associated with disease of the uterus, and Fallopian tubes, the abscess points in the groin, or in the ileoinguinal region. Large accumulations of pus, or sero-purulent fluid, occasionally form in chronic disease of the ovary. In a case of this kind, reported by Ur. Taylor, of this city, the quantity amounted to four gallons. The disease was of long standing, and the organ was converted into a large, vascular sac, weighing seventeen pounds after the removal of its contents. In the treatment of ovaritis, the principal remedies, in its earlier stages, are venesection, especially when there is marked plethora, leeches to the hypogastrium and perineum, followed by fomentations, light diet, strict recumbency, and the use of aconite and morphia, with the neutral mixture. When there is much tenderness of the abdomen, a large blister should be applied. The lower bowel is maintained in an empty condition by enemas, but purgatives should be proscribed, as calculated to aggravate the disease. In ovaritis, consequent upon the puerperal state, the vagina should be frequently washed out with de- mulcent injections, medicated with chlorinated sodium or permanganate of potassium If matter be detected, it may be evacuated through the posterior wall of the vagina, by means of a long, curved trocar, the canula of which may be retained for a few days, to insure patency of the puncture. If pointing occur in the groin or iliac region, the opening is, of course, made there, but not until there is reason to believe that the sac of the abscess has formed tirm adhesions to the surrounding structures. In chronic abscess, the matter sometimes escapes spontaneously by the vagina, or through an aperture in the wall of the abdomen. Should artificial evacuation be demanded, it may easily be effected by a puncture through the linea alba. 902 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. DISPLACEMENTS. Displacements of the ovary are of two kinds, the internal and external, or those in which this organ remains within the pelvis, and those in which it escapes from it so as to form a veritable hernia. The former of these changes are generally dependent upon alterations experienced by the uterus, upon diseased conditions of the ovary itself, or finally, upon the presence of various kinds of morbid growths, by which the ovary is compressed and forced out of its natural relations. A tumor of the ovary, originally de- veloped in the pelvis, will, if unrestained, rise out of this cavity and ultimately, at least in many cases, ascend to a great height in the abdomen. Many of these displacements are irremediable ; others admit of relief by rectifying the malposition of the associated organ, as in reti’oversion and anteversion of the uterus, and others, again, require formi- dable surgical interference. The external displacements of this organ are of great interest, both in a diagnostic and practical point of view. The most common of all are those in which the ovary passes out at the inguinal ring, in the ordinary situation of a hernia of the groin. The descent here may be single, or double, as in the celebrated case of Mr. Pott, and is often congenital, or, if not congenital, it arises within a short time after birth. The organ which may be healthy, or diseased, is sometimes displaced by itself, but more generally it escapes along with the uterus, or the Fallopian tube', or both. Now and then, it is accompanied by a portion of intestine, which is then placed in front, and which always materially augments the bulk of the tu- mor. Cruveilhier has reported a case in which the ovary was lodged in one of the labia, so as to bear a strong resemblance to a testicle in the scrotum. Examples of its escape at the umbilicus, the femoral ring, and the sciatic notch, have been recorded by dif- ferent observers, and are referred to by Deneux in his “ Memoir on Displacements of the Ovary.” Finally, an instance is mentioned by Ruysch, in which the ovary passed through an opening into an abscess of the wall of the abdomen. The diagnosis of a hernia of the ovary is generally extremely difficult. The affections with which it is most liable to be confounded, when it takes place at the groin or the upper part of the thigh, are intestinal hernia, and various morbid growths, as enlarged lymphatic glands and cystic tumors. The situation of the ovary alone will usually suffice to dis- tinguish the disease from a swelling of a lymphatic gland, as the former is nearer to the middle line than the latter. Besides, it is seldom, in the latter affection, that the disor- der is confined to one of these bodies ; on the contrary, considerable numbers are com- monly involved, and they are, moreover, almost invariably more or less tender, red, and infiamed. The ovary always lies at one of the rings, immediately beneath the skin, forming#, firm, movable, clearly defined swelling, free from pain, and unaccompanied by any change of color on the surface. Dragging sensations are experienced in the groin, pelvis, and hypogastrium, increased by walking and other exertion; and the tumor, as already stated, feels hard and solid, not soft and gaseous, as in hernia. The size of the tumor may be considerable when the descent is accompanied by the uterus, or a portion of the bowel ; and in the latter event the mass may be partly soft and partly solid, very much as in an entero-epiplocele, as was first pointed out by Lassus. When there is any doubt, valuable information may be elicited by the shock impressed upon the tumor through the uterus by the finger in the vagina or rectum. The history of the case must also be carefully considered. The treatment consists in restoring the dislocated organ, if possible, to its natural situ- ation, and in preventing a recurrence of the accident by the employment of a truss. Strangulation may require the use of the knife. Lassus, in a case of this kind, left the ovary in its abnormal position in the hope that it might act as a permanent obturator, and a similar plan was adopted by Deneux. Excision may become necessary when the organ is so exquisitely tender and painful as to interfere seriously with comfort and usefulness, as in the case of Mr. Pott, in which both glands were in this condition. A ligature being applied to each pedicle, severance was effected with the knife, followed by speedy con- valescence. TUMORS. The principal innocent growths of this organ are the fibromyomatous and cystic, the latter of which may be either single or multilocular. Of the malignant, by far the most common is the encephaloid ; the colloid, melanotic, and scirrhous being very infrequent. Sarcoma is occasionally met with. CHAP. XVIII. TUMORS OF THE OVARY. 903 Tlie jibromyomatous tumor of the ovary is uncommon ; in most cases it occurs in asso- ciation with more or less cartilaginous matter and osseous concretions. Its density is, consequently, very great, so much so as to bear a close resemblance to a mass of scirrhus, thus sometimes deceiving the unwary in regard to its real character. Occasionally cysts of considerable size, tilled with various kinds of materials, are interspersed through its substance. In cases of long standing, the fibrous tissue is sometimes almost entirely replaced by the cartilaginous and osseous. The tumor is of a whitish, grayish, or drab color, irregularly lobulated, of slow growth, free from pain, or nearly so, and capable of attaining a large bulk, often weighing many pounds, and greatly incommoding by its pressure. The unilocular cyst, or the simple cystic tumor of the ovary, is, as the name implies, a single bag, consisting essentially of the peritoneal and albugineous tunics of the organ, greatly thickened by interstitial deposits, and occupied by serous fluid, of a pale straw color, viscid in its consistence, and composed of a large proportion of albumen, as is shown by the fact that it is nearly all converted into a solid mass on the application of heat. Its quantity varies in different cases, and under different circumstances, from a few ounces to a number of gallons, as many as thirteen having been removed at a single operation. When the disease is of long standing, the fluid is often remarkably changed in its physical properties. Thus, it may be thick and ropy, like soft soap; green and tremulous, like jelly ; or dark and thick, like molasses. The cyst is, at first very thin, and, perhaps, almost translucent; but, as the disease progresses, it steadily augments in thickness and strength, and eventually acquires almost a leathery firmness. Under these circumstances, also, it generally forms adhesions to the surrounding parts, especially the wall of the abdomen, the bladder, uterus, omentum, and small intestine. Vessels of considerable size may be seen passing over its surface and dipping into its substance. Of the causes of ovarian dropsy, properly so called, nothing is known ; it is often, it is true, ascribed to external injury, as a blow, fall, or kick upon the abdomen, or violence sustained during parturition, but whether it is really ever produced in this manner admits of doubt, Although hardly any period of life, after puberty, is perhaps entirely exempt from this disease, experience has shown that it is most common between the twenty-fifth and fortieth years, or the period of the greatest activity of the sexual organs. A case has been reported by Dr. A. F. Carr, of New Hampshire, in which an ovarian cyst, weighing nine pounds, was found, on dissection, in a child not quite three years of age. The annexed cut, fig. 707, represents a unilocular ovarian cyst of large size, from a preparation in my cabinet. The uterus is seen to retain its natural form and volume. Attached to its left horn, at the origin of the Fallopian tube, is a small, globular cyst, adherent by a short, slender pedicle, and entirely unconnected with the ovary on that side. The multilocular tumor, or compound cystic growth of the ovary, fig. 708, is composed of a congeries of cavities closely connected together, or developed, as it were, within each other, of variable size and shape ; some being small, and others large, some round, and others ovoidal, or more or less irregular, and most of them occupied by different substances. The youngest generally contain a thin, serous fluid, whereas the older are filled with a thick, glu- tinous material, resembling jelly, soft soap, suet, honey, molasses, or a mixture of blood and starch. The larger cysts are often as big as an adult’s head, and the walls are then frequently from three to six lines in thickness, very strong, and remarkably vascular. The multilocular tumor is usually of rapid development, and is capable of acquiring an enormous bulk, becoming early united to the surrounding parts, and seriously implicating the general health. Cases, however, occur in which its progress, at least for a time, is very slow. Thus, in a middle-aged woman who was under my charge last summer, the disease was of nearly twenty years’ duration. The adjoining sketch shows the secondary cysts on the wall of the largest primary cysts with broken dowm partitions. Fig. 707. Unilocular Ovarian Cyst. 904 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. The two forms of cyst here briefly described, wrhich depend essentially, there is good reason for believing, upon cystoid degeneration of the Graafian follicles and the stroma ot the ovary, are sometimes associated ; one part of the tumor being unilocular, the othei Fig. 708. Section of a Multilocular Ovarian Tumor. multilocular. Again, instances occur in which they contain, as already intimated, vari- ous kinds of solid matter, as papillary, adenomatous, cartilaginous, and osseous formations. Sometimes they are occupied by hydatids, or acephalocysts, either attached to the inner surface of the sac by narrow, slender necks, or floating about in serum. An ovarian tumor occasionally contains teeth, hairs, and foetal bones, either in separate cysts, or enveloped in a peculiar, saponaceous, fatty, or suety substance. These dermoid cysts, as they are termed, are nothing more than enlarged Graafian follicles, the walls ot which have the structure and properties of the outer skin, and are endowed with great formative power. They sometimes attain the volume of a foetal head, are observed in intrauterine and early extrauterine life, and should not be regarded as rudimentary foetuses, h in ally, cystic ovarian growths, whether simple or compound, are liable to take on inflammation, eventuating occasionally in suppuration, or in the formation ot abscesses. Malignant growths of the ovary are very rare occurrences. The most common is the encephaloid; the scirrhous, colloid, and melanotic being, as already stated, extremely infrequent. Encephaloid occurs late in life, in single, as well as in married women, and usually runs its course with frightful rapidity. The brain-like matter, which distinguishes this disease, is generally found in small, irregular masses, inclosed in distinct cysts, ot a fibrous texture. They are usually of different shades of color, being ot a pale olive, brownish, or mahogany in some places, white, cream-like, or grayish in others. Branches of vessels may often be traced, in great numbers, into their structure; and not unfre- quently they contain large cysts, filled with serum, pus, or sanious fluid. Scirrhus may occur by itself, forming a hard, dense mass as large as a fist or even a child’s head, of an irregular globular shape, of a whitish, grayish, or drab-colored aspect, and intersected by a great number of membranous filaments. The disease is most liable to show itself about, the decline of the menses, and occasionally coexists with other morbid growths. Colloid of the ovary, fig. 709, may occur alone, or it may coexist with other morbid products, particularly the fibrous and encephaloid; it is capable of attaining a large bulk, and exhibits the same structure as in other parts of the body. It is, however, doubtful whether the majority of so-called carcinomas are not really examples ot colloid degenera- tion of the fibrous tissue of the ovary without any malignant tendency. CHAP. X V 111. TUMORS OF THE OVARY. 905 Melanosis of this organ is not only extremely rare, but probably never occurs without similar disease in other organs. It is most common as an accompaniment of encephaloid, in middle-aged and elderly subjects. Fig. 709. Section of a Colloid Tumor of the Ovary. Ovarian dropsy and tumors of large size and of long standing are generally attended with remarkable changes in the wall of the abdomen. The muscles, from the great and constant pressure exerted upon them, are gradually attenuated, and ultimately almost completely deprived of their characteristic features. In a case under my care, not long ago, in an elderly lady who had suffered from enormous ovarian distention for upwards of thirty-five years, the abdominal muscles were reduced to mere fibrous membranes, per- fectly white, and without any trace, apparently, of the natural structure. The diaphragm had undergone a similar transformation. When, on the contrary, the disease is of rapid formation, these parts experience no material alteration, and the abdomen may even be unusually loaded with fat. The adhesions which the tumor forms with the surrounding structures vary in degree and extent. In recent cases the tumor is not unfrequently entirely free, whereas, in old ones, strong and extensive attachments may generally be looked for, not only to the wall of the abdomen, but also to the viscera, especially the b.owels and omentum, the latter of which may at the same time be remarkably hypertrophied and vascular. Finally, ovarian dropsy and tumors may be complicated with, or give rise to, various other affections, as hernia, especially of the umbilicus, hemorrhoids, and prolapse of the rectum, vagina, uterus, and even the bladder, as in a remarkable case under my charge a few years ago. Such occurrences, which are most liable to take place when the morbid growth is solid, or partly solid and partly fluid, and firmly adherent to the pelvic viscera, always add greatly to the patient’s suffering. In the case here adverted to, the woman was so uncomfortable that she was hardly able to walk or sit, and was constantly annoyed with a desire to urinate. Diagnosis Tumors of the ovary, from whatever cause arising, are liable to be con- founded with various other affections, of which the principal are ascites, tumors of the uterus, pregnancy, and enlargement of the omentum, liver, spleen, and kidney. The greatest difficulty usually occurs when the morbid growth is of a solid nature. From ascites, cystic tumors of the ovary are usually distinguishable by the following signs:—1. They are more tense, circumscribed, and protuberant. 2. They are situated more to one side, especially in the earlier stages of their progress, whereas in general dropsy the distention is equally diffused. 3. They are but little, if any, influenced by change of posture, while in ascites the fluid gravitates towards the lowest part of the ab- domen when the patient sits up, and towards the posterior part when she lies down. 4. In ovarian dropsy the neck of the uterus is usually drawn up into the pelvis, perhaps almost beyond the reach of the finger; in peritoneal effusion, on the contrary, it occupies its accustomed situation, and may generally be easily pushed from one side to the other. Important information is usually furnished by the state of the general health in the two affections. In ovarian dropsy, especially the unilocular variety, the health nearly always remains natural, or nearly so, for a long time; whereas in ascites it is commonly more or less seriously disturbed from the first, the disease which causes and accompanies it having firmly impressed itself upon the constitution before the effusion shows itself. To these circumstances may be added the fact that ovarian dropsy is usually very tardy in its 906 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. progress, while ascites is ordinarily quite the reverse. When the disease is complicated with abdominal dropsy, the diagnosis may generally be promptly established by para- centesis. The ordinary situation of the cystic tumor of the ovary is well shown in fig. 710, the wall of the abdomen having been cut away. Fig. 710. Unilocular Ovarian Cyst, uncovered. Finally, valuable assistance may commonly be elicited by a microscopic inspection of the fluid after tapping. If the tumor be ovarian, there will always be, especially in old cases, an abundance of disintegrated blood globules, large granules, epithelial cells, oil cells, pigments, and crystals of cholesterine, as ex- hibited in fig. 711. In ordinary ascites, on the con- trary, there is generally an absence of these bodies. Mehur, who has very recently made numerous ex- aminations of the contents of ovarian cysts, dis- covered cholesterine only nine times in one hundred and fifteen specimens taken from sixty-one patients, and only in two specimens of ascitic fluid in three hundred cases, one of the women being the subject of an ovarian tumor, and the other of local peritonitis with albuminuria. Hence, we may conclude that the presence of cholesterine in ovarian fluid possesses a certain but not particular diag- nostic value. Dr. T. M. Drysdale, of Philadelphia, who has enjoyed uncommon opportunities of ex- amining ovarian tumors, has described what he calls “ovarian granule cells,” as charac- teristic of ordinary ovarian cystic tumors. In malignant growths, on the other hand, as shown by Mr. Thornton, of London, there are, as a rule, groups of large pear-shaped, round or oval cells, containing granular material, interspersed with nuclei, nucleoli, and vacuoles, or transparent globules. The facts recorded by these observers are of great diagnostic value, and point to the necessity of making, in all cases of doubt, a thorough microscopic examination before attempting an operation. Tumors of the uterus may be mistaken for ovarian, and conversely, as is proved by the fact that numerous operations have been undertaken for morbid growths that were sup- posed to be ovarian, but turned out to be uterine. The diagnosis between the diseases of these two organs is by no means always easy. The enlargement of the uterus may depend upon the presence of a solid tumor in its cavity, within its walls, or upon its outer surface, and the consequence may be that the organ is pushed to one side, thereby closely imitating the situation ot an ovarian tumor, especially in its earlier stages, and rendering it quite impossible to discriminate between them. As the affection of the uterus advances, how- ever, the effacement of the neck of the organ generally affords unmistakable evidence of the fact that the disease is not ovarian. In cases of doubt, the fundus of the uterus, if free from disease, may often be distinctly felt above the pubes, upon the introduction of the sound. A fluctuating tumor of the uterus is .sometimes formed by the retention of the menstrual fluid; but its median situation, its globular figure, the absence of the catamenia, and the obliteration of the mouth of the organ, will afford a sufficient guarantee against any errors Fig. 711. Microscopical Characters of the Fluid of an Ovarian Tumor. CHAP. XVIII. TUMORS OF THE OVARY. 907 of diagnosis. Similar changes occur in dropsy of the uterus and in cystic myomatous tumors; while in physometra, or gaseous accumulations, the remarkable resonance ac- companying the disease is always characteristic. Finally, in ovarian disease, the uterus generally retains its natural shape and size. Pregnancy has been mistaken for ovarian disease ; such an accident, however, can hardly happen to a cautious, educated surgeon. The chief signs of distinction are, the history of the case, as the morning sickness and the absence of menstruation ; the median situation and gradual development of the tumor; the changes in the breast and in the mouth and neck of the uterus ; and, by and by, the discovery of the pulsations of the foetal heart and of the placenta. A sarcomatous enlargement of the omentum has been mistaken for an ovarian tumor. The patient, about to be operated upon, has suddenly died, and the dissection has revealed remarkable disease of the omentum, but none whatever of the ovary. A floating spleen or kidney may be a cause of embarrassment. An enlarged liver, or spleen, or morbid formations connected with these organs, have occasionally led to errors of diagnosis, and instances have been reported where, under such circumstances, the abdomen was laid open under the conviction that the morbid growth was a diseased ovary. The elevated and lateral situation of the tumor ; its gradual development from above downwards, instead of from below upwards, as in ovarian disea.se; the continuance of the menstrual function ; and the natural position of the neck of the uterus, will generally suffice to prevent mistake. The history of the case will also serve to throw important light upon the diagnosis ; for in organic maladies of the liver and spleen, there are always symptoms peculiar to the affections of each of these organs, and which, consequently, are wanting in ovarian tumors. A renal cyst, hydronephrosis, or dropsy of the kidney has been mistaken for ovarian dropsy. A little care, however, will generally suffice lor a correct diagnosis. In renal disease, the tumor is developed from above downwards, is confined originally to the ilio- lumbar region, and only after a long time descends into the pelvis. The growth is fixed in its position from first to last, and there is always, as was first pointed out by Mr. Wells, a narrow cord-like bridle of intestine, movable on manipulation, in front of the cyst. In renal disease the menstrual function remains natural, and the urine contains an undue quantity of mucus and epithelium, either alone, or, if the ureter is still pervious, mixed with pus, albumen, or both. The exploring needle and the microscope should be em- ployed in case of doubt. Finally, inordinate distention of the abdomen from the accumulation of gas and fecal matter has occasionally been mistaken for ovarian enlargement. Any doubt, however, arising from such an occurrence, may readily be dispelled by an efficient cathartic. The diagnosis of an ovarian tumor is sometimes rendered difficult by the existence of air in its interior, either generated by the partial decomposition of its contents, or introduced through an opening of communication between the sac and the uterus, vagina, or intesti- nal tube. However this may be, the abdomen always yields a hollow, tympanitic sound on percussion. The most reliable circumstances here, as it respects the diagnosis, are the history of the case, and the inequality in the consistence of the morbid mass, some por- tions being soft and sonorous, while others are hard and dull. The diagnosis between ovarian growths themselves is not always so easy as might at first sight appear. The multilocular cyst is usually distinguishable from the unilocular by the greater rapidity of its growth ; its more solid character, one part feeling hard and another soft; by a sense of greater weight and pressure ; by the more early failure of the general health ; and by the more marked enlargement of the subcutaneous veins of the abdomen. The fibrous, cartilaginous, and other solid non-malignant tumors may generally be readily distinguished, at least in their early career, by their lateral situation, by their great firmness and mobility, by the tardiness of their progress, and by the want of dis- turbance of the general health, which frequently remains unaffected for years. Malignant ovarian tumors, on the other hand, are characterized by the rapidity of their progress, by their great bulk, by the severity of the local suffering, and by the inroads which they always make upon the constitution even at a very early period of their existence. In encephaloid growths the surface of the abdomen is generally knobby, or very irregular, being hard and firm at one point, doughy and semisolid at another, and, perhaps, elastic at a third. The disease, in its latter stages, is always accompanied by great enlargement of the subcutaneous veins. 908 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. The presence of adhesions between the tumor and the surrounding parts may generally be inferred by the want of mobility of the morbid mass, as determined by the variation of the patient’s posture, a careful digital examination, and the effects of a full inspiration, during which, if the tumor be non-adherent, it is sensibly depressed by the descent of the diaphragm. In case of great doubt, in which all the ordinary means of diagnosis have signally failed, the hand may be cautiously inserted into the large bowel. The fingers being car- ried about through the pelvic and abdominal cavities, in different directions, the surgeon will thus be able to ascertain whether the morbid growth is ovarian, uterine, renal, sple- nic, omental, hydatid, or cystic. Such explorations of course should always be conducted with the greatest care and delicacy, otherwise the anus and bowel may be serionsly in- jured from overdistention, or, as has happened in several instances, the patient may perish from shock, rupture of the bowel, peritonitis, or other causes. Progress The progress of ovarian tumors is extremely variable. In the benign forms it is often remarkably slow, causing hardly any suffering, either local or constitutional. Hence, the patient often lives in comparative comfort for years together, and may even bear children, although, in general, abortion takes place if pregnancy occurs, owing to the in- ability of the uterus to expand, so as to accommodate itself to the gradual growth of the child. In most cases, however, she suffers great inconvenience and annoyance, and ulti- mately dies, within the first five or ten years, exhausted, either from the drain upon her system, or from constitutional irritation. The multilocular tumor is always a more serious disease than the unilocular, or fibrous ; while the encephaloid pursues a most rapid and unrelenting course, death usually occurring within from ten to fifteen months from the invasion of the malady. In the simple cystic tumor, the sac is sometimes ruptured, either spontaneously or ac- cidentally ; occasionally followed by a radical cure, especially when the tumor is small, but very frequently also by death. Thus, of 72 cases of this kind collected by Mr. Tilt, 32, or nearly one-half, perished from peritonitis. When a spontaneous cure is effected, the water escapes through the Fallopian tube, vagina, bowel, bladder, umbilicus, or wall of the abdomen. In a case mentioned to me by the late Dr. William Pepper, an enormous ovarian tumor, of many years’ standing, emptied itself through the bladder. The lady, feeling a desire to relieve herself, filled in rapid succession six large chamber pots with fluid; the swelling immediately subsided, and a cure gradually followed. In another case reported to me by Dr. T. P. Gibbons, the water apparently escaped through the Fallopian tubes. The woman, who was fifty-two years, woke up suddenly one night, and found, to her surprise, her bed completely deluged with fluid. The tumor gradually decreased, but subsequently refilled, until it had at- tained a greater bulk than before. At the end of about twelve months, however, it again gave way, and the discharge now continued until all trace of the disease had disappeared. I have the notes of two cases in which the tumor emptied itself through the wall of the abdomen, the cure in one being permanent. In a case of this disease, in a young lady of twenty-four, whom I saw with Dr. Joseph H. Wythes, the tumor had formed a communication between the fundus of the bladder and the descending colon, eventuating in the establishment of a stercoraceous fistule. After much suffering and annoyance, the opening in the abdomen finally closed, but death oecurrred three months subsequently from an attack of typhoid fever. On dissection, the ovarian cyst, of an oval shape, and about five inches in diameter, was found to be occu- pied by a large mass of sebaceous matter, intermixed with a considerable quantity of hair and two irregular pieces of bone, studded with well-formed teeth. A case in which a fibroid tumor of the ovary, of a spherical shape, and about six inches in diameter, occasioned fatal peritonitis by the twisting of its pedicle, has been reported by Professor Van Buren, of New York. When ovarian disease coexists with pregnancy, the woman may go to the full term and be safely delivered, provided the tumor is not very bulky or the cyst unusually thin. When this is the case, there is, as Mr. T. Spencer Wells has conclusively shown, great danger of abortion ; or, if the full term be reached, of a painful and protracted labor with a dead child; or, what is still worse, the cyst may burst and the mother perish from shock, hemorrhage, or peritonitis. Death, however, even in such an event, is not in- evitable. If the tumor be at once removed, and the abdominal cavity thoroughly cleansedi, gestation may proceed safely to the full term. Mr. Wells refers to several cases in which the uterus was punctured during ovariotomy, in only one of which recovery took place, CHAP. XVIII. TUMORS OF THE OVARY. 909 owing, as was supposed, to the fact that delivery was effected before the completion of the operation. Treatment—Medical treatment exerts little, if any, direct influence upon the progress and termination of ovarian disease of any kind. A cure, it is true, is occasionally effected in unilocular dropsy of this organ, but the occurrence is so extremely infrequent that it must be regarded as altogether of an exceptional character. The remedies upon which the greatest reliance has hitherto been placed are the dif- ferent preparations of iodine, as Lugol’s solution and iodide of potassium, given in mode- rate doses, three times daily, dilute ointment of biniodide of mercury, and tincture of iodine, applied freely to the tumid abdomen, at least twice in the four-and-twenty hours. Pressure has also been highly recommended, but, although I have frequently tried it, I do not know that it has ever afforded any good in my hands, and the same remark, in fact, is true of everything else that I have ever used in the way of general and local medication. Mercury, carried to gentle and persistent ptyalism, has been employed in numerous instances without any benefit. Electrolysis offers no promise of relief; for, although instances of its successful employ- ment have been reported, I have no confidence whatever in its efficacy. The treatment, in the cases hitherto published, was always exceedingly tedious, and we are left in doubt respecting its ulterior results; or, in other words, whether it was not generally, if not always, followed by relapse. If it be of any use at all, it can be so only in the incipient stages of the complaint, before the inclosing cyst has undergone any serious structural changes, or become adherent to the surrounding viscera. The period at which death occurs in ovarian diseases, if left to itself, must necessarily vary with so many circumstances as to render it impossible to lay down any definite laws upon the subject. Before ovariotomy became generalized, many women, the subjects of this affection, lived for many years in comparative comfort, and eventually died of other maladies. Even now we occasionally meet with cases of many years’ duration. Rapid growth, even when non-malignant, is very liable to undermine the general health propor- tionately fast, while the malignant often makes frightful inroads upon the system in the space even of a few months. Some authors have attempted to fix upon an average during which a woman may live with an ordinary ovarian tumor; the period agreed upon rang- ing from three to five years ; but this is certainly too short, while in the more severe forms it is evidently too long. The treatment, so far as surgical interference is concerned, may be divided into pallia- tive and radical; the former consisting of occasional tapping, to take off the weight and pressure of the fluid from the diaphragm and abdominal viscera; and the latter in the removal of the tumor, or, if it be encysted, in the injection of certain fluids, or the ex- cision of a portion of its walls, with a view to the obliteration of its cavity. Tapping Tapping of the unilocular form of ovarian dropsy is frequently requii’ed with a view to palliation ; but it should not, as a general rule, be performed so long as the patient is comparatively comfortable, experience having shown that when it has once been done it will usually have to be done soon again. I am acquainted with an instance, in which the cyst, however, is combined with a solid tumor, where the operation has been performed upwards of sixty times in less than a year, the quantity of fluid removed at each operation being from four to eight quarts. The patient usually gets on best after tapping when the cyst is perfectly simple, or when it is associated with a stationary fibrous tumor of small size. In a case upon which I operated for the late Professor Meigs, in October, 1856, para- centesis had been performed twenty-seven years previously, and yet the general health had all along been very good. Twelve months after this the patient desired to be again tapped, but this I declined doing, and she bore her burden until the spring of 1860. The operation was repeated in May, 1862, thrice in 1863, and once in March, 1864. She died, completely exhausted, the following April, at the age of seventy-one. The quantity of fluid drawn off during this time amounted to sixty-nine gallons ; it was generally of a dark color, highly coagulable, and of the temperature of 98°. The sac, which was uni- locular and extremely thin, with a very narrow pedicle, contained five gallons of fluid after death. The only inconvenience which this lady experienced during the seven years and a half of my attendance upon her was of a mechanical character, growing out of the immense size of the abdomen interfering with exercise, good looks, and, at times, with respiration. Her general health was usually most excellent. Altogether she lived upwards of thirty-four years from the time of the first operation. 910 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. One of the most interesting features in this case was the existence of thousands of little buds or papillary vegetations upon the inner surface of the sac, resembling very much the granulations of a healing ulcer of the skin. They were of a rounded or ovoidal figure, ex- tremely vascular, and of a beautiful florid color. In size they varied from a clover seed to that of a large pin head. The microscopical appear- ances of these vegetations are well illustrated in fig. 712, from a drawing by Dr. Packard. In general, the water rapidly reaccumulates after tapping, despite everything that can be done to prevent it. In most of the cases in which I have performed it, the tumor was nearly as large in three or four weeks, and sometimes even at the end of a fortnight, as at the time of the operation. In consequence of the steady drain thus established, the patient generally rapidly declines in flesh and strength, and ere long dies completely exhausted. Now and then, as happened in my own case, the patient lives many years in comparative comfort after such interference. Nockler, father and son, tapped a female, in thirty-one years, 122 times, from sixteen to eighteen quarts of fluid being drawn off at each operation. She was in good health at the age of sixty-nine. A still more remarkable instance has been recorded by Roloff, in which a woman, forty- four years old, was tapped altogether, during seven years, 187 times, 125 times by her medical attendant, and 62 times by herself. The operation was, at first, performed very seldom, but latterly every third day. In the celebrated case of Martineau paracentesis was performed 80 times in twenty-five years, the entire quantity of water drawn off being, in round numbers, 829 gallons. Sir Astley Cooper has recorded the case of a woman who died in her twenty-third year, after having been tapped in less than four years 155 times. Temporary relief occasionally follows paracentesis in the multilocular variety of ovarian dropsy, even Avhen the quantity of fluid removed is comparatively small. Tapping should not be performed suddenly; the general health should be seen to; if disordered, it must be corrected, and the bowels gently moved. The urine should be passed immediately before the operation, and great care taken to ascertain by palpation and percus- sion that no adherent coils of intestine lie directly over the tumor in the line of puncture. Any large subcutaneous veins must also be avoided. The skin may sometimes be divided with the scalpel as a preliminary step to guard against the shock of the puncture, and, if the patient be very nervous or timid, partial insensibility may be produced by an anaesthetic, although this will seldom be necessary. The best point for performing the operation is the site of ordinary paracentesis, con- stituting what is known as abdominal ovariocentesis. The patient is placed in a similar posture, with the same precaution as to the support of the abdomen, and the most suitable instrument is the trocar of Hears or Wells, in which the fluid flows through a long gum- elastic tube into the receiver. When the tumor occupies the side of the abdomen, care must be taken to puncture it external to the course of the epigastric artery, otherwise this vessel might be wounded, and the patient die of hemorrhage. The operation may some- times be advantageously performed at the umbilicus, which, when the tumor is large, and of long standing, often presents a pouting appearance, in consequence of the separa- tion of the straight muscles. In a case under my observation not long ago, the patient, a very respectable lady, was in the habit of tapping berself here with an ordinary thumb- lancet whenever she suffered more than usual oppression. In tapping for the relief of the multilocular variety of dropsy, the puncture should be made in the most prominent and fluctuating portion of the tumor, the instrument, which should be large, and at least six inches in length, being afterwards thrust into the smaller cysts until all the accessible fluid has been evacuated. It is seldom that more than one external opening is required. When the operation is over, the abdomen should be firmly compressed by means of a thickly folded cloth and a broad bandage, in the hope of preventing early reaccumulation. Fig. 712. Granulations of an Ovarian Cyst. a. Papillary Process of one of these Bodies. 6. Part of a Papilla undergoing Fatty Degeneration, the Nuclei and Cells becoming indistinct, c. A Detached Cell. d. De- tached Nuclei. CHAP. XVIII. TUMORS OF THE OVARY. 911 The effect should be steadily maintained for several weeks, and should be aided by atten- tion to the diet, bowels, and urinary secretion. Simple tapping is by no means always a safe operation. Of 117 cases reported by Kiwisch, Lee, and Velpeau, 16 perished during the first twenty-four hours; nearly as many within the first month ; and a still greater number during the first year. I have myself never met with such an accident, except in one instance, although I have per- formed the operation a large number of times. But, even in that case, death was at- tributable, not to the operation, but to the imprudence and obstinacy of the patient, who, despite my most earnest remonstrance, went home, a distance of upwards of one hundred miles, on the third day after she was tapped, and died a short time after from peritonitis. Perhaps it would he well, as a rule, not to tap an ovarian tumor if it is in such a condition as to admit of removal, as the operation, as now performed, is hardly more hazardous than paracentesis. Death has occasionally been produced by the perforation of a large venous trunk, ramify- ing on the surface of the cyst; and an instance has been related by Scanzoni, in which fatal hemorrhage was caused by the wound of a vessel of an adherent omentum. Tapping has sometimes been combined with the permanent retention of the canula, in the hope that it might excite inflammation in the sac, and thus cause obliteration. Le Dran, who, in 1736, was the first to employ this procedure, has published two interesting cases .of cure by it; and in modern times it has also occasionally succeeded, although in quite a number of instances it has proved fatal, either from peritonitis or constitutional irritation. Vaginal Ovariocentesis, notwithstanding the favorable opinion formerly entertained of it, has become, in great measure, obsolete, experience having shown that it is a dangerous procedure, as it is extremely difficult, in any case, and with every possible precaution, to prevent the entrance of air into the empty cyst, and the evil consequences thence arising, as decomposition of the new secretions, suppuration, and septicemia, attended with a low grade of fever, generally soon followed by death. The only forms of ovarian dropsy in which, with our present more enlightened views, such an operation, if ever justifiable, are those in which the tumor has contracted firm adhesions to the sur- rounding parts, or those in which it lies deep in the pelvic cavity, behind an enlarged uterus; or, in other words, where it is impossible, from any cause whatever, to approach the cyst through the wall of the abdomen. A canula or drainage tube should, under such circumstances, be retained in the sac, which should be washed out repeatedly during the twenty-four hours with some antiseptic fluid, as a solution of carbolic acid, chlorinated sodium, or permagnate of potassium. Rectal Ovariocentesis is still more objectionable than tapping through the vagina. Here the danger is twofold, from the entrance of air and from the introduction of foul gas from the rectum, which but too surely destroys the patient by the induction of violent inflam- mation, suppuration, and septicemia. It might be supposed, a priori, that the tapping of an ovarian cyst during pregnancy would be followed by miscarriage, or premature labor, but that this is not the case is abundantly proved by the experience of the last twenty-five years. Mr. T. Spencer Wells declares that he has repeatedly performed the operation, and never witnessed any bad effects. Partial Excision A cure has now and then followed excision of a portion of the sac, drawn out through a small wound in the linea alba; the rest of the sac being either secured to the edges of the external opening, or permitted to sink into the pelvis. The procedure, however, is one of much hazard, as it is generally succeeded by violent inflam- mation and death. Nearly one-half of the cases that have been thus treated have perished, so that the operation is far more fatal than ovariotomy itself. Injections Attempts at a radical cure by injections have occasionally been made. The operation was, at one time quite the fashion, and was only arrested by its want of success, or, rather, by its mortality, which was, on the whole, proportionately very large. Even in many of the cases that were reported as successful, the dropsy eventually re- turned, and soon attained its former height. The favorite article for injecting the sac was tincture of iodine, sometimes pure, but more generally considerably diluted, and intro- duced in (juantities varying from one to six or eight ounces, according to the size and age of the cyst. As might have been supposed, the operation was often followed by severe inflammation, leading to copious sero-sanguinolent effusion, and not unfrequently extend- ing to the peritoneum. It must be evident that such a procedure is chiefly applicable to small and recent ovarian cysts, but even here one should hesitate a good while before resorting to it. 912 DISEASES OF T’HE FEMALE GENITAL ORGANS. CHAP. XVIII. Statistics of this operation have been supplied by different surgeons. Of 130 cases re- ported by Velpeau G4 were cured, 30 died, and 36 were temporarily ameliorated. It is proper to add that, in 20 out of the 30 patients who died, the injection was associated with the retention of the canula in the sac for a long period, with a view ot facilitating drainage. Of 158 cases, collected by Gunther, in six of which, however, the result is not given, 32 were cures, 61 failures, and 59 died. Boinet has reported 45 cases, in 34 of which the cyst was simple, and in 11 compound. Ot the former ol were cured, and 3 died, while of the latter there were 5 failures, and 6 deaths. Professor Thomas has analyzed 347 cases, of which 117 were cured, 95 failed, 79 died, and 56 are reported as uncertain. In 4 cases treated in this way by Scanzoni, the result in every one was fatal, and the mortality in the hands ot several other practitioners has been almost as gieat. Simpson, on the contrary, lost only 1 patient out of upwards of 40 after this operation. My conviction, nevertheless, is, that iodine injections, however carefully performed, are fraught with danger, and that, although they may occasionally be productive of tem- porary benefit, they are seldom, if ever, followed by a permanent cure. Cases of this operation have been recorded in which death was caused by mere shock without evidence of peritonitis. . . The injection may be performed with an ordinary gum-elastic bag, provided with a long narrow nozzle and a stopcock, the contents of the sac having pieviously been thoroughly evacuated with along trocar and canula. The quantity ot fluid to be intro- duced must vary, according to the age and size of the tumor, from two to eight ounces, which may either be left in the sac, or, if productive of severe pain, be partially with- drawn. The officinal tincture of iodine, diluted with from two to eight parts of alcohol, is the most suitable preparation. The danger ot the operation will be materially dimi- nished if the injection be withheld until the second tapping, performed within a short time after the 'first, as this affords the sac an opportunity of shrinking. The abdomen should be well kneaded in order to bring the fluid in contact with every part ot the sac, and care taken that no air is admitted. When the operation is over, the puncture is closed with adhesive plaster, supported by a large compress and a broad bandage. I he after- treatment must be strictly antiphlogistic. If symptoms of septicemia supervene, no time should be lost in perforating Douglas’s cul-de-sac, and inserting a large drainage tube, in order that the fluid may have free vent, as fast as it forms, and the cyst be washed out from time to time with some weak antiseptic lotion. Ovariotomy.—Ovariotomy had many trials and difficulties, as well as many preju- dices, to encounter, but it has triumphantly surmounted them all, and now stands foith, not only as one of the recognized procedures ot surgery, but as one which can boast ot a more brilliant record than any capital operation whatever. For its wonderful achieve- ments it is indebted to many gynecologists, chief among whom may be mentioned the two Atlees, Washington and John, who manfully battled for it in this country, and Clay and Wells, who successfully introduced it into Europe, after it had been almost forgotten on both sides of the Atlantic. The operation is no longer regarded as a murderous one, or as an opprobrium of the profession, but as one which, when judiciously performed, gen- erally ends in recovery, and one which has already added nearly titty thousand years to the life of woman. Ovariotomy is of American origin, having been first performed in December, 18(. , by Dr. Ephraim McDowell, of Kentucky. The patient, a married woman, the mother of several children, recovered without any untoward symptoms, surviving the operation thirty-two years. The tumor, partly solid and partly fluid, weighed twenty-two pounds and a half. Until recently it was generally imagined that this operation had been devised and first practised, in 1776, by L’Aumonier, of Rouen ; but in my Report on Kentucky Surgery, presented to the Kentucky State Medical Society in 1852, I clearly showed that the case of the French surgeon was one simply ot abscess ot the ovary and the Fallopian tube, occurring in a prostitute consequent upon parturition, lor the purpose of affoi cling free vent to the purulent fluid, which had for some time escaped by the vagina, an incision, four inches in length, was made along the lower edge ot the external oblique muscle, when, the diseased parts being separated from each other, the ovary was removed. Ihe oi’gan, which was encysted, was about the volume ot an egg, and of great hardness. From data furnished me by some of McDowell’s contemporaries I have reason to believe that he performed this operation altogether about thirteen times, with the result of eight cures, four deaths, and one failure, due to inability to complete the operation on account of extensive adhesions of the tumor. Ilis first three cases were published in the seventh, and the next two in the ninth, volume of the Philadelphia Eclectic lieper- CHAP. XVIII. TUMORS OF THE OVARY. 913 tory. Of these five cases, three recovered, one perished from peritonitis, and the other remained well for nearly five years, when the tumor, which had been tapped, but which it was found impossible to extirpate, recommenced growing, and gradually regained its former bulk. Professor Nathan Smith, of New Haven, in 1822, extirpated an ovarian cyst, contain- ing eight pounds of fluid, from a woman, thirty-three years of age, the mother of five children, who recovered without any grave occurrence. The incision, made along the linea alba, was not more than three inches in length. The next case, also a successful one, which occurred in this country, was that of Dr. David L. Rogers, of New York, in 1829. Removal was effected by the long incision, the tumor, partly solid and partly fluid, weighing ten pounds and a half. The circumstances which, in my opinion, render ovariotomy proper, are the following: 1st. Simple cysts, attended with more or less rapid accumulation, and a regular, steady, downward tendency, rendering it probable that, if relief be not soon afforded, the disease will prove fatal, or pass beyond the limits of'safety for surgical interference. 2d. Multilocular cysts, steadily progressive, but without strong adhesions, and accom- panied by gradual decline of health and strength. 3d. Solid tumors, of a non-malignant nature, whether fibrous, cartilaginous, partly cartilaginous, and partly osseous ; especially when they are rapidly increasing in size, or have already attained a large bulk, and are attended with ascites and more or less dis- order of the general health; provided, of course, that there are no serious adhesions. In this category may be included those tumors of the ovary which are caused by extrauterine fetation and by conception by inclusion, particularly when there is reason to believe that the patient will perish unless assisted in this way. On the other hand, an operation may be considered as unjustifiable, 1st, when the tumor, whatever may be its structure, is strongly and extensively adherent; 2dly, when the disease, from neglect, mismanagement, or other causes, has been productive of such a degree of exhaustion as to render it probable that the patient will not be able to bear the shock of the operation ; 3dly, when the tumor is unequivocally of a malignant nature; and, 4thly, when it is impossible to arrive at a satisfactory diagnosis, especially after having made an exploratory incision, which, under such circumstances, is often not only proper but highly necessary. No operation, of course, is to be thought of when there is serious organic disease of other organs, as the heart, lungs, liver, or kidneys. The existence of albuminuria is a positive contraindication to interference, and a similar rule is applicable to extreme de- pression of spirits. No operation should be undertaken during the prevalence of an epidemic. While pregnancy is not a positive bar to ovariotomy, surgical interference should, if possible, be postponed until after delivery. The most reliable statistics of ovari- otomy during pregnancy were recently furnished by Dr. II. P. C. Wilson, of Baltimore. He finds that in all 29 operations were performed, with 24 women and 20 children saved. Of these cases Mr. Wells had 10, Schroeder 7, Kimball 2, W. L. Atlee 2, and J. Marion Sims, J. F. Bird, A. L. Galabin, Lawson Tait, and T. G. Thomas, each 1. I have myself had 1 case in a young woman, pregnant four months, who miscarried the night after the operation, but made an excellent recovery. Dr. Wilson, instead of temporizing in ovarian disease complicated with pregnancy, is in favor of prompt interference, espe- cially during early pregnancy, and in cases in which repeated tappings might increase the risk of the formation of adhesions. Some preliminary treatment is generally proper, but this should not be carried too far, otherwise it may prove prejudicial. The secretions should always be carefully corrected ; and, if the patient is debilitated, she should be subjected for at least a fortnight to the use of tonics, especially quinine and iron. Women in robust health do not bear the opera- tion as well as those whose system has become enured to suffering, which thus establishes a certain degree of tolerance to the employment of the knife. Age is no bar to ovari- otomy, provided the patient has sufficient strength to bear it, or there are no serious com- plications. Professor Jouon, of Nantes, performed the operation successfully upon a girl only twelve years of age, and in a case in the hands of Basil, of Bonn, the child was only two years old. Nearly all cases occurring at this tender age are examples of der- moid cysts. The instruments that are required for ovariotomy are, a large scalpel, a probe-pointed bistoury, a trocar, a clamp, a dozen flexible metallic pins, and several long acupressure needles. Only very soft and fresh sponges should be used. Warm and cold water should be at hand, together with two rolls of cotton, a broad double flannel bandage, 914 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. and an ordinary sized breakfast-table, well covered with blankets, and provided with several large pillows. The day before the operation the bowels should be thoroughly cleared with castor oil, followed in the evening by a warm bath and ten grains of quinine, a similar dose being administered in the morning. The breakfast must be a light one, consisting of a cup of beef-tea with a cracker, toast and tea, or a glass of milk punch. The bladder must be emptied just before the operation, and it will be well to throw one-third of a grain of mor- phia under the skin, or, what I prefer, to give twenty-five drops of acetate of opium by the mouth, to prevent the unpleasant effects of the ether. If very weak, the patient should take from half an ounce to an ounce of whiskey. A flannel sacque and drawers should be worn during and after the operation, and the feet incased in woollen stockings. The operation should be performed under antiseptic precautions, but it is not necessary to tear up the carpet of the room, to empty the bureaux, or to make the surgeon and his assist- ants change their clothes. The air of the apartment should be moist, and heated to a temperature of 80° Fahr. A narrow bed will be much more convenient for the nurse than a double one. No operation of this kind should be performed in the amphitheatre of a college or hos- pital, in the presence of a medical class, inasmuch as it is entirely impracticable under such circumstances to maintain a proper degree of temperature and other requisite hygie- nic conditions so essential to success. I should consider a surgeon as criminal who disre- garded this injunction. The operation, as now practised, is performed at the middle line of the abdomen, either by the long or short incision, as it is termed, the choice depending upon the nature of the case, especially the size of the tumor, and the presence or absence of adhesions. Mc- Dowell, in his first case, made his incision on the left side, some distance from the outer edge of the straight muscle, its length being nine inches. Subsequently, he cut through the linea alba, the place now universally selected for the operation, the patient lying upon her back on a narrow table, with the head and shoulders well elevated, and the feet rest- ing on a high chair. The bowels and bladder are, as above stated, thoroughly emptied as a preliminary step; and it will be well to confine the knees and elbows to prevent struggling. During the operation the patient is kept thoroughly warm and fully under the influence of an anaes- thetic. The superficial incision is made with an ordinary scalpel along the linea alba, through the skin and connective substance, and varies in length, according to the nature and size of the tumor, from five to ten inches. If the tumor is large and solid, the wound must necessarily be proportionately long, otherwise it will be impossible to draw it out without the further use of the knife. If, on the other hand, the contents are fluid, or chiefly fluid, an incision two and a half or three inches in length, mid- way between the pubes and umbilicus, will be quite sufficient. In some of the recorded cases the wound has been canned as high up as the xiphoid cartilage. No vessels of any size are divided in this stage of the operation. For the deep incisions the proper instrument is the probe-pointed bistoury, guided upon the index and mid- dle fingers of the left hand. The operation will be greatly facilitated, especially if the tumor be unusually bulky, by evacuating its contents, as may always be easily done when they are fluid, with a large trocar, a good form of which is that of Dr. J. Ewing Hears, represented in fig. 713, care being taken that none of the matter escapes into the cavity of the abdomen. The trocar of Mr. Wells is shown in fig. 714; it has two spring handles, each furnished with a series of hooks soldered to the outside of the canula, by which the latter can be securely fastened to the cyst until it is turned out of the abdomen. The bowels, during the dissection, are held out of the way by an assist- ant, and, if necessary, kept warm with flannel wrung out of warm water. The tumor, it perfectly loose, is now separated at its pedicle, previously embraced in a very stout, car- Fig. 713. Mears’s Trocar. Fig. 714. Wells’s Trocar. CHAP. XVIII. TUMORS OF THE OVARY. 915 bolized catgut ligature, tied very firmly, the ends being cut off close to the knot, and the whole so arranged as to prevent the possibility of hemorrhage. If any adhesions exist they must be broken up with the fingers, either alone or with the aid of the knife or scissors, which, however, should only be used as a matter of absolute necessity. The instrument, indeed, must be employed most warily, chiefly for the division of narrow, slender bands; for, if the attachments are uncommonly firm and extensive, such a procedure would in- evitably be followed by copious hemorrhage, and violent, if not destructive, peritonitis. If the omentum be inseparably united to the tumor, it must be retrenched, the stump, if not very large, being tied up in a mass, and fastened in the upper angle of the wound; or each vessel is secured separately with the catgut ligature. The extirpation being completed, the bleeding arrested, and any fluid, whether san- guineous or ovarian, that may have fallen into the pelvic cavity removed with the sponge, the clamp, fig. 715, if used, is brought out at the lower extremity of the wound, the edges of which are next approximated by numerous points of the twisted suture, the pins being carried through the peritoneum, fully one-third of an inch away, in order that, in the event of recovery, the woman may not be annoyed with hernia. In some cases it may be necessary to leave the lower angle of the wound slightly open, to facilitate drain- age, the skin alone being embraced in the stitch. Immediately before the introduction of the sutures a flat sponge should be placed in the abdominal cavity beneath the flap, in order to catch and absorb any drops of blood that may escape from the punctures made by the needles. Long adhesive strips are stretched across the intervals of the pins, nearly around the abdomen, which should be still further supported with a roll of wadding and a broad double flannel bandage. Some operators prefer closing the abdominal wound with interrupted sutures made with strong silk ligature, catgut ligature, or silver wire, passed with a Wilson’s needle, Fig. 715. Thomas’s Clamp. represented in fig. G89, or with, what will answer equally well, the needle of Dr. Skene, of Brooklyn, depicted in fig. 716. In my opinion it matters little, if any, what method of uniting the wound be adopted. The woman is now placed in bed, with her head and limbs elevated, to prevent tension of the abdomen, a jug filled with hot water is applied to the feet, the weight of the bed- Fig. 716. clothes is warded off with cross hoops, and a third of a grain of morphia, unless adminis- tered before the operation, is injected under the skin for the triple purpose of allaying pain, inducing sleep, and quieting the bowels, which should not be disturbed for days together, except by an occasional enema, in the event of unusual flatulence and colicky suffering. The anodyne is from time to time repeated; thirst is allayed with ice; the Skene’s Xeedle. 916 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XV III. urine is drawn oflf at least every eight hours; and the air of the apartment is kept gently moist at a temperature of about 80° Fahr. The diet is a matter of primary import- ance after ovariotomy. Dr. Keith gives neither food nor drink nor medicine during the first twenty-four hours, and occasionally not even so early. This is certainly an un- necessary hardship. I can see no valid reason why beef-tea, milk, or water, in small quan- tity, as a half tablespoonful every hour or two, if the patient is weak or harassed with thirst, should be inadmissible. Thirst, if not allayed, is sure to cause irritability of the system. As the case progresses food should be given more freely, but still in a fluid form, solid articles being abstained from for at least a fortnight. To relieve the flatulence and indigestion so often met with after such operations, I know of nothing that answer so well as iced champagne taken frequently in small quantity, and two grains of quinine admin- istered every four or five hours, along with six or eight drops of dilute nitric acid and twenty drops of compound tincture of cardamom. Above all, care is taken not to expose the patient to draughts of cold air. As the great danger of this operation is peritonitis, everything should be done to ward off the attack. If serous, sanguinolent, purulent, or sero-purulent effusions occur, the lower extremity of the wound should be partially re- opened, to admit of their easy escape, otherwise they may not only cause severe inflam- mation, but even pyemia. In general, indeed, the best plan will be to wash out the pelvic cavity several times a day with a tube and syringe charged with tepid water, slightly im- pregnated with chlorinated sodium, or, what is preferable, a small quantity of permanganate of potassium. Such a procedure is often indispensable to recovery. Dr. Peaslee, who strongly insists upon its importance, and who ascribes the recovery of a number of his cases to its employment, states that in one of his patients not less than 135 injections were used in eighty-four days. The pins should not be removed until there is firm union, and the parts should be well supported for a long time afterwards to prevent the occur- rence of hernia. The ligature, when the ends are brought out through the wound, is de- tached at a period varying from one to several months. When both ovaries are diseased, they should be removed in immediate succession; an operation first performed by Dr. John L. Atlee, his case, which terminated successfully, having occurred in June, 1843. It has since been executed by Dr. Peaslee, Koeberle, Wells, Keith, A. R. Jackson, and other surgeons. In one of the cases reported by Ko- eberle both ovaries were successfully extirpated along with the uterus. Dr. W. Boinet has reported the case of a woman, forty-eight years old, from whom he successfully re- moved both ovaries at an interval of ten months. The first tumor weighed nearly thirty- seven pounds, and the second eighteen and a half. It is an interesting fact that, although both these organs may have been extirpated, menstruation still goes on. Professor Goodell has furnished a table of twenty-six cases attesting the truth of this statement. The chief source of the hemorrhage in this operation is the separation of the adhesions, which is often followed by a copious flow of blood caused by the rupture of enlarged veins, which, as they are without valves, are not always easily controlled. When the attach- ments are so extensive as to carry the peritoneum along with them in the attempt to destroy them, the small arteries of the wall of the abdomen may bleed quite freely, the blood either spirting in a full stream or oozing out at numerous points. When the hem- orrhage does not yield to torsion, compression with the finger or sponge, or the use of Pagliari’s styptic, Monsel’s salt, the only thing to be done is to occlude the vessels, whether venous or arterial, in the grasp of an acupressure needle, passed through the wall of the abdomen. It is not often that the vessels of the omentum bleed much, even when the adhesions between it and the tumor are old and extensive. Should this, however, be the case, they must be carefully tied with the catgut ligature with the ends cut short. Cases of fatal hemorrhage from the wound in the abdomen have been reported ; but such an event will hardly happen if the edges have been properly adjusted. Wounding of the bladder is an occasional occurrence in this operation, especially liable to arise when there are extensive adhesions between this organ and the ovarian tumor, or between the bladder and omentum. In either event, the bladder is generally drawn up above the pelvic cavity, and spread out over the morbid mass in the form of a bluish tumor which cannot always be easily distinguished from the surrounding structures. The danger in such a condition is not always avoidable even after the water has been thoroughly evacuated immediately before the operation. When such a complication is suspected to exist, the proper plan is to insert a gum-elastic catheter, and to carry it about in every direction, with a view of ascertaining whether the bladder is collapsed or re- mains expanded after the discharge of its contents. The accident in question has hap- pened several times in the hands of very skilful and experienced operators; and the only CHAP. XVIII. TUMORS OF THE OVARY. 917 way to remedy it is to close the edges of the wound at once with sutures made of carbo- lized catgut, the ends being cut off close. An accidental wound in the bowel should be treated in a similar manner. One of the great evils during and after this operation is the gastric distress arising from the use of anaesthetics, which sometimes continues for a number of hours despite our best directed efforts to avert it. The article generally employed in this country is ether, which rarely fails to cause nausea, if not more or less vomiting, especially when the ope- ration is at all protracted. Chloroform is less liable to produce these effects, but the pre- judice against its use is so great that it is now seldom administered in any operation on this side of the Atlantic. Mr. Wells’s favorite anaesthetic is chloromethyl, which he has used without any serious accident in most of his cases, upwards of one thousand in number. Whatever article be employed in this operation, its administration should always be confided to a trustworthy assistant, one who has had more or less experience, and who is consequently perfectly familiar with its effects. In regard to the best modes of securing the pedicle in ovariotomy, there seems to be no fixed plan, some operators preferring one method and some another. Mr. Wells says, “ I use the clamp whenever I can,” and his experience certainly entitles him to speak with the force of authority. Air. Keith believes in the superiority of the cautery, and in confirmation of the propriety of his choice he states that of the last 120 cases thus treated only 2 were lost. Mr. Clay employs a combination of crushing and cauterization with the ecraseur and the hot iron. Maslowsky uses a long pair of forceps which, although it compresses the pedicle at only a few points, holds it very securely, and is applied before the clamp is removed. Some operators secure the pedicle with two long, stout pins in- serted at right angles, and the arrangement, as a rule, is a very excellent one. The car- bolized catgut ligature has its advocates, and is particularly adapted to cases in which the pedicle is so short as not to admit of being clamped, or brought out at the lower angle of the wound. The material of which the ligature is made should consist of the best and strongest pure silk, thoroughly prepared, and applied in such a manner as to prevent it from slipping. At least three knots should be made in tying the cord. When a ligature is thus used it soon becomes encapsulated by plasma, and is probably finally absorbed, although in some cases it has been known to retain its characteristic features for a long time. However this may be, it is always harmless, and for this reason is admirably adapted to the object. Silver wire is sometimes used for this purpose, with the ends cut off close, with a view to permanent retention ; but it is not so manageable as the ligature, and is more liable to lose its hold, especially if the precaution is neglected of not fastening it with a stout pair of forceps. I prefer myself the clamp, because by it we effectually suspend the uterus, and thus protect it against future displacement; but I have also wit- nessed excellent effects from the catgut ligature, and from dropping the parts into the pelvis. Circumstances must, as a rule, guide the surgeon in the choice of his material and of his method. The more simple the procedure generally is the better. When the Fallopian tube is closely adherent to the pedicle, it is best to include it in the clamp or ligature, or, if diseased, to remove it altogether. Finally, care must be taken not to pull up the uterus too high into the abdomen; an occurrence which may always be avoided if the incision in the abdomen be carried well down to the pubes, and the pedicle be not cut off too short. Before the wound is closed, search should be made for the other ovary, which, if found diseased, should next be removed in the same manner, both pedicles being of course em- braced in one clamp. Sometimes its surface is simply roughened, or, perhaps, studded with serous cysts. In such an event, the operator contents himself with laying the cysts freely open, and sponging up their contents. Fibrous growths of the uterus may be removed at the same time, provided they are attached by narrow footstalks, otherwise they should not be meddled with, as death may result from shock, hemorrhage, inflammation, cellu- litis, or pyemia. The importance of removing every particle of blood and serous fluid from the peritoneal cavity before the external wound is closed, is of vital importance, and cannot be too strongly enforced. Numerous clamps have been devised for fastening the pedicle, all of more or less ex- cellence. Those of Wells and Thomas are perhaps the most trustworthy. Mr. Hutchin- son, of London, in 1858, was, I believe, the first to introduce such an instrument to the notice of the profession. Dr. H. 11. Storer’s clamp shield may often be used with admi- rable effect as a temporary compressor, and is especially adapted for securing deep tissues after extirpation of the uterus and its appendages, attended with hemorrhage. The drainage-tube forms a valuable addition to the armamentarium of the gynecolo- 918 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. gist; it must not, however, be employed indiscriminately, and in most cases, especially the more simple ones, it is best to dispense with it entirely. When there have been extensive adhesions, and there is a probability that there will be some effusion of blood or serum after the operation is completed, it will be well, in anticipation ol mischief, to insert a drainage-tube into the pelvis through the lower angle of the wound ; otherwise interference of this kind should be omitted until symptoms of pyemia arise, when thoiough drainage cannot be too soon established, the pelvic cavity being washed out repeatedly perhaps every few hours with some w7eak antiseptic fluid, otherwise the worst conse- quences will be sure to insure. Phe finger, under such circumstances, should always be inserted into the vagina, and, if there is any bulging in Douglas’s cul-de-sac, the trocar should at once be used to draw off the fluid by which it has been caused. The antiseptic injections may afterwards be thrown up in this direction, as more likely to prove tho- roughly effective. An ordinary drainage-tube may be employed ; but some gynecologists prefer a glass tube, and Dr. Thomas uses a tube of his own invention, provided with a stopcock,0the advantage of which is that it does not allow any air to enter. Most ovariotomists object to the perforation of the Douglas’s cul-de-sac, as a primary operation, for the purpose of establishing drainage, on the ground that the opening thus made would admit foul air from the vagina and thereby predispose to the occurrence of pyemia. Peaslee, however, was a w arm advocate of this mode of drainage, and the re- sults of his experience seemed to have justified his practice. Listerisrn no longer enjoys the favor it once did in this operation. Mr. Keith, after having employed it in many of his cases, has entirely abandoned its use on the ground of its injurious effects; and Mr. Tait has never had any confidence in its efficacy, either in ovariotomy or in any other surgical operation. Mr. Wells, on the contrary, is of opinion that it has done good service in his hands, and this opinion is shared by oilier prominent gynecologists, especially on the continent of Du rope. I have myself no confidence what- ever in the efficacy of the spray, while, in common with my professional brethren in all parts of the civilized world, I have unbounded faith in antiseptic treatment, properly so called. In no field of surgery is this treatment of more importance or of greater value than in ovariotomy and in the surgery of the pelvic organs generally. The length of the abdominal wound in this operation must necessarily vary with the circumstances of each particular case. In small tumors it need not, as a rule, be more than about four inches, while, under opposite conditions, it may be necessary to carry it to three or even four times that distance. A longer incision is always required when there are strong or extensive adhesions than when the adhesions are slight, or when, as not unfrequently happens in recent cases, the tumor is entirely tree in the abdominal cavity. The practice now universally pursued of emptying the cyst prior to its extrac- tion generally renders a long incision unnecessary, it not absolutely improper, as adding to the danger of the operation. In ordinary cases the cut should extend from a few inches above the pubes to within a few inches of the umbilicus; but when the tumor is uncommonly bulky, or when it is tied down by strong adhesions, it should begin near the pubes and terminate either at or above the navel. The result of ovariotomy is, I pre- sume, influenced less by the extent of the incision than by the circumstances necessitating the operation. A few inches, one way or another, could of themselves make no material difference in this i*espect. The adhesions should always, if possible, be broken up with the fingers passed around the tumor until the object is fully attained. The greatest possible care must be taken in separating the tumor from the omentum, bladder, bowrels, and other viscera. When the adhesions are very strong the aid of the knife or scissors may be required. Very firm or very extensive adhesions must always be regarded as serious complications, liable to give rise to more or less troublesome hemorrhage and to increase the dangers of the operation by the induction of shock, and, if the patient survive, of inflammation. The closing of the external wound must be conducted with extra care. Unless this be done it may, during a severe fit of coughing or vomiting, reopen before complete reunion has taken place, and thus necessitate interference at a time when such a procedure might not only be inconvenient but very annoying, if not dangerous. Again, if the operation be not well done, the parts may gap after the patient gets up and moves about, from their inability to bear the weight and pressure of the abdominal viscera. A huge hernia con- sequent upon ovariotomy is a blunder and a calamity. Two rows of sutures are generally required, one deep and the other superficial, the number of each ranging, on an average, from six to ten, according to the length of the incision; and it does not matter, judging from my observations, whether they be twisted or interrupted and composed of silk or wire. In either case the deep sutures must be passed through the entire thickness of the abdominal CHAP. XVIII. TUMORS OF THE OVARY. 919 wall, peritoneum and all, fully half an inch from each edge of the wound, and about the same distance from each other. The superficial sutures should merely embrace the com- mon integument. The latter may be removed at the end of a week, the former not under twelve days or a fortnight. If pins be used they should be galvanized to prevent oxida- tion. The abdomen should be well supported and straining guarded against for a long time after the patient resumes the erect posture. Statistics.—Among the most extended and reliable statistics of ovariotomy are those ot Dr. George H. Lyman, of Boston, published in 1856. They are founded upon an analysis of 300 cases, performed indiscriminately for various kinds of diseases, including the one by L’Aumonier, undertaken for the relief of an abscess of the ovary and Fallopian tube. Of these cases, the operation was completed by the removal of the tumor only in 208; in 78 it was found to be impracticable ; in 10 it was performed partially ; and in 4 the result has not transpired. Of 299 cases in which the result is declared, 179 recovered, and 120 died, or at the rate of a little over 40 per cent. Of the 208 cases in which the operation was completed, 119 recovered, and 89 died, or in the proportion of 42.78 in the 100. Of the 78 cases in which extirpation could not be executed, 55 got well of the operation and 22 died, the result in one not being given. Of the 10 cases in which the tumor was only partially removed, 5 recovered and 5 died. Of the 88 cases in which the operation could not be completed, the causes of failure in 68, were adhesions of the tumor, of which 24 were lost. In 8 no tumor could be found ; and in the remainder it was either uterine, pelvic, or abdominal. The incision in 117 cases was short; and in these, the operation was completed in 60, of which 37 recovered, and 23 died. Of the 57 cases in which it was abandoned or in- complete, 44 got well, and 13 perished. Of 143 cases of the long incision, the operation was finished in 123, 72 recovering, and 51 dying. Of the 20 cases in which the extirpa- tion was abandoned, or left incomplete, 11 escaped, and 9 were lost. The average age, in 221 cases, was 34.33 years, the youngest patient being 17, and the oldest 68. Both ovaries were removed in 13 cases, of which 8 proved fatal. The cause of death is given in 85 of the cases. Of these, 36 perished of peritonitis, 20 of hemorrhage, 12 of exhaustion, 2 of shock, 2 of pneumonia, and 2 of diarrhoea. The mortality was least between the ages of 50 and 60, and greatest under 23. The duration of the disease exercised considerable influence upon the result of the operation, recovery happening most frequently when the tumor had existed between three and four years. The difference in the mortality between the married and single was trivial. Finally, the danger of the operation was greatly increased by the presence of uterine and other maladies. The following table, which I compiled in 1872 from various sources, shows the rate of mortality of ovariotomy in the hands of the most prominent operators up to that period. Some of the statistics of the English and German operators were given on the authority of Dr. Grenser, while those of American surgeons were principally derived from the third edition of Dr. T. Gaillard Thomas’s Treatise on the Diseases of Women. Table of 1408 Cases of Ovariotomy. Operators. Cases. Recoveries. Deaths. T. Spencer Wells . 400 293 107 C. Clay . . 210 138 72 Kimball . . 130 86 44 Baker Brown . . 120 84 36 Keith . 100 81 19 Dunlap . . 69 42 27 Koeberle . 60 48 12 • J. L. Atlee . 35 28 7 Nussbaum . 34 18 16 Bradford . 31 28 3 Bryant . . 28 17 11 Peaslee . . 26 17 9 White . . 25 17 8 Thomas . . 24 17 7 McRuer . . 22 16 6 Skolberg . 21 17 4 Emmet . . 17 8 9 Tyler Smith . . 17 14 3 Spiegel berg . . 16 10 6 W'illett . . 12 4 8 Sims . 11 10 1 1408 993 415 920 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. An inspection of the table shows that the mortality of ovariotomy is 29 per cent., or in the proportion of 1 death in every 3§ cases. This result, when compared with that of the earlier cases, exhibits a decided gain ; a circumstance, apparently, mainly due to the recent improvements in the operation itself and to a more judicious after-treatment. The statistics here delineated are retained simply to show the dangers and impossibili- ties which formerly environed this operation. Experience in this as in every other field of operative surgery has led to vast improvements, and to a greatly reduced mortality. Hence the brilliant achievements in the hands of Clay, Wells, Keith, Tait, and other gynecologists; successes not due to the selection of their■ cases, but to the greater care which they have taken in the preparation of their patients, in the use of the knife, in the dressing of the wound, and in the after-treatment. The experience of Keith has shown that the beneficial effects of Listerism have been greatly overrated, and that in some of his later cases it was even productive of harm. Ovariotomies are now of daily occur- rence in all parts of this and other countries; and, although the results may not, as a rule, be so good as in the hands of the specialists, it is sufficiently flattering to justify their generalization. Women no longer wait to seek relief before they are worn out with suffering, and hence we rarely hear of those bad, complicated cases which were formexdy everywhere so common. Well may it be said, in view of its many triumphs and wonder- ful successes, that ovariotomy has taken a new departure, with a record of which no other capital operation can boast. Wells, in his first 100 cases, had 34 deaths, and only 11 in his last 100; Professor Schroeder 17, and only 7 in his last 100 ; Pean, in his last 100, lost only 14, a great im- provement upon his previous results; and Keith’s last 140 cases show 135 recoveries, or the almost incredibly low death-rate of 3.51 per cent. The statistics of other celebrated operators are equally striking and convincing. The only exceptions to this statement, so far as I am aware, are those of the late Dr. Washington L. Atlee, who had altogether 387 ovariotomies, with a loss of, as I am informed by his son-in-law, Dr. Drysdale, of about 30 per cent. To account for this discrepancy, it is proper to state that the cele- brated Philadelphia gynecologist was unable, in many of his cases, owing to the peculiar circumstances in which they were placed, to superintend the after-treatment, upon which, as is well known, so much of our success generally depends. He visited many of his patients at a great distance from his home, and usually left them either immediately, or, at most, within a few hours, after the operation. With such disadvantages it is not sur- prising there should have been so high a death-rate. The subjoined table, derived from Mr. Wells’s statistics, shows the results of 2658 cases of ovariotomy in the practice of some of the principal European operators up to date:— Year. Cases. Recoveries. Deaths. Per cent Wells . 1880 1000 768 232 23.2 Keith . 1881 381 340 41 10.76 Pean . 1881 306 245 61 19.93 Nussbanm . 1881 332 239 93 28.01 Billroth 1881 222 142 80 36.03 Schroeder 1881 276 237 39 14.13 Olshausen . • 1881 141 121 20 14.18 2658 2092 566 21.29 C. Clay, up to 1879, had had 276 cases with 76 deaths, Dunlap 143 with 31 deaths, T. G. Thomas 129 with 33 deaths, and John L. Atlee 57 with 12 deaths. The mortality of’ Dr. Kimball’s cases, up to that period, was in the ratio of 1 to 4. Olshausen, in 1877, tabulated 613 cases of this operation by German surgeons, of which 353 recovered, and 260 died, showing a mortality of 43 per cent. Switzerland, according to Mr. Wells, has had 231 cases, distributed among twenty-five operators, with a death-rate of 23.3 per cent. In Russia, of 302 ovariotomies reported as having occurred in the hands of forty surgeons, 169 recovered, and 133 perished. Norway, up to the present year, had had 104 cases with 45 deaths, or a mortality of 43.27 per cent. At the Samaritan Hospital, London, an institution devoted to the treatment of the diseases of women, there were, in 1881, 84 ovariotomies with 10 deaths. Of these cases Mr. Knowsley Thornton had 41 with 2 deaths; Mr. Bantock 34 with 8 deaths; and Mr. Meredith 9 without any deaths; the operations of the first and the last having been per- formed under antiseptic precautions. CHAP. XVIII. TUMORS OF THE OVARY. 921 The following table, copied from Mr. Wells’s recent work, shows the results of his 1000 cases, the last of which was reached in June, 1880. To this number he had added up to May, 1882, 60 more cases, with a loss of 4. No. Date. Cases. Recoveries. Deaths. 1 From February, 1858, to June, 1864 . 100 66 34 2 “ June, 1864, “ March, 1867 . 100 72 28 3 “ March, 1867, “ January, 1869 . 100 77 23 4 “ January, 1869, “ December, 1870 . 100 78 22 5 “ December, 1870, “ June, 1872 . 100 80 20 6 “ June, 1872, “ January, 1874 . 100 71 29 7 “ January, 1874, “ April, 1875 . 100 76 24 8 “ April, 1875, “ October, 1876 . 100 76 24 9 “ October, 1876, “ June, 1878 . 100 83 17 10 “ June, 1878, “ June, 1880 . 100 89 11 1000 768 232 The general mortality in the above cases is 23.2 per cent.; the largest in any 100, 34, and the smallest 11. Of 5153 cases of ovariotomy by American and European surgeons, tabulated by Dr. Baum for Professor Agnew, 3651 recovered, and 1502 died, showing thus a mortality of 29.13 per cent. Of these cases 4969 were single, and 183 double, with a death-rate for the former of 28.94 per cent., and for the latter of 34.42 per cent. Pregnancy existed in 21 of the women, of whom 17 recovered and 4 died. The operation was performed twice on the same patient in 15 cases, of which 12 recovered and 3 perished. Adhesions were present in 975 cases, with a mortality of 32 per cent. ; and no adhesions in 548 cases, with a death-rate of only 20 per cent. The principal causes of death were perito- nitis, shock, hemorrhage, septicemia, cellulitis, and various intercurrent diseases, as pneumonia and gastro-intestinal disturbance. Death from tetanus was an occasional, but very uncommon, occurrence. Vaginal Ovariotomy—Ilemoval of a diseased and enlarged ovary through the vagina has been practised in a number of instances, the first having occurred in the hands of Pro- fessor T. G. Thomas, in 1870. Since then the operation has been performed, among others, by Gilmore, of Mobile, Wing, of Boston, Goodell, of Philadelphia, Davis, of Wilkesbarre, and Battey, of Georgia, all the cases having had a favorable issue. The cyst or tumor, in its earlier stages, while it is yet quite small, is, as is well known, situated low down in the pelvis, in Douglas’s cul-de-sac, and, consequently, within easy reach of the finger and knife. In order to remove it, all that is necessary is to make an incision over it through the septum, to draw it into the vagina, and to separate it from its connec- tions, the pedicle having previously been secured with a stout, carbolized catgut ligature. To avoid the risk of cellulitis, septicemia, and other ill consequences, the best plan is to leave a drainage-tube in the wound, and to wash out the pelvic cavity several times a day with carbolized water, or weak solutions of any of the so-called antiseptic fluids. In Dr. Thomas’s case, in which the wound was closed by sutures, the patient came very near losing her life from an attack of cellulitis. Ovariotomy by the vaginal section is still on trial. The results, thus far obtained, are certainly very encouraging. Obviously, the range of the operation is very limited; and, with our present improved procedures, it is questionable whether it is any safer than ova- riotomy by the abdominal section, while the latter has the advantage of affording a much larger field for the necessary manipulations. Rectal Ovariotomy—A unique case of rectal ovariotomy was reported by Dr. W. W. Shocks, in the Boston Medical and Surgical Journal for October, 1875. The tumor pro- jected through the anus, pushing before it the anterior wall of the bowel, and making known its character by the fact that the Fallopian tube could be felt through the vagina, as forming a portion of the morbid growth. The excision was successfully effected by a longitudinal incision carried through the wall of the rectum. Complications—Tumors of the ovary are liable, as previously stated, in their progress to form attachments to the neighboring viscera, especially if large, of rapid growth, or of long standing. Under such circumstances an operation for their .removal is often attended with great risk and not a little embarrassment to the surgeon. When the omentum is in- volved the operation is sufficiently simple, since all that is generally necessary is to exsect the adherent portion, if it cannot be liberated, and to tie up the bleeding vessels. But it 922 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. is otherwise, when the uterus, bowel, spleen, or liver is concerned. In such a condition the safest plan, perhaps, as a rule, is to shave or scrape off the tumor as closely as possible from the involved organ, and to trust to the ordinary means for a cure, special pains being taken to provide free drainage and to protect the patient from the risk of septicemia and other ill consequences. It would hardly be safe to excise a portion of the liver or spleen in the event of firm adhesions between one of these organs and an ovarian tumor. The risk would certainly be very great. A small portion of bowel might possibly be removed with impunity, if the ends were immediately stitched together with carbolized catgut sutures. In regard to the uterus, the best plan, when the adhesions cannot be broken up, would be extirpation of the organ, as was recently done successfully in such a case by Dr. T. Gaillard Thomas. Obviously, however, the time has not arrived for laying down anything like satisfactory rules in regard to the conduct of the surgeon in such try- ing circumstances. A timid surgeon, unless instructed by the light of experience and the teachings of men of accredited position in the profession, would be likely to abandon the woman to her fate; whereas, a more daring one would, probably, not hesitate to subject her to the risk of killing her in the hope of saving her. The proper treatment ot wounds of the bladder, when accidentally inflicted in ovariotomy, is stated in a previous page. OOPHORECTOMY BATTEY’S OPERATION. Oophorectomy may be regarded as ovariotomy in miniature, in contradistinction to the ordinary procedure in which the diseased ovary is removed in mass. The first operation of the kind was performed, in 1872, by Dr. Robert Battey, of Georgia, who, eight years previously, had conceived the idea that it might be successfully practised for the relief ot certain affections, without a knowledge that a similar view had been formally suggested by Dr. James Blundell, of London, in 1823. His object, as set forth in the report of his first case, was to bring about a premature establishment of the menopause by the removal of the healthy or of slightly diseased ovaries, hoping thereby to effect a cure of certain affections of the genital organs which could not be reached in any other manner. His first case was one of inveterate neuralgia of the ovaries, the removal of which eventuated in complete relief. Dr. Hegar, of Germany, introduced the operation into Europe, which soon became an approved procedure in surgery. Professor Thomas, in his Treatise on the Diseases of Women, issued in 1880, gives a table of 152 cases of oophorectomy by different surgeons, American and foreign, of which 17 were by elytrotomy with 4 deaths, and 135 by laparotomy, or the abdominal section, with 89 recoveries and 23 deaths. Of the latter cases, 42 are credited to Hegar with 35 successes and 5 losses. Mr. Lawson Tait, in July, 1880, reported 25 cases with only 1 fatal result, and Mr. Savage more recently 26 cases without a death. The dangers of oophorectomy are rapidly diminishing under the improved methods of operating. Oophorectomy is performed for a variety of disorders, not merely of the genital organs but of the general system, as amenorrhcea, dysmenorrhoea, menorrhagia, neuralgia, and certain nervous affections, as epilepsy and insanity due to disease of the ovaries. It has also been employed for the cure of different kinds of tumors of the uterus, especially fibroids. No operation, of course, is proper until after thorough trial has been made ot other remedies, for it is at all times, and even under the most favorable circumstances, a dangerous undertaking. There are two routes by which the ovaries may be reached for the cure of the affections in question. One of these is by the abdominal section ; the other by the posterior vaginal cul-de-sac. Dr. Battey’s earlier operations consisted of elytrotomy, but he now in com- mon with most, if not all, gynecologists, prefers laparotomy, as being more easy of exe- cution, better adapted to efficient work, and yielding more favorable results. When the abdomen, however, is loaded with an unusual quantity of fat, as in a case recently in his hands, elytrotomy should be performed. The preference for the abdominal over the vaginal operation is based upon the facts, first, that, as the field of the operation is greater, the eye can more readily follow every step of the procedure; secondly, that adhesions, by no means of infrequent occurrence, are more easily broken up; thirdly, that the pedicle is more conveniently ligated ; fourthly, that the details of the antiseptic treatment can be more fully carried out ; fifthly, that the cavity of the pelvis admits of more thorough cleansing, a matter of vital importance to success; and, lastly, the assurance that every vestige of the diseased organs has been removed. The incision in the abdomen should, on an average, not exceed two and a half or three CHAP. XVIII. OVARIOSALPINGECTOMY. 923 inches. The ovary is seized with two fingers passed behind the uterus along the broad ligament, and, being brought fully into view, the pedicle is transfixed with a double cat- gut ligature, one-half being tied firmly on each side with three knots, and the ends cut off short. The other organ being treated in a similar manner, all bleeding arrested, and the pelvic cavity thoroughly sponged, the external wound is closed precisely as in ordi- nary ovariotomy. The quantity of blood lost in the operation seldom exceeds a few drachms. The after-treatment in this and in the vaginal procedure is conducted upon general antiphlogistic principles. The instruments required in the vaginal operation are, a perineal retractor, a polyp- forceps, a pair of scissors with long handles and short blades, a tenaculum, and an ecra- seur. The patient, lying on her left side with the limbs well drawn up, the perineum is retracted and the uterus dragged down, when the surgeon with a tenaculum and pair of scissors opens the vaginal cul-de-sac in the middle line, beginning at the posterior wall of the uterus, and extending backwards nearly two inches towards the rectum. The index finger is now passed through the wound and swept along the broad ligament until it en- counters the ovary, which is then brought out either with the digit alone or the digit and the forceps. A temporary ligature being thrown around the pedicle, the organ is allowed to retract, when, the other being brought down in a similar manner, both are slowly severed with the ecraseur fastened behind the cord, from ten to fifteen minutes being thus spent upon each operation. Sponge probangs are used for cleansing Douglas’s cul- de-sac, and the wound, which generally unites very rapidly, is left open for drainage. Prolapse of the bowel is a rare occurrence. Ellytrotomy is now seldom performed; first, because it is very difficult on account ot the narrow area within which it is restricted, greatly interfering with the necessary manipulations; and, secondly, because there is always more or less risk of septicemia from the entrance of the noxious secretions of the vagina and uterus. The result of this operation is generally very gratifying, although some time must necessarily elapse before the genital organs and the system at large accommodate them- selves to their new relations. The artificial menopause does not attain perfection at once. The change of life is a gradual process. When the operation is thoroughly done, the menses cease at once and never reappear. In those cases in which this function is said to have continued after double ovariotomy, more or less of ovarian stroma was left be- hind ; in other words, excision was performed imperfectly. The sexual functions remain unimpaired, and there is no loss of the feminine graces. A tendency to embonpoint is generally noticed; the uterus becomes atrophied, sometimes remarkably so; fibroid tu- mors of that organ usually decrease in size, and not unfrequently wholly disappear, while the hemorrhage provoked by their presence generally ceases altogether. OVARIOSALPINGECTOMY TAIT’s OPERATION. Under this caption I shall briefly describe an operation which has been recently brought to the notice of the profession by Mr. Lawson Tait, of Birmingham, and which, although it is not, as yet, accepted as an established procedure in surgery, is attracting universal attention. It consists, as the name implies, in the total extirpation of the uterine append- ages for the cure of menorrhagia. In an elaborate article in the American Journal of the Medical Sciences for January, 1882, Mr. Tait strongly advocated its claims as a substitute for oophorectomy, and adduced the particulars of thirty-one cases in support of its beneficial effects. The hemorrhage in a number of these cases was so profuse as to reduce the poor sufferers to the very brink of the grave. All had been faith- fully subjected to the various methods of treatment, local and constitutional, usually adopted for the arrest of uterine hemorrhage, without any permanent amelioration. Some had been temporarily improved under the use of ergot and the salts of potassium, espe- cially the chlorate and the bromide, and by the application of nitrate of silver, and various astringents ; but the bleeding continued despite these remedies, and only dis- appeared after the excision of the structures in question. Mr. Tait performed his first operation in 1873, but being discouraged by the loss of two of his cases, he did not repeat it until 1879, and then only after the signal failure of various other plans of treatment. Since then he has performed total excision of the ute- rine appendages in twenty-six cases with two deaths, or a mortality of 7.7 per cent. The operation in all the cases was by the abdominal section. The cause of the hemorrhage in twenty of the thirty-one cases was uterine myoma, in six cystoma of the ovaries, in four ovaritis, or ovarian disease, and in one cysts of the Fallopian tubes. Mr. Tait con- 924 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. eludes, as the results of his observations, first, that removal of the uterine appendages is a much more certain means of arresting menorrhagia, however induced, than the mere ex- cision of the ovaries; secondly, that it is quite as justifiable as any of the major proce- dures in surgery; and lastly, that, so far as the secondai'y effects are yet known, it holds out abundant encouragement for further trial. Of course no operation of so serious a char- acter as this unquestionably is, should be undertaken unless the case is a very intractable one, or a fair trial has been made of other remedies. SECT. Ill DISEASES OF THE FALLOPIAN TUBES AND BROAD LIGAMENTS. Owing to the great difficulty of their diagnosis, the diseases of the Fallopian tubes offer, surgically considered, little of interest. In fact, the only one that requires any particular notice in a work of this kind, is dropsy. Incidentally it may be observed that the tube is liable to displacements, morbid adhesions, inflammation, abscesses, hypertrophy, tuber- culosis, carcinoma, and different kinds of tumors. Dropsy of the Fallopian tube, fig. 717, is most common in middle-aged and elderly women who have borne children; the disease may be single or double, and is usually associated with organic lesion of the ovary, uterus, and pelvis. The cause of the affection is, in the first instance, occlusion of the orifices of the tube, which is thus placed in the Fig. 717. Dropsy of tlie Fallopian Tube. condition of a shut sac. Gradually the mucous lining is transformed into serous tissue, which, taking on inflammatory action, pours out the fluid, upon the presence of which the dropsy depends. This fluid is perfectly clear and limpid, saline in its taste, and coagula- ble by heat, alcohol, and acids. In its size the cyst—for so it may be termed—varies from that of the small intestine to that of a fist, or even a foetal head ; it is of an elonga- ted, conical shape, convoluted, folded, or bent upon itself, much larger at its fimbriated than at its uterine extremity, and irregularly consti’icted upon the surface, or divided by tight fibrinous bands. A cyst of this kind, described by De Haen, weighed seven pounds. A number of vessels, tortuous and varicose, generally ramify over its exterior. The symptoms of tubal dropsy are generally so closely merged in those arising from disease of the ovary as to render it extremely difficult to discriminate accurately between them. The most important diagnostic signs are, 1st, the remarkable mobility of the tumor in the pelvis, where, unless it is of extraordinary size, it may be freely pushed about independently of the uterus ; 2dly, its elongated, conical form, with the rounded base cor- responding to the fimbriated extremity of the tube ; and, 3dly, its wavy, convoluted out- line, or its undulated and indented surface, as if fibrous bands were stretched across it. The cyst is smaller than in ovarian disease, and seldom ascends materially above the level of the pubes. The difficulty of the diagnosis will be lessened, if, as suggested by Sir J. Y. Simpson, the pelvic organs be examined simultaneously with both hands, one being placed over the fundus of the womb on the hypogastrium, while two of the fingers of the other are inserted into the vagina and anus, so as to make pressure in opposite directions. If all other means fail, recourse is had to the exploring needle, passed through the roof of the vagina. The escape of a clear, limpid, saline, and coagulable fluid will generally de- termine the true nature of the case. The only treatment for this disease is tapping, performed with a delicate trocar, intro- duced through the upper and lateral portion of the vagina, pushed behind the broad liga- ment, at the posterior surface of which the cyst is situated. The fluid is drained off gradually, and a sufficient degree of inflammation generally succeeds to counteract any CHAP. XVIII. EXTRAUTERINE PREGNANCY — DERMOID CYSTS. 925 tendency to further secretion. Simpson, in eight instances which he thus treated, was not obliged to repeat the operation in a solitary one. If paracentesis fails, a little dilute tincture of iodine may be thrown into the sac. Some vigilance is necessary, in either case, during the after-treatment, as the resulting inflammation may be too severe. Extir- pation should be performed when the affection proves rebellious. Examples are recorded in which rupture of a Fallopian cyst occurred from overdisten- tion, ulceration, external violence, or severe bodily exertion, quickly followed by effusion of its contents and fatal peritonitis. The broad ligament is occasionally the seat of different tumors, more especially the cystic and fibroid. Their origin is undetermined, their progress generally tardy, and their diagnosis obscure, it being difficult, if not impossible, to distinguish them from similar affections of the ovary and uterus. A rare case of colloid growth, apparently springing from the broad ligament, and successfully removed by the abdominal section, lias been reported by Professor John E. Owens, of Chicago. It reached as high as the umbilicus, was of a red, purplish color, and consisted of a hard, fibrous stroma, the alveoli of which were filled with a thin, jelly-like substance. Two similar but much smaller tumors were attached to the uterus. The veins of the ovaries, like those in other parts of the body, are liable to enlarge- ment and varicosity. The occurrence is most common in advanced life, in fat, corpulent women, the subjects of habitual constipation of the bowels, hypertrophy of the uterus, or pelvic tumors. The vessels, in this condition may give way, either spontaneously or under the efforts of straining, eventuating in copious or even fatal hemorrhage. Fallopian pregnancy is often followed by fatal bleeding; and a similar occurrence has been known to follow the accidental rupture of a varicose vein of a healthy Fallopian tube, as, for example, in the case of a celebrated actress, in whose pelvic cavity two quarts and a half of blood were found after death from this cause. Such accidents of course do not admit of an accurate diagnosis, and the treatment must, therefore, necessarily be emperical. SECT. IV EXTRAETERINE PREGNANCY AND DERMOID CYSTS. Extrauterine pregnancy is an uncommon occurrence, manifesting itself in three varieties of form, the tubal, in which the ovum is retained and developed in the Fallopian tube; the interstitial, in which the germ is arrested partly in the tube and partly in the uterus ; and the abdominal, or that in which the ovum is dropped into the abdominal cavity and be- comes adherent to the surface of the peritoneum, where it grows and either causes death by exciting local and constitutional irritation, or becomes encysted, and remains, at least for a time, a comparatively harmless tenant. In many cases ulceration takes place, and some of the foetal remains are discharged through the neighboring structures, as the wall of the abdomen, the large intestine, especially the rectum, the vagina, or the bladder. Tubal preg- nancy is always a dangerous affection, usually proving fatal within a very short time after its occurrence. Of 45 cases collected by Ilecker, the rupture in 26 was noticed in the first month, in 11 in the third, in 7 in the fourth, and in 1 in the fifth month. Abdomi- nal pregnancy is the least dangerous form of extrauterine foetation. Of 132 cases tabulated by Hecker, 76 ended in recovery; in 28 after expulsion of the foetus by the anus, in 15 after elimination through the wall of the abdomen, in 17 after calcification of the cyst, in 11 after laparotomy, and in 3 after the vaginal section. The most common causes of death are hectic fever, peritonitis, septicemia, and hemorrhage. Tubal pregnancy nearly ahvays proves fatal by hemorrhage during the first, second, or third month of gestation, The diagnosis of extrauterine pregnancy is generally difficult, often indeed impossible. The most reliable signs of the tubal form are the sudden prostration of the patient, fol- lowed, if speedy relief be not afforded, by collapse and death, the excessive pallor of the countenance, and the rapid formation of a tumor in the pelvic or hypogastric region, with all the other evidences of great and sudden loss of blood. The affections with which the other twm varieties of extrafoetation are most liable to be confounded are, natural preg- nancy, hypertrophy of the uterus, and various kinds of morbid growths, as uterine, ovarian, abdominal, and pelvic. A careful examination alone can throw any positive light upon the nature of the affection. The history of the case will also be entitled to some weight, as the morning sickness, the absence of quickening, and the empty or gravid con- dition of the uterus, and the situation of the tumor. The treatment of the tubal form of extrauterine pregnancy, terminating in rupture of the sac, admits of no delay; our efforts must be prompt and decided. The only thing that holds out the slightest prospect of relief is to open the abdominal cavity by a free incision, to 926 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. ligate the tube near the uterus with the carbolized catgut ligature, to cut off the ruptured portion of the tube, to remove the extravasated blood, and to support the sinking powers of life. Nothing short of this management cannot do the least good. Ihe interstitial variety rarely admits of surgical interference; at all events, few surgeons will be so bold as to cut down upon the tumor with a view of enucleating it, and yet such a procedure may, for aught that is now known, become at no distant day the only feasible expedient. In an exceptionally rare case, at the full term, in charge of the late Dr. Lenox Hodge, that gentleman, recognizing its true character, cut through the parenchymatous structure which shut the child off from the uterus, and safely delivered his patient. In the abdominal variety the safest plan, as a rule, will be found to be a “ masterly inactivity,” or, in other words, to let the parts alone, unless there should be decided evidences of impending mis- chief, likely, if permitted to proceed, to imperil life, when laparotomy must take the place of indecision. Dermoid cysts of the abdomen are congenital products, the result of generation by in- clusion ; they are most commonly found in the ovaries, but, now and then, are situated in the abdominal cavity in connection with the peritoneum. However this may be, they are always composed of organic foetal remains, as different pieces of bone, teeth, hair, tegumentary tissue, and fatty matter, or a substance strongly resembling adipocere. Such tumors should not be meddled with, so long as they are quiescent, as they generally are for many years, or even during a long lifetime. Eventually, however, they are liable to take on inflammatoiy action, and to create not only grave local, but also severe constitu- tional, disturbance, rendering surgical interference imperatively necessary. Laparotomy is of course the proper procedure, although it is beset by many dangers, and must, there- fore, often prove fatal. Occasionally, this danger may be avoided, or, at any rate, materi- ally lessened, especially in chronic cases attended with ulcerative perfox-ation of the ab- dominal wall, the l-ectum, or the vagina, through which the contents of the cyst may be partially, if not completely, evacuated, simply, it may be, by enlai’ging existing sinuses. SECT. V AFFECTIONS OF THE VAGINA. The vagina is liable to various congenital malformations, inflammation, morbid occlu- sion, polyps, varix, prolapse, and diffei'ent kinds of tumors. a. The tube is sometimes absent, as a congenital defect. Of this variety I have seen three cases, all occurring in young married women. The breasts in all were well devel- oped, and the sexual desire was quite as strong as ih the natural state, thus rendei’ing it extremely pi-obable that there was no defect on the part of the ovaries. A careful exami- nation by the finger in the rectum, and a catheter in the bladder, showed that the sep- tum between these two organs consisted simply of their opposed walls. The vagina is occasionally very short, not, perhaps, exceeding a few lines, half an inch or an inch in extent. When the defect is associated with absence of the urethra, the tube terminates in a cul-de-sac. Cases occur in which it opens into the bladder, or into the rectum, thus receiving the contents of these reservoirs. A double vagina is uncom- mon. A septum in this condition extends the whole length of the tube, dividing it into two cylindrical canals, each of which terminates inferiorly by a separate aperture. Cal- lisen refers to two cases in which the canals thus formed were closed each by a perfect hymen. In some instances the septum is situated transversely, constituting a kind of diaphragm, which prevents the flow of the menstrual fluid. Lastly, the tube may be pi’esent and be well developed, but closed by a hymen or by solid matter. Of the foi’mer of these occuiTences Mi’. II. M. Madge has met with an instance in four sisters. Some of these malfoi’mations admit of relief; others do not. Nothing is to be done when there is an absence of the vagina; the woman is impotent, and, therefore, disquali- fied for marriage. When the tube exists but is closed by a gristly growth or membrane, surgical interference will be necessary, consisting, genei'ally, in a few simple incisions. M lien the rectum terminates in the vagina a proper outlet must be made for it with the knife, an operation which is usually very easy, as the oi’ifice nearly always exists very low down. A vagino-vesical opening should be closed by suture. /3. foreign bodies, as pessaries, glass bottles, and pieces of wood, are occasionally inserted into the tube, whei’e, if allowed to remain for any length of time, they are sure to cause severe inflammation, attended with exquisite pain and tenderness, and the most offensive discharge, simulating that arising from malignant disease. When they keep up constant pressui’e ulceration may occur, so as to establish a communication with the blad- der or rectum, and the vagina is then also liable to become gi’eatly conti’acted. Riddance CHAP. XVIII. AFFECTIONS OF THE VAGINA. 927 of the intruder may generally be effected, although sometimes not without much difficulty, with the fingers and forceps. When the resistance is excessive it may be necessary to break the foreign body, or divide it with a saw, each piece being afterwards extracted separately. y. The vagina is liable to ordinary and specific inflammation. The disease is marked by the usual anatomical characters, and is often attended with a profuse discharge of purulent matter, of a very acrid nature, and mixed at times with blood. In bad cases abscesses are formed in the submucous connective texture, and instances are witnessed where the parts are rapidly destroyed by gangrene. A coating of adventitious membrane is sometimes observed, especially when the inflammation is connected with disease of the mouth and neck of the uterus. Occasionally, again, there is a remarkable hypertrophy of the papillae, giving the surface of the vagina a peculiar granular appearance, the bodies standing out like so many round, shot-like projections of a vivid red color. The affection is particularly common during pregnancy, but is also met with both in ordinary and in specific vaginitis. Ulcers of the vagina are generally referable to a syphilitic, carcinomatous, or scrofulous condition, and do not differ from those of the same class of sores in other regions of the body. A peculiar irritable ulcer, crack, cleft, or fissure, is sometimes met with at the mouth of the vagina, chiefly at its posterior commissure, as a consequence, generally, of the slight laceration of the perineum so liable to occur during first labor. It is usually very super- ficial, seldom, if ever, extending beyond the mucous membrane, and is often extremely painful, especially in walking, defecation, and sexual intercourse, or when urine is brought in contact with it, which always causes severe burning and smarting. The edges of the ulcer are red, rough, everted, and slightly elevated, its surface being inerusted with aplastic lymph, and the seat of a thin, sanious discharge. If neglected, the disease may last for years, and produce great local and constitutional distress with progressive emacia- tion and debility. The nature of these different lesions may be suspected when there is more or less copi- ous discharge, but can only be positively determined with the aid of the speculum. The treatment is antiphlogistic, by rest, purgatives, and light diet, with astringent in- jections, as solutions of lead, zinc, alum, or copper. If ulceration exist, nitrate of silver or acid nitrate of mercury may be necessary. Separation of the opposed surfaces with a a tent of cotton, charpie, or patent lint, wet with some medicated lotion, as Goulard’s extract, acetate of lead, or subsulphate of iron, or smeared with very dilute ointment of nitrate of mercury, will always greatly expedite the cure. In granular vaginitis great benefit often results from the use of a strong solution of chromic acid. The treatment of specific vaginitis is briefly discussed in the section on gonorrhoea. The most effectual remedy for fissure of the vagina is free scarification, forcible dilata- tion with the thumbs, or complete division of the sphincter muscle. Sometimes the milder cases recover under the use of nitrate of silver. Iodoform is also worthy of trial. Children of a scrofulous temperament, and of a weak, relaxed habit of body, are very liable to inflammation of the vagina, or, rather, of this canal and of the vulva. It some- times comes on within a very short time after birth, and is often met with during denti- tion, but is most frequent from the second to the seventh year. The exciting causes are various. In the great majority of instances the disease is manifestly dependent upon dis- order of the general health, the strumous diathesis, dyspepsia, constipation of the bowels, anemia, the presence of ascarides, or the irritation of teething. Want of cleanliness some- times produces it. The discharge is usually of a thin, whitish, muco-purulent character, not very profuse, somewhat fetid, and more or less acrid, often slightly eroding the skin with which it comes in contact. Occasionally it is sanious, sanguinolent, or mixed with flakes of lymph. The affected surface, seldom very red, is sometimes studded with aphthae, and there are cases in which it exhibits a fissured, eczematous, or excoriated ap- pearance. The vulva commonly suffers more than the vagina. When the disease is neglected, it may be protracted into puberty before it finally disappears. Slight as this affection commonly is, it is very often a source of great anxiety to the parents of the child, especially when the discharge is unusually profuse, under an appre- hension that it has been communicated by personal contact. Such an opinion should always be promptly discountenanced. Numerous trials for rape have grown out of an erroneous diagnosis in cases of this kind, much to the discredit of the professional attendant. The treatment of this variety of leucorrlioea consists, first, in removing, if possible, the 928 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. exciting cause; secondly, in invigorating the general health, by tonics, nutritious diet, and change of air; thirdly, in the observance of perfect cleanliness; and, lastly, in the use of mildly astringent washes and injections. Laxatives, leeches, and nitrate of silver, con- joined with rest and recumbency, may be necessary when the inflammation is unusually severe, obstinate, or protracted. Alum and lead are the best local remedies. The offensive discharges which so frequently attend upon affections of the vagina and uterus are best relieved by the use of deodorizers, as chlorinated sodium, permanganate of potassium, and similar articles. A solution of chloride of zinc, in the proportion of one grain to the ounce of water, also answers an excellent purpose; and Simpson speaks very favorably of injections of sulphite of lime and magnesium, with the addition of a small quantity of carbonate of lime. Thorough cleanliness in all diseases of these organs is a cardinal virtue. 8. Hemorrhage of the vagina is usually the result of external injury, and must be treated by ligation of the bleeding vessels, if practicable; by plugging and astringents, if not. Exposure of the part to the cold air and the application of ice will also prove bene- ficial. I have thrice seen very copious bleeding from laceration of the lower extremity of the vagina from the effects of copulation. New-born children are liable to a discharge of red, fluid blood, from the vagina, or va- gina and vulva, which often continues without any material interruption for several days and even weeks. The affection is unattended by any of the ordinary evidences of inflam- mation, such as discoloration, pain, heat, or swelling, and there is no perceptible derange- ment of the general health. What its precise source and nature are has not been deter- mined. It is always free from danger, and usually disappears of its own accord, the only thing required in the way of treatment being attention to cleanliness. t. Occlusion of the vagina is observed chiefly in married females, as a result of severe and neglected inflammation after delivery. The trouble may be caused by direct adhe- sion from deposit of plasma, or through the agency of bands of cicatricial tissue. Child- ren and young girls, however, are by no means exempt from it. The affection occurs in several varieties of form and degree. In the milder cases, the adhesion generally exists very low down, merely as a slight agglutination of the contiguous surfaces ; but, under opposite circumstances, the union may be complete, reaching from one end of the tube to the other. Such an effect may be the result of ordinary inflammation, and is then a com- paratively simple affair, especially if it has not been too long neglected; very frequently, however, it is caused by injury done to the parts during labor, eventuating in gangrene and sloughing, and the ultimate development of an inodular, inextensible tissue, render- ing the case one almost of a hopeless character. The only remedy for this affection is the separation of the contiguous surfaces, which, as already hinted, is occasionally easy enough. When the case is a slight one, the fingers alone sometimes suffice for the purpose. At other times the operation is readily performed with the handle of the scalpel, aided, perhaps, by a few touches with its cutting extre- mity. But the task is a very different one when the adhesion is firm and extensive. In such a case nothing but the most patient and cautious dissection wdll suffice, the knife being carried up in the natural direction of the tube, while the left index-finger is in the rectum and a catheter in the bladder, to serve as guides to the instrument, lest it should penetrate these cavities, and thus cause an intestinal or vesical fistule. Moreover, the operation is not undertaken without due preparation of the system, and a statement of its dangers. I have myself seen two women speedily perish from peritonitis induced by attempts to reestablish the vagina, although I am perfectly certain that the operation could not possibly have been better done. Ihe treatment after these operations must be conducted with great care and vigilance. A well-oiled tent of patent lint is inserted, to prevent readhesion of the contiguous sur- faces, renewal being effected wlienever it is demanded by cleanliness. When the cicatri- zation is completed, a gum-elastic bougie should frequently be introduced, to restore the tube to its normal diameter. When there has been loss of substance of the vagina, even to a slight extent, incessant vigilance will be required to counteract the tendency to con- traction and readhesion. f. Stricture, properly so called, of the vagina, from morbid deposits within its walls or the presence of firm cicatrices, is occasionally met with, and may require attention on account ot its interference with coition, parturition, and cleanliness. The milder cases will generally yield to dilatation ; in the more severe, moderately free incisions, aided by tents of compressed sponge, will be necessary. Firm cicatrices, obstructing the descent of the child’s head, must be thoroughly divided, by two or three small incisions on each CHAP. XVIII. AFFECTIONS OF THE VAGINA. 929 side of the vagina, the operation being performed during the existence of a labor pain, when the parts are upon full stretch. The anterior and posterior walls of the tube should not be interfered with, lest the bladder and rectum be endangered. Large incisions should be avoided. rj. Fibrous or myomatous tumors sometimes occur in the wall of the vagina as intra- parietal growths, forming comparatively soft structures, capable of attaining the volume of a double fist. Occasionally they assume the form of polyps, but in this event the mass is made up of fibrous tissue, only a few instances being recorded in which muscular elements were present. Tumors of this description may attain a very considerable magnitude, so as to distend not only the whole tube, but project some distance down between the thighs. Their weight has been known to exceed ten pounds. The proper remedy is evulsion or ligation. They are readily enucleated. 0. Prolapse of the vagina is most common after middle age, in married females who have borne children, and who have long suffered under a relaxed condition of the genito- urinary apparatus. The disorder, which is generally cojnbined with, if not directly de- pendent upon, prolapse of the uterus, may be limited to the anterior or posterior wall of the tube, or it may embrace its entire circumfer- ence. In the latter case, the vagina forms a large tumor, soft, elastic, and of a red, bluish, or lead color, passing beyond the vulva, and hanging down between the thighs, as in fig. 718. In prolapse of the anterior wall, there is generally a descent of the bladder, which ex- hibits itself as a globular or ovoidal swelling at the upper part of the vulva, and which may be greatly reduced in size, if not entirely ef- faced, by catheterism. Considerable irritability of the bladder gen- erally accompanies this complaint, attended with a frequent desire to micturate, and more or less tenesmus. As the organ can never entirely empty itself, the retained urine soon becomes decomposed, fetid, and surcharged with ropy mucus, or mucus and pus. Prolapse of the vagina is liable to be confounded with protrusion of the uterus and polyps of this organ. The principal points in the diagnosis are the soft and compressible character of the tumor, and its conical, globular, or ovoidal shape. In prolapse of the uterus, the swelling is hard, and the examiner may always readily determine the exist- ence of the orifice of the organ. A polyp is firm, incompressible, and irreducible. In prolapse of the anterior wall of the vagina, constituting what is usually termed vaginal cystocele, the tumor enlarges as the urine accumulates, and diminishes during its evacua- tion. The treatment of this affection consists, in its earlier stages, in the use of astringent in- jections, and of medicated tents, large enough to oppose the descent of the parts, and retained by an appropriate apparatus. In the anterior protrusion, the bladder should be frequently emptied, to prevent the pressure of the water from forcing down the tumor, and the uterus should be well supported with a stem pessary, worn steadily for several months, the woman being nearly all the time recumbent. By careful perseverance with this treat- ment, an excellent cure may occasionally be effected in a very short time, even in cases of an apparently unpromising character. When the cystocele is of long standing, or unusually obstinate, an elliptical portion of the mucous membrane of the vagina may be carefully dissected off, and the edges of the wound brought together by several points of the interrupted suture; the object being retrenchment of the redundant structures. In the posterior descent, special attention must be paid to the state of the bowels, as straining and the impaction of fecal matter are the most frequent causes of the complaint. When the case is utterly intractable, and the woman has passed the menstrual period, the orifice of the vagina should be closed by paring the surfaces of the labia, and uniting them by suture, as in the more aggravated forms of prolapse of the uterus. t. A cystic tumor, consisting in a morbid enlargement of one of the mucous follicles, is sometimes observed in this tube. It has a strong, thick, fibrous wall, with a polished in- Fig. 718. Prolapse of the Vagina. DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. X V I 11 . ternal surface, and is occupied by a clear, glairy, yellowish, viscid fluid. Seldom exceed- ing the volume of a chestnut or a pigeon’s egg, it is more or less tense, but fluctuating, tardy in its growth, very sensitive, and, at times, even painful. I once saw a growth of this kind immediately beneath the orifice of the urethra in a young lady, the mother of four children. It was of a spherical shape, about the size of a walnut, and of a white, glossy appearance, with a rough, corrugated surface. It had existed for eight years. The tumor was freely opened with the lancet, the incision giving vent to a considerable quantity of viscid, glairy fluid, like the white of egg, and the parts were soon permanently healed. x- A 'papillary tumor is occasionally developed in the vagina, particularly in its upper portion, where it forms an irregular, very vascular, cauliflower-like excrescence, which is liable to bleed under the slightest irritation. It consists essentially of hyperplasia of the normal papillae, and resembles in every respect similar growths of other mucous surfaces. The proper remedy is excision, followed by the application of chromic acid. Occasionally the morbid mass may be effectually scraped off. The operation, however, must be per- formed with care, otherwise the peritoneal cavity may be laid open, and death ensue from inflammation. •k. Epithelioma of the vagina may occur as a primary affection, beginning as a hard nodule, fissure, or warty, cauliflower-like excrescence in the mucous membrane; or, as is most generally the case, as an extension of carcinoma of the uterus, vulva, anus, or rectum. However arising, it is characterized by the usual symptoms, the most prominent of which are sharp, shooting pains, exquisite sensibility, and foul, sanious, or bloody discharge, followed, at no distant period, by enlargement of the iliac and sacral lymphatic glands. The treatment demands nothing peculiar. When the disease arises as an independent affection, the only rational thing to be done is to excise the parts as early and thoroughly as possible, and to approximate the edges of the wound, whether situated in front or behind, with a suitable number of sutures, managed in the same manner as in vesico- vaginal or recto-vaginal fistule. When the affection is secondary, the morbid structures must be removed along with the organs primarily involved, care being taken not to injnre the peritoneum. When the disease embraces the vulva, nymphae, or lower extremity of the vagina, the sphincter muscles of the anus may participate in the destructive action, and must, in that event, be included in the incisions. /x. Under the name of vaginismus, Dr. J. Marion Sims, in 18G2, described a peculiar affection of the vagina, previously noticed by Miclion and Debout, characterized by pain- ful spasmodic contraction of its sphincter muscle, accompanied by such a degree of’ sensi- tiveness of the surrounding structures as to form a complete barrier to coition and to the introduction of instruments. Its discovery is generally purely accidental. The gentlest touch with the finger, a probe, a feather, or even a hair pencil, causes the most exquisite agony. Every portion of the outlet of the vagina is sensitive, but often the most tender point of all is at the fourchette. The hymen is usually thick and bulky, while the orifice of the vagina is as firm and unyielding as if bound by a firm cord. The sphincter muscles of the anus, in many cases, feel almost as hard as a ball of ivory. The general health is commonly much deranged, the patient being exceedingly nervous, impressible, and wretched. The affection, which is occasionally accompanied by marked evidence of in- flammation, as patch-like redness and enlargement of the mucous papillae, is invariably complicated with rectal and vesical irritation. Its exciting cause cannot always be ascer- tained. In a case under the care of Professor AVillard Parker, the affection was due to a very small irritable caruncle of the urinary meatus, the removal of which was followed by prompt relief. The pathognomonic sign of vaginismus is spasm of the sphincter muscle of the vagina attended with supersensitiveness of the surrounding surfaces. The only affections with which it is liable to be confounded are occlusion of the vagina and the existence of an imperforate hymen. The disease obviously possesses a strong resemblance to anal fissure. In the milder forms of this affection, as in several instances under my care, relief is promptly afforded by forced dilatation with the fingers, employed in the same manner as in the treatment of fissure of the anus. Cases of excessive vaginismus have been reported, in which a rapid and complete cure was effected by the use of bromide of potassium, or of this article and chloral. The treatment which has been found to be most efficacious in the more rebellious forms of vaginismus is free division of the affected parts. The patient being fully anaesthetized, and placed on her back, as in the operation for lithotomy, the surgeon inserts the left index and middle fingers into the vagina, and, separating them laterally as wide as possi- CHAP. XV III. AFFECTIONS OF THE HYMEN. 931 ble, thus puts the fourchette well on the stretch. A deep cut is then made with a common scalpel through the resisting tissues, on each side, from ten to fifteen lines in length, com- mencing a short distance above the upper border of the sphincter muscle, passing across its substance for a short distance, and terminating at the raphe of the perineum. If the hymen be thickened, red, and supersensitive, it should be thoroughly removed at the same time. Any hemorrhage that may attend is easily controlled with Monsel’s solution. To complete the cure, a suitable dilator, generally one of hard rubber, glass, or gilt metal, is worn until the incisions are cicatrized. Sometimes relief may be procured simply by incising the mucous and submucous connective textures. SECT VI AFFECTIONS OF THE HYMEN. The principal affections of the hymen are inflammation, ulceration, laceration, imperfo- ration, and inordinate rigidity, interfering with copulation, parturition, and menstruation. Inflammation of the hymen is no doubt often primary, but more frequently secondary, or the result of an extension of the morbid action from the adjacent parts, as the vagina, nymplue, or vulva. It may be acute or chronic, simple or specific, diphtheritic, ecze- matous, or erysipelatous, and must be treated upon general principles; by rest, recumb- ency, laxatives, saturnine lotions, injections, and isolation of the vulva. In young chil- dren, laboring under vaginitis, much of the discharge attendant upon the morbid action is derived from the hymen. Ulceration of the hymen is most commonly of a specific character, being caused by the contact of the venereal virus, and must be treated by gentle cauterization with nitrate of silver, cotton tampons wet with a solution of alum or nitrate of lead, and charpie anointed with very dilute ointment of acid nitrate of mercury. Laceration of this membrane is often followed by considerable pain and hemorrhage, requiring rest, cold applications, and sometimes even styptics, as pounded ice and subsul- phate of iron. Occasionally the ligature is required to arrest the bleeding. When the hymen is torn irregularly, the shreds may be so much in the way of con- venience and comfort as to call for the use of the knife or scissors. In a case narrated by Boivin and Duges, an excrescence of this kind, of a pyriform shape and reddish color, adhered to the posterior part of the right nympha, and was two inches in length at the time of its removal, which was followed by copious hemorrhage, for the arrest of which it was necessary to cauterize the raw surface and plug the vagina. Surgical interference may be required when the hymen offers a serious barrier to sexual intercourse, to the descent of the child’s head in labor, and to the evacuation of the men- strual fluid. The membrane, however, is commonly so thin and fragile as to give way under the slightest force, and it is, therefore, seldom that any particular injury is sus- tained, whether the laceration is effected acci- dentally or designedly. A little blood may flow, and for a few days the parts may be sore and tender; but the trouble soon ceases, the angles of the wound shrink, and no further complaint is made. Division of the membrane is always easily effected with a probe-pointed bistoury. One of the evil consequences of an imperfo- rate hymen after the age of puberty is retention of the menstrual fluid, the diagnosis of which can only be determined by the history of the case and by a careful examination of the parts. More or less severe pain will be experienced at every monthly period, without any discharge in the natural direction, and the vagina will grad- ually become distended by the accumulated fluid, forming ultimately a pelvic tumor, readily de- tectable by the finger in the rectum and by the sight and touch upon separating the vulva, where there is often a marked bulging, of a dark blu- ish or livid color. The fluid, as it increases in quantity, not only completely fills the vagina, but distends the uterus, as in fig. 719, and even the Fallopian tubes, which, in conse- Fig. 719. Hematometra. Imperforate Hymen causing Disten- tion of Uterus and Vagina, h. Hymen ; v. Vagina ; u. Uterus; 6. Bladder; r. Rectum. DISEASES OF THE FEMALE GENITAL ORGANS, chap, xviii. quence, sometimes acquire the volume of a finger, or even of the small intestine. If the obstruction is not removed, one of the tubes may give way, and thus allow its contents to escape into the peritoneal cavity, followed by fatal inflammation ; or, instead of this, the fluid may find a partial vent through the rectum, bladder, or urethra, although such an occurrence is very uncommon. Division of the hymen for the relief of retained menstrual fluid is often followed by very serious consequences, and should, therefore, be performed with the greatest possible care. The plan formerly adopted was to make a free crucial incision, so as to admit of rapid drainage ; but, experience having shown that the operation when thus executed is liable to occasion peritonitis, the method now generally pursued is just the opposite one; that is, the membrane is pierced with a delicate trocar, the opening being made purposely small to allow' the uterus time to contract upon its contents as they slowly dribble away. The danger of the old operation is due to the fact that the large cavity left after the rapid evacuation of the tumor is speedily followed by the decomposition of what fluid remains in the womb, and that this occurrence, in its turn, is soon succeeded by a slow form of irritative fever, similar to that engendered by pyemia, and almost equally destructive. In other cases, again, the operation is followed by the rupture of one of the Fallopian tubes, which are always more or less distended with menstrual fluid, and the escape of which into the sac of the peritoneum invariably excites violent, if not fatal, inflammation. SECT. VII AFFECTIONS OF THE VULVA. 1. Labia—The labia are liable to hemorrhagic infiltration from a rupture of some of the neighboring vessels, which, as seen in fig. 720, from Kobelt, naturally abound here Fig. 720. Plexus of Veins of the Vestibule and Labium. and in the vestibule, and when injured pour out blood more or less freely The lesion which usually involves only one of these organs, may he caused by straining by the pres- ence of the child’s head during parturition, and by incised, punctured” or lacerated wounds I he tumor which is thus formed is generally of an irregularly oblong shape, with a dark livid surface, more or less compressible, and about the size of a hen’s eU Occasionally, however, it is much larger, equalling the volume of a foetal head, and con- taining from ten to twenty ounces of blood. The effusion commonly takes place suddenly or in a very short time and, when copious, it almost always makes its escape spontane- ously, by lacerating the superincumbent textures; or it remains, and speedily induces inflammation and gangrene. In the latter case the blood is generally of a very black color, partly fluid and partly coagulated, and emits a highly offensive odor. The infil- trated tissues are sometimes frightfully lacerated, and converted into a dark, shreddy substance, without any trace whatever of their original characters. J When the tumor is small, it will usually soon disappear under cooling sorbefacient an plications, as solutions of acetate of lead, alum, or, best of all, chloride of ammonium, CHAP. XVIII. AFFECTIONS OF THE VULVA 933 along with opium ; but, under opposite circumstances, the only effectual remedy is prompt evacuation by free incision. Any bleeding vessels must be sought for and tied. In some cases the hemorrhage is best controlled by plugging the vagina and applying counterpres- sure to the affected labium ; in others, again, the object is most readily attained by means of compresses wet with Monsel’s solution and confined with a suitable roller. The labia are liable to incised, lacerated, and contused wounds, the chief interest of which arises from the excessive swelling and hemorrhage that so often attend them. Numerous cases have been reported in wdiich the bleeding, in incised wounds, was so copious as to prove fatal in a few hours. The treatment involves nothing peculiar. Acu- pressure is sometimes required to arrest the hemorrhage. Inflammation of the labium may be produced by various causes, and requires the usual remedies for its subdual. The formation of matter will be denoted by increase of heat and swelling, the inordinate hardness of the part, and the throbbing character of the pain. Relief is afforded by an early and free incision, the surgeon not always waiting for distinct fluctuation. A chronic abscess sometimes occurs here, as in the case of a married female, twenty- six years of age, who came to me with a swelling in the left labium of nearly four months’ standing, hard, free from pain, and without any constitutional disturbance. The inser- tion of an exploring-needle was followed by an escape of pus, which, when fully evacu- ated, amounted to upwards of five ounces. The exteimal lip may be the seat of different kinds of ulcers, either simple or specific, most commonly seated upon its mucous surface, or at the junction of this surface with the cutaneous. The disease sometimes affects the mucous follicles, the sore presenting itself in the form of a small depression, perhaps not larger than a pin’s head. The chancroidal ulcer is generally readily distinguished by its history, its large size, its tendency to spread, its obstinacy, and the abundance of the attendant discharge. The common ulcer is often occasioned by want of cleanliness, friction, or disorder of the digestive apparatus. The treatment of ulceration of the vulva must depend upon the nature of the exciting cause. The most important remedies are frequent ablutions with soap and water, and astringent lotions, applied by means of patent lint in such a manner as to insure constant isolation of the opposed surfaces. Recumbency, light diet, and purgatives are indispen- sable auxiliaries. If the ulcers have a tendency to spread, they should be gently touched, once a day, with a weak solution of acid nitrate of mercury. A chancre may require slight ptyalism. Gangrene of the vulva is uncommon. It is most liable to occur in worn-out intem- perate, anemic females, as a consequence of syphilis, and must be treated upon general principles. Mr. Kinder Wood, many years ago, described a fatal disease of the vulva of young children, which, commencing at one or more points of the mucous surface, rapidly spreads over the nymphse, clitoris, and hymen. Gangrenous spots appear in a very short time, and continue to enlarge until the parts are converted into dark-colored, fetid sloughs. Great prostration of strength, accompanied by fever and severe pain, is the most promi- nent symptom of the complaint. The treatment consists of tonics, milk punch, anodynes, and the application of dilute acid nitrate of mercury, with warm water-dressing, simple or medicated. (Edema of the vulva is occasionally witnessed; chiefly during the latter months or pregnancy, or soon after delivery, and in females of a broken constitution, in association with ascites and anasarca. Enormous tumefaction, either circumscribed, or more or less diffused, may thus be produced, terminating, unless timeously relieved, in severe suffer- ing, if not in gangrene. The proper remedy consists in the removal of the exciting cause, and a few minute punctures, to admit of the escape of the pent-up fluid, followed by astringent lotions, or pencilling of the affected parts with dilute tincture of iodine. Erysipelas of the vulva is usually of the oedematous character; the disease is easily recognized by the nature of the pain and swelling, and is treated upon general princi- ples, early and free incisions forming an important element of the management. Fistule of the vulva is generally caused by an imperfectly healed abscess or ulcer, and is often a very troublesome complaint, keeping up discharge and irritation. It may be limited to the labium, or extend into the vagina, perineum, anus, or even the bladder. The diagnosis can only be established with the probe. A cure may sometimes be effected by strong injections of iodine, but the best and speediest remedy, by far, is the free divis- ion of the parts with the blunt-pointed bistoury. The operation, however, is liable to be 934 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. followed by profuse venous hemorrhage, and should, therefore, be conducted with propel circumspection. . . There is a form of inflammation of the vulva, which, occurring at different periods of life, but especially in married females, has its principal seat in the mucous crypts. It usually shows itself in small patches, of a red, almost scarlet complexion, studded with minute points, which are slightly ele- vated above the surrounding level, and per- fectly distinct from each other. As it progresses, the points increase in volume, and ultimately coalesce, so as to impart to the surface a rough, granulated appearance. At this stage, and, indeed, often before the morbid action has reached this height, some of the glands become ulcerated, the sore looking, at first, like a mere speck, but gradually growing larger and larger until it has acquired the size of a split currant or small pea, its edges being steep, ragged, and, perhaps, partially undermined. The affection is, in every respect, analogous to follicular ulceration of the bowel. The crypts are liable to chronic inflam- mation, attended with hypertrophy. When thus affected, they present the appearance of little vesicles, charged with a thick, mu- cous fluid, not unlike the white of egg, or the contents of the enlarged follicles which are sometimes seen upon the lips of the uterus. These appearances are well illustrated in fig. 721. In the treatment of this affection the most suitable local remedies are leeches, astrin- gent lotions, and nitrate of silver. When it assumes the chronic form, great relief will be afforded by weak citrine ointment. Rest, light diet, and purgation are important aux- iliaries. Pruritus of the vulva, or eczema of the mucous membrane of the vulva and vagina, is often met with, both in single and married women, but more especially in the latter, and is frequently a source of very great distress, from the violence of the accompanying itch- ing. The disease is most common in females with light hair and eyes, and is generally dependent upon disorder of the digestive apparatus. It is often associated with leucor- rhoea, and is so constant an attendant upon diabetes that some authors look upon it as a diagnostic sign of this affection. The parts, which are frequently very dry, have usually a cracked, chapped, or fissured appearance. Minute vesicles, resting on a reddish base, are sometimes present. There is seldom much discharge at the immediate seat of the disease. The treatment is very uncertain. The most reliable remedies are steady purgation, a restricted, cooling diet, frequent ablutions, inunctions with chloral and camphor ointment, and the application of solutions of borax, acetate of lead, and bichloride of mercury, of which the last is one of the best. Hot water often affords temporary relief. If plethora exist, blood may be taken from the arm, or by leeches from the groins and vulva. If, on the contrary, the patient is anemic, chalybeate tonics should be prescribed, and the very best, as a general rule, is the tincture of chloride of iron, either alone or in union with quinine. Inversion of the hairs of the labia, an affection first described, in 1862, by Dr.'Meigs, and closely resembling trichiasis, is occasionally met with, and may become a source of great suffering from the teasing irritation which it keeps up in the mucous membrane, attended with great redness and excessive itching. The remedy consists in pulling out the stiff and incurvated hairs with a pair of tweezers. Papillomas or warty excrescences are often seen upon the labia, extending, in some instances, into the vagina, and down the perineum as far as the margin of the anus. Their number may be very great. I have occasionally counted upwards of a hundred, of all sizes, from a mustard-seed to that of a raspberry. Usually they are of a pale, florid color, of a fibroid consistence, rough on the surface, pedunculated, and somewhat painful Fig. 721. .follicular Disease of the Vulva. CHAP. XVIII. AFFECTIONS OF THE VULVA. 935 on pressure. Occasionally they are grouped together, running into each other, and thus forming large, irregularly fissured, or cauliflower-like masses. Their origin, in most cases, is referable to the effects of the gonorrhoeal or syphilitic poison. The treatment is similar to that of warty excrescences upon the penis. The most effica- cious remedy is chromic acid, applied every other day, the parts being in the mean time thoroughly isolated. The largest growths occasionally require excision. If the disease is very rebellious slight ptyalism may be useful. What is known as the oozing tumor is nothing but a species of papillary growth, spring- ing from one or both labia, in the form of a cauliflower-like excrescence, the seat of a con- stant and profuse acrid, watery discharge, almost insupportably fetid. It is of a reddish, bluish, or purplish color, very vascular, and of a soft, spongy consistence. Its origin is obscure, but is never, so far as can be determined, of a syphilitic nature. Want of clean- liness, keeping up local irritation, may possibly have something to do with it. It is generally of slow development, but is capable, in time, of acquiring a considerable bulk, and is then always a source of more or less suffering and inconvenience. Itching is often a very disagreeable symptom. The tumor is generally described as being most common in elderly, corpulent women, but, while this may be true, it has also been repeatedly noticed in young girls, and in the single as well as in the married. Palliation is afforded by rest and attention to cleanliness. Dusting the surface of the growth with powdered oxide of zinc, lycopodium, or fuller’s earth sometimes affords great comfort. The only radical remedy is excision, an operation generally attended with pro- fuse bleeding. Repullulation is counteracted with escharotics and attention to rest, cleanliness, and separation of the labia. Polyps of the vulva are of very unfrequent occurrence. They are generally of a pyri- form figure, conical, or globular, and attached by a long, narrow pedicle. In volume they vary between an almond and a child’s head, although they rarely ex- ceed that of the fist. Occasionally they are so large as to hang down between the knees. At an early period they are of a spongy consistence and of a bright florid color; but they are liable to become hard, and to assume a pale, mottled appearance, especially when they project beyond the vulva. Ulcera- tion occasionally occurs, followed by a copious discharge of bloody, fetid mat- ter. Their structure is usually of an cedematous, fibrous nature, either uni- formly, or interspersed with cysts, or masses of fibro-cartilage. The only remedy is removal with the knife, ecraseur, or ligature. The labia, nymphae, and lower part of the vagina are sometimes the seat of varicose veins, as seen in fig. 722 ; the disease, which is most common in mid- dle-aged subjects, is usually associated with varicose enlargement of the veins in the inferior extremity, and is liable to great aggravation during pregnancy and delivery. The veins are spread out in an irregular arborescent manner, and may be many times the natural size. The coats of the vessels may be entirely healthy, but more frequently they are diseased, being attenuated at one point and thickened at another. In some cases the lining membrane becomes in- flamed, causing coagulation of the blood and the formation of pus. During parturi- tion the enlarged veins may be ruptured by the pressure of the child’s head, inducing copious, if not fatal, hemorrhage. No treatment is generally required beyond an occa- sional purgative, recumbency, and the use of cold water. Should the veins be acci- Fig. 722. Varicose Veins of the Vulva. 936 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. dentally ruptured, and the hemorrhage become serious, the bleeding vessels must be sought for and ligated or acupressed. Cavernous Angioma or Ncevus of the vulva is by no means of unfrecpient occurrence. I have met with it several times as a congenital affection, but it may also arise later in life, chiefly as a venous growth, of a bluish, purple, or mulberry color, and soft, spongy consistence, varying in size from a filbert up to that of a hen’s egg. Occasionally it has a lobulated appearance, as in one of my cases, that of a lady fifty-six years of age. The growth is not always confined to the labium, but is liable, as it advances, to extend to the nympha, the perineum, or even the thigh. When the tumor is not very large the best plan is to strangulate it with the ligature ; when the reverse is the case, or the tumor is pendulous with a narrow neck, and is devoid of arterial structure, the ecraseur should be employed. Sometimes the use of the continuous ligature will be necessary. Occlusion of the vulva, dependent upon adhesions of the labia, or the labia and nymphm, is not uncommon. The occurrence is sometimes observed in very young children, occa- sionally, indeed, in infants at the breast, and is, of course, always the result of inflamma- tion, not unfrequently caused by want of cleanliness or the accidents of parturition. When the adhesion is slight it is easily broken up with the probe or finger; when, however, it is extensive, the knife may be required, used prudently, lest more be divided than is proper. E-pitlielioma of the labia is witnessed in females of middle age and advanced years. Commencing usually as a warty excrescence or a fissure, it exhibits the same characters, symptoms, and progress as carcinoma of other muco-cutaneous surfaces. The pain is sharp, pungent, and lancinating, the discharge is exceedingly fetid, the edges are under- mined, the surface is tuberculated, with a tendency to hemorrhage, and the inguinal lymphatic glands are early involved. The treatment is conducted on general principles, early and free excision being indicated when the disease has not made too great progress, simply with a view to palliation, as recurrence is usually inevitable. Finally, the labia are liable to various kinds of tumors, as the fibrous, cystic, fatty, myxomatous, and sebaceous, as well as to scirrhus, encephaloid, and sarcoma. Th a fibrous tumor does not always originate in the labium, but may take its rise deep in the pelvis, and, advancing outwardly, involve the vulva secondarily. It is most common in young married females, and is capable of acquiring a large bulk, especially in the tropics, where it is much more frequent than in this country. Its shape is usually somewhat pyriform, its attachment being by a small base which often extends to a con- siderable depth. It is of a firm, slightly elastic consistence, movable, free from pain and discoloration, and little disposed to ulceration, the principal inconvenience being caused by its weight and bulk. As it enlarges, it gradually distends the labium, elongating it and dragging it down between the thighs. Dr. William J. Holt, of Montgomery, Alabama, has communicated to me the particulars of a case in which a growth of this kind measured twenty-three inches in circumference. A section of the tumor displays a dense, firm, glistening tissue, not unfrequently inter- spersed with small cavities, resembling cysts, filled with a clear, serous, gelatinous, or sanguinolent fluid, sometimes spontaneously coagulable. The older growths of this de- scription occasionally contain nodules of cartilage, or small earthy concretions, similar to those found in fibrous formations of the uterus. The fibrous growth of the labium, notwithstanding it sometimes attains a great bulk, possesses little vascularity; its production is occasionally traceable to the effects of ex- ternal injury, and it now and then, as in a case which I attended along with the late Dr. McWliinney, presents a distinctly fibro-serous envelope. The only remedy for the cure of this tumor is excision. In some instances the whole mass may readily be got rid of by enucleation. When the growth is prolonged into the pelvis, the pedicle, after suitable exposure, should be included in a ligature. The opera- tion is seldom attended with much hemorrhage. A cystic tumor, filled with serous, glairy, or dark-colored fluid, and of a spherical, ovoidal, or pyriform shape, is occasionally met with in the labium, or in the labium and the groin; it is generally unilocular, semitransparent, circumscribed, more or less fluctu- ating, and firmer than oedema, but not so hard as a fibrous tumor. It may be caused by external injury, and, if unmolested, may ultimately attain a bulk equal to that of an in- fant’s head. The treatment is by iodine injections, seton, or, what is better, excision. A\ hat is called hydrocele of the female, is generally a serous cyst, the consequence ot an old, or partially cured hernia, in which a portion of the proper sac remains, and becomes CHAP. XVIII . AFFECTIONS OF THE VULVA. 937 afterwards, under the influence of chronic irritation, a serous cyst. The most common subjects of this form of tumor are married women. The fatty and myxomatous tumors of the labium are uncommon; they are of slow growth, soft and doughy in consistence, and seldom attain much bulk. Occasionally they present a nodulated appearance, as if they were composed of several distinct masses. They require the same treatment as similar formations in other parts of the body. Dr. G. B. A. Hanuschke has recorded a case of fatty tumor in the labium of a woman thirty-six years of age, that weighed nearly twelve pounds. It formed an immense pen- dulous mass, of a pyriform shape, with a large pedicle firmly attached to the branches of the ischium and pubes. The operation, although very bloody, was perfectly successful. The sebaceous tumor of the labia is also very rare. It is generally of a globular form, perfectly movable, free from pain, firm, but semielastic, and from the volume of a hazelnut to that of a pullet’s egg. The treatment is by excision. Scirrhus and encephaloid of the labia may occur as primary affections, but more frequently they extend to these structures from the clitoris and the nymphse; in some cases they are evidently offsprings of carcinoma of the uterus and vagina. The two dis- eases are characterized by the same phenomena as scirrhus and encephaloid in other organs, and demand the same treatment, the only reliable remedy being early extirpation. In a case under my care, of primary scirrhus of the left labium of a woman forty-six years of age, removal was followed in four months by a return of the disease in the inguinal, iliac, lumbar, and anterior mediastinal glands. The liver, after death, eight months subsequently, weighed fourteen pounds, from involvement in the morbid action. The secondary deposits were of an encephaloid character. Sarcomatous or fibroplastic tumors occasionally occur in the labia, where they may attain large dimensions. They present the same general features as sarcomatous forma- tions in other structures, and, therefore, do not require special description. 2. Nymphce The nymphaa are not often the subjects of disease, independently of that of the great lips. They are occasionally the seat of hypertrophy or chronic enlarge- ment, so excessive as to require excision, of cystic tumors, of epithelial carcino- ma, and of encephaloid sarcoma. Of the latter disease, I met, many years ago, with an extraordinary case, in a girl, five years of age, who died, exhausted, at the end of nine months from the first appear- ance of the tumor. The morbid growth, as seen in fig. 723, had extensively in- volved the lymphatic glands of the groin and pelvis. The clitoris was also greatly enlarged. A cystic tumor, filled with serum, some- times occurs in the nympha; generally in married females, from the twenty-fifth to the fortieth year. It is soft, fluctuating, of a rounded or ovoidal form, and of vari- able dimensions, from an almond to that of an oi'ange. The diagnosis is easily established by the exploring needle. The most effectual remedy is excision, but a cure may also be effected by the seton and by iodine injections. There is a form of cystic tumor of the nympha which is occupied by a thick, glairy, mucous fluid, and which is evidently occasioned by the closure of the duct of the gland of Bartholine with retention of its natural secretion, which is sometimes excessively fetid. It is similar to the tumor sometimes found on the lip, and requires similar treatment. A polyp occasionally grows from the nympha, as in a case under my notice in 1802, in a little girl only eight years of age. The tumor was of a scarlet color, granulated and fissured on the surface, destitute of sensibility, fibrous in structure, and about the size of a large hickory-nut. It adhered to the outer surface of the nympha by a short, narrow pedicle, and completely closed the orifice of the vulva. It had been first observed about one year previously. Removal was readily effected by ligation. 3. Clitoris The principal affection of the clitoris is hypertrophy, which may be so great as to be a serious inconvenience and annoyance. In some countries this organ is Fig. 723. Encephaloid Sarcoma of the Nympha; and Clitoris. 938 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. naturally much larger than in America and Europe. In Persia, Turkey, and Egypt, hypertrophy of the clitoris is often immense, the tumor thus formed perhaps equalling the size of an adult’s head. The disease, which is sometimes congenital, is generally caused by protracted irritation. Courtesans were formerly supposed to be particularly liable to attacks of this kind, but the researches of Parent-Duchatelet and others have shown that this is not the fact. The annexed cut, fig. 724, affords a good idea of this affection. The Fig. 724. Hypertrophy of the Clitoris and Nymph®. growth was associated with hypertrophy of the nymphae. When the tumor has acquired a large bulk, the only remedy is excision. The operation is usually attended with a good deal of hemorrhage. When the disease is in its infancy, repression may be attempted with cooling and astringent lotions, tincture of iodine, and other sorbefacient means. Clitoridectomy may be required on account of excessive enlargement of the clitoris, the presence of malignant disease, or epilepsy dependent upon the practice of masturbation. For the relief of the latter affection the operation has of late years been performed with very happy results in a considerable number of cases. Professor White, of Buffalo, reported three instances of this kind, in twro of which the operation seemed to have been perfectly successful. Excision of the clitoris is sufficiently easy ; but the hem- orrhage is often very profuse, and is generally most readily and effectually controlled by acupressure. Professor White has suggested the substitution of the subcutaneous divi- sion of the pubic nerves for the more offensive mutilation of clitoridectomy. The clitoris has occasionally been removed on account of erotomania, even when it was not materially enlarged. Such an operation is on a par with the amputation of the penis for the cure of masturbation. Nothing could be more absurd. A case of ivound of the clitoris, followed by fatal hemorrhage within an hour after its occurrence, has been reported by Mr. Gutteridge, in the London Lancet for October, 1846. The accident was caused by a kick. The wound, situated at the entrance of the vagina, along the ramus of the pubes, was one inch in length by three-quarters of an inch in depth, and completely exposed the left crus of the clitoris, the cavernous structure of which was thoroughly crushed. 4. Urethra.—The female ui’ethra is rarely diseased. The principal lesions to which it is liable are malformations, stricture, vascular excrescences, dilatation, and prolapse. Dr. Skene, of Brooklyn, has devised a very useful endoscope, fig. 725, for inspecting the tube and the interior of the bladder. Various other contrivances of a similar kind are to be found in the cutler’s shops. a. The orifice of the urethra, in certain congenital malformations, opens into the vagina at some distance from the external aperture. Occasionally, as when the mouth of the vagina is closed by a dense membrane, the urethra is so much dilated as to admit the male organ. CHAP. XVIII. AFFECTIONS OF THE VULVA. 939 b. Spasm of the urethra, attended with more or less pain in micturition, if not also with dribbling, or even retention of urine, may depend upon various causes, as suppres- sion of the cutaneous perspiration, a rheumatic or gouty state of the system, irritating urine, or disease of the kidneys, vagina, uterus, anus, or rectum ; and usually yields readily to anodynes, diaphoretics, and the hip-bath. Fig. 725. c. Organic stricture of this passage is exceedingly infrequent. The most common cause is inflammation, provoked by external injury or by violence inflicted during partu- rition. Marked diminution of the canal is occasionally produced by a granular condition of the mucous membrane. Gonorrhoea rarely acts as an exciting cause. The obstruction, which may affect any portion of the tube, is characterized by the ordinary phenomena. The treatment must be conducted upon the same principles as that of stricture in the male, or by gradual or forcible dilatation, and, in obstinate cases, by urethrotomy. The elm bougie is well adapted to promote rapid and efficient dilatation. Electrolysis has occasionally been employed, and seems to have been especially beneficial in the hands of Dr. Robert Newman, of New York. When the coarctation is accompanied by excessive irritability of the canal, the treatment should be aided by the application of nitrate of silver. d. Vascular, papillary excrescences, caruncles or polyps sometimes spring from the female urethra, or are seated around its orifice, as shown in fig. 726. They are of a bright scarlet color, exquisitely sensitive under pressure, and of a soft, spongy, erectile structure, with a smooth, fissured, or granulated surface, not unlike that of a raspberry. Their shape is gen- erally pear-like, and in size they vary from a small pea to that of a horse-bean. The vessels, which are exceedingly numerous, and very fine and deli- cate, are arranged in undulating curves, and termi- nate mostly in short, abrupt loops. The walls are very brittle, and hence they generally bleed more or less profusely when rudely touched. Nerves also abound in these neoplasms, a circumstance which readily accounts for their extreme sensitiveness. Vascular growths of the orifice of the urethra are most common in middle-aged, married women, but are also met with in young girls, and are, as a rule, productive of great suffering, often telling fearfully upon the general health, and rendering life utterly miserable. The only suffering at all comparable with it is that arising from fissure of the anus, or the presence of a neuroma of the skin. Scalding and spasm, in micturition, are always prominent symptoms, the parts are intolerant of the slightest touch, and walking is attended with more or less pain, along with separation of the thighs to guard against friction. The cause of these excrescences is unknown. The only reliable remedy is excision, an opera- Skene’s Endoscope. Fig. 726. Vascular Excrescences of the Urethra. 940 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. tion often attended with considerable hemorrhage. To prevent repudiation, the ten- dency to which is very great, the raw surface should be well rubbed with chromic acid, gently seared with the hot iron, or destroyed with Faquelin s thermo-cautery. . I lie ope- ration should always be performed with the aid of an anesthetic. In very rebellious cases, recurrence may sometimes be prevented by forcible dilatation of the urethra with the bougie, by the finger carried into the bladder, or by the instrument delineated in the chapter on stone in the female bladder. Apart from the ordinary growths above described, there is another, more of the nature of a true polypoid papilloma, usually attached by a narrow footstalk to the orifice of the urethra, of a reddish color, soft in consistence, rounded or pyriform, free from pain and tenderness, of variable size, but capable of acquiring considerable bulk, and most com- monly met with in young Avomen. Removal may be effected by ligature or with the knife. e. Varicosity of the vessels of the spongy tissue or of the veins surrounding the urethra is occasionally met with in the form of an ovoidal, soft, compressible tumor, the surface of which is pervaded by small vessels. It may attain the size of a walnut, and is characterized by a sense of fullness, tension, and discomfort in the erect posture, which disappears during recumbency, by pain in coition, and by frequent desire to micturate. Ligation, or the injection of carbolic acid, as in the treatment of hemorrhoids, is* the proper remedy. f. Urethrocele is an occasional but very uncommon affection involving the posterior wall of the urethra, where it forms a soft, elastic, fluctuating rose-colored tumor, varying in size from a filbert to that of a pullet’s egg. Wickel has collected four cases of it, occur- ring, respectively, in the practice of Foucher, Gilette, Simon, and Priestley. To these may now be added two more recently reported, respectively, by Dr. V. Ingersley, of Hol- land, and Dr. Andrew F. Currier, of New York. All the women had borne children, and their ages ranged from twenty-five to forty-five. The disease consists essentially in a dilated or expanded condition of the mucous membrane of the urethra and of the vagina, with thickening of the intervening structures and a great increase in the vascularity of all the tissues. The tumor, which often remains stationary for a long time, may eventu- ally acquire a bulk the size of a small hickory-nut, and be the seat of considerable pain, as well as of more or less muco-purulent discharge. Unless great care be taken it may be confounded with a polyp, or myxomatous growth in this situation, although its nonpedun- culated shape, and the fact that it forms a distinct ring around the orifice of the urethra, are generally sufficiently diagnostic of its character. The only effectual remedy is the removal of an elliptical portion of the mucous covering of the tumor, and the closure of the Avound Avith interrupted sutures. In one case, that of Currier, Dr. T. G. Thomas excised all the redundant portion of the urethra. The patient during the operation is placed in the abdominal position, as in the operation for vesico-vaginal fistule, the Aragina is dilated Avith a Sims’s speculum, and a sound is securely held in the bladder to serve as a guide to the knife and scissors. The after-treatment is conducted upon general principles. 5. Urinary Bladder—The diseases and injuries of this organ in the female are similar, in all essential particulars, to those of the male, and necessarily require similar treatment. There are, nevertheless, a feAv points which require separate consideration for their detec- tion and mode of management. a. What is called fissure of the neck of the bladder consists essentially, as the name indicates, in the existence of one or more small, superficial ulcers, generally limited to the mucous membrane, but occasionally also involving the fibrous coat, if not also the mus- cular. The affection is always attended Avith excessive pain, of a spasmodic nature, with a frequent, in some cases, indeed, almost a constant desire to pass AArater, and a severe scalding or burning sensation during the evacuation of the last drops of urine. The affec- tion is most commonly met Avith after middle life, generally arises without any assignable cause, and is very liable to be confounded Avith other disorders of the urinary apparatus. One of the most important diagnostic signs, unquestionably, is the persistent character of the pain, and its intensification during and immediately after micturition, especially as the last drops are passing off. An endoscopic examination Avould at once reveal the true nature of the disease, but it is not easily made, and few practitioners are provided Avith the necessary instruments. The affection is very liable to be mistaken for ordinary cys- titis, and it should not be forgotten that it is often simulated by irritability of the neck of the bladder dependent upon gout, or rheumatism, reflex action of the kidneys, or dis- ease of the neighboring organs, as the uterus, vagina, anus, or rectum. CHAP. XVIII. AFFECTIONS OF THE VULVA. 941 For the cure of this distressing disease two methods of treatment have been proposed, both being designed to place the muscular fibres of the affected portion of the bladder in a state of complete rest. One of these is forcible dilatation of the urethra; the other vaginal cystotomy. The objection to the first is its liability, however carefully prac- tised, to lead to permanent incontinence of urine, a sufficient reason why it has such few advocates. Cystotomy is performed by making an opening through the vesico- vaginal septum, close up to the neck of the bladder, and keeping it patent until relief is afforded, when it is to be closed by suture, as in ordinary vesico-vaginal fistule. Through the opening thus made, or, what will be more convenient and effective, through the ure- thra, the fissure may be medicated with tents wet with astringent lotions, weak solutions of nitrate of silver, or an ointment conposed of cosmoline and iodoform. Applications of solid nitrate of silver are often useful but always excessively painful. The general health, which generally suffers terribly in this disease, must receive proper attention, and the exquisite pain assuaged with anodyne suppositories and hypodermic injections of morphia. Bicarbonate of sodium should be freely used when the urine is loaded with uric acid, and in order to prevent the formation of this substance the diet should consist almost exclusively of bread, milk, and eggs. b. Cystorrhcea in women, as in men, is always a painful and troublesome affection. Its characteristic sign is a superabundant discharge of mucus of a thick, ropy character, not unfrequently loaded with pus, and occasionally even with phosphate of lime. The urine is high-colored, passed with great frequency, and rapidly undergoes decomposition. The pain is always severe, more or less constant, and of a spasmodic character. The general health is always seriously implicated, and the local distress is sure to be aggravated by exposure to cold, rough exercise, derangement of the bowels, dyspepsia, or, in short, whatever has a tendency to disorder the digestive apparatus. The milder forms of chronic cystitis often yield to absolute rest in the recumbent posture, assisted by anodyne suppositories and irrigations several times daily of the blad- der with hot water medicated with laudanum and acetate of lead, sulphate of zinc, or nitrate of silver. Whatever fluid be used, it must be thrown in with great care. The bowels must be relieved with enemas, the diet must consist largely of milk, and the sys- tem must be kept thoroughly influenced with quinine and tincture of chloride of iron. Balsam of copaiba, although sometimes useful, is a disagreeable remedy, and is generally to be avoided on account of its tendency to disorder the digestive organs. Bicarbonate of sodium and bromide of potassium, either alone or in union with chloral, will be bene- ficial when there is dyspepsia with acidity and flatulence. In chronic cystitis, incurable by the above treatment, the only possible chance of relief is by colpocystotomy, by which an opening, about three-quarters of an inch in length, is made through the middle line of the vesico-vaginal septum, as a means of conducting off the urine as fast as it descends from the kidneys. To prevent the opening from closing prematurely, it may be necessary to use a stout gum-elastic tube, made after the fashion of a cuff stud. Suitable treatment after the operation must not be neglected. c. When the urethra is greatly dilated and the bladder relaxed and weakened, inver- sion and prolapse of the bladder may occur under two distinct varieties of form, the complete and the incomplete ; the first consisting in an inversion of all the tunics of the bladder, while, in the second, the inversion is limited exclusively to the mucous mem- brane. The exciting cause is violent and frequent straining, such as accompanies various impediments to the evacuation of the urine and feces. Severe coughing may be men- tioned as a predisponent. Dilatation of the urethra from overstretching, performed for the relief of neuralgic and other affections, and for diagnostic purposes in diseases of the bladder, is an evil of no ordinary magnitude, from its liability to be followed by permanent incontinence of urine. For this reason, certainly a most powerful one, such operations should, as a rule, be dis- carded from practice. Dilatation of the anterior portion of the tube is a comparatively harmless procedure ; but when it is carried through its entire length the consequences are generally disastrous in the extreme. Two remedies present themselves in such a condi- tion ; one is to lessen the injured canal by the removal of a longitudinal section, and unit- ing the edges with the button suture; the other is to place the parts at rest by means of colpocystotomy until, with the aid of nitrate of silver and various astringent applications, especially alum and tannic acid, the affected structures have regained their normal con- tractility. In the treatment of the incomplete form of inversion and prolapse, the circumstances 942 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. mainly to be attended to are, first, to enjoin strict recumbency for a long time ; secondly, to reduce the tumor carefully, and to counteract afterwards any tendency to protrusion by the frequent use of the catheter, and by astringent washes and injections ; and, thirdly, to correct the general health by chalybeate tonics and other means. The bowels should he maintained in a soluble condition, and the urine should be passed in the recumbent pos- ture, the patient lying on her side or back. Excision of the protruded part should be studiously avoided, as it might lead to fatal results. Of the complete variety of inversion and prolapse of the bladder, very little is known. The most important signs, in a diagnostic point of view, are, the gradual development of the tumor, its soft, elastic feel, its red, vascular appearance, its pyriform shape, and its situation between the labia, immediately below the clitoris, and in front of the vaginal orifice. When we add to these circumstances the fact that there are usually three distinct aper- tures on the surface of the tumor corresponding with those of the urethra and ureters ; that the tumor is easily reduced by pressure; that the patient is unable to retain her urine; that the part is not particularly tender, sore, or painful; and that there is not, at least not necessarily, any derangement of the general health, the practitioner can hardly fail to detect the true nature of the malady. So far as I know, only four cases of complete inversion of this organ have been placed upon record, reported, respectively, by Crosse, Murphy, Lowe, and Croft, all occurring in children, the youngest being only fourteen months of age, and the oldest four years. In the reduction of the tumor, the patient is placed upon her back, the head and shoulders are elevated, and the thighs, flexed upon the pelvis, are widely separated from each other. The labia are then held apart by an assistant, while the surgeon applies his fingers, previously oiled, to the surface of the tumor, and pushes up that part which came down last, the pressure being maintained steadily, but gently, until the whole of it has slipped up behind the pubic symphysis. When the swelling is bulky, and of long standing, it may be necessary to assist these efforts by means of a catheter, applied to the fundus of the bladder, and carried up in the direction of the urethra. If the tumor has become irreducible, an attempt should be made to diminish its volume and hardness by leeches, fomentations, and other relaxing measures. Anaesthesia is a valuable adjuvant during replacement. When the parts are restored, the patient should observe the recumbent posture, the urine should be frequently drawn off, and, if the protrusion be considerable, a compress, confined by a T -bandage, should be worn upon the mouth of the urethra. When the patient gets up, she should wear an abdominal supporter. W hen the urethra is much dilated astringent injections, aided by electricity, may be serviceable. If this should fail an operation may become necessary. The inferior por- tion of the tube may be divested of its mucous membrane, after which the raw surfaces are approximated by a few points of interrupted suture, care being taken to draw off the urine several times a day, until consolidation is effected. d. Retention of urine may be caused : 1st, by the presence of a foreign body, as a calculus, or various substances introduced from without; 2dly, by spasm, as from cold, strangury, or stimulating medicine, food, or drink ; 3dly, by organic stricture of the urethra; 4thly, by contusion and swelling of the urethra, as after external injury and the use of the forceps ; othly, by paralysis of the bladder; 6thly, by mechanical pressure upon the neck of the bladder or urethra, as in pregnancy, in ovarian disease, in distention of the rectum, in pelvic tumors, and in prolapse, anteversion, retroversion, or lateral displacement of the uterus; and, lastly, by hysterical conditions of the mind, in which the bladder retains its power but cannot be influenced by the will. The manner of meeting these various contingencies is fully pointed out in a previous chapter. In the retention of urine, consequent upon protracted labor, or copious flooding, the patient will frequently not be able to pass a drop of water, so long as she remains in the supine posture; but the difficulty at once vanishes if she gets on her side, raises her head and shoulders, or turns on her knees and elbows. e. Catheterism must be performed with great delicacy under cover of the clothes, while the patient lies upon her back near the edge of the bed. Ocular inspection can only be justifiable when the parts are in a state of great disease, or when the tube has undergone much change in its relative position. The best mode of proceeding is to apply the left index-finger to the upper margin of the mouth of the vagina, which thus serves as a guide to the instrument, which is placed upon its palmar surface, and then moved upwards along the middle line, until its point arrives at the dimple-shaped depression marking CHAP. XVIII. GONORRHOEA IN THE FEMALE 943 the situation of the orifice of the urethra.. The catheter is then passed on, with its concavity upwards, until it reaches the in- terior of the bladder. Or, the instrument may be held against the under surface of the right index-finger, as in fig. 727, and pushed on as soon as its tip has discovered the meatus. During parturition the orifice of the urethra is sometimes drawn backwards un- der the arch of the pubes, and in prolapse of the uterus it is occasionally concealed by the tumor. The canal may be changed in its direction, and the bladder itself may be dragged down into the protruded parts, so that, as was long ago observed by Verdier, in passing a catheter it must be directed downwards and backwards. Retention, after parturition, may be due to two causes—contusion of the urethra and atony of the bladder —both requiring the use of the catheter. The female catheter is made of silver, and is not more than five inches in length. Its vesical extremity is somewhat bent, to adapt it to the shape of the urethra, and is perfo- rated with numerous foramina, instead of having eyelets, as that of the male. The other end is provided with two rings, in order to fasten the instrument, when it is necessary to retain it in the bladder, by means of tapes, to a "1"-bandage. When the urethra has been materially changed in its direction, the most suitable instrument will be a gum catheter or the ordinary silver male catheter. It has long been known that the female catheter will occasionally slip into the bladder, being suddenly and unexpectedly drawn from the fingers of the surgeon. It is not very easy to explain the reason of this occurrence. It is probably owing to the con- tractile power of the urethra, aided by capillary attraction, and by the suction of the bladder. Although the female catheter is generally more easily withdrawn than introduced, yet occasionally the reverse is the case. The occurrence is favored by a relaxed condition of the parts, and appears to be directly dependent upon the intromission of a fold of mucous membrane into the eyelets of the instrument. To avoid this contingency, as awkward as it is painful, the instrument should be provided with numerous small aper- tures, which will effectually prevent the intrusion of the lining membrane, however flabby. The proper remedy is the retention of the catheter until the accumulating urine forces the impacted folds into their natural situation. In case of urgency relief may be afforded by throwing a full stream of water into the instrument. All attempts at forcible extrac- tion should be avoided. 6. Hydrocele in Women There is occasionally a collection of serum in the groin, or in the groin and labium, constituting a species of hydrocele, either congenital or acquired. It is situated in the peritoneal sheath of the round ligament, known as the canal of Nuck, contains a thin, watery fluid, and forms a soft, elastic, fluctuating swelling, which some- times communicates with the abdomen. It is of an elongated, globular, or pyriform shape, and ranges in volume between an egg and a fist. In a case observed by Scarpa, the cyst, attached by a narrow footstalk, was fourteen inches in circumference, and contained nearly a pint and a half of fluid. The tumor receives no impulse on coughing or strain- ing, and is generally more or less opaque, although in rare cases it is translucent under transmitted light. The diagnosis is readily established by the history of the case and by the use of the exploring needle. A cure may be effected by incision, by seton, or by in- jection. Dr. Charles A. Hart has reported a case in which a growth of this kind was laid open under the belief that it was a strangulated hernia. A serous tumor, as previously stated, occasionally forms here in the sac of an old hernia, the neck of which has been obliterated by the pressure of a truss or by inflammation induced some other cause. Such an occurrence is, of course, very uncommon, but its possibility is well attested, and is worthy of remembrance in connection with the diagnosis of the various affections liable to arise in this particular region of the body. SECT. VIII GONORRHCEA IN TIIE FEMALE. Gonorrhoea in women is a very different affection from gonorrhoea in males ; in the latter, the disease is generally exclusively confined to the urethra, or it exists simulta- Fig. 727. Method of some Surgeons of Holding the Female Catheter. 944 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. neously in this canal and on the head of the penis. In the female, on the contrary, it usually expends its force upon the lining membrane of the vulva, vagina, and uterus, the urethra being seldom implicated to any considerable extent, if, indeed, at all. Of 250 patients in the Aberdeen Royal Infirmary, only 9, according to Pirrie, had this canal affected. The parts which are generally most violently inflamed are the mucous follicles around the urinary meatus, and the upper portion of the vagina. Occasionally the dis- ease extends to the cavity of the uterus, and thence along the f allopian tubes and ova- ries, the attack thus presenting an analogy with gonorrhoea in the male, eventuating in epididymitis. The interior of the uterus is most liable to become affected in females in whom that organ has an uncommonly large mouth, thereby allowing the more easy entanglement and retention of the gonorrhoeal virus. The occurrence is, however, under any circumstances, unusual. The time which elapses between the contamination and the outburst of the disease is generally somewhat shorter than in men, owing to the fact that the poison is brought in contact with a larger surface. The disease may be simple or complicated; it is more frequently associated with chancre than in the male, and is often followed by excoriations and simple ulcers, especially of the neck of the uterus and of the lower extremity of the vagina. The symptoms of the disease are essentially similar to those which characterize gonor- rhoea in the male. The parts, at first the seat of itching and smarting, soon become hot, swollen, painful, and affected with muco-purulent discharge, often bloody, usually exces- sively profuse, and, at times, very fetid and even acrid. The scalding in micturition is considerable, although rarely as gi’eat as in the male, and the labia, nymph*, vagina, and the neck of the uterus, are frequently covered with aphtha?, fissures, and excoriations. In the more severe forms of the disease, there is a sense of weight and of fullness in the lower part of the pelvis, with aching pains in the groin, thigh, and perineum. The lining mem- brane of these parts is of a fiery red color, and covered, here and there, with patches of lymph, of a pale yellowish hue, tough and stringy, and firmly adherent to the surface beneath. During the progress of the attack, the lymphatic glands in the groin are liable to suffer, although much less frequently than in the male, becoming sore, and swollen ; and so much distress is often experienced in walking as to compel the woman to keep her bed. Occasionally the inflamed surface, instead of being bathed with pus and mucus, is remarkably dry, and the suffering is then often proportionately much greater. Such an occurrence, however, seldom lasts beyond twenty-four hours, when it is generally followed by an abundant secretion. In uterine gonorrhoea, the most common symptoms are, unnatural discoloration, and a discharge of thick, opaque mucus, filling up the mouth of the womb, or hanging from this organ into the vagina, and so tough as to be detached with considerable difficulty. Super- ficial ulceration is also a sufficiently frequent attendant upon this form of the disease. Peritonitis occasionally occurs from an extension of the disease along the Fallopian tubes. The complication is most common in prostitutes, and is characterized by the usual symptoms. The disease often assumes a chronic form, lingering in the vulvo-uterine canal for months, and sometimes even years, liable to occasional exacerbations from the slightest causes, especially from exposure to cold, fatigue, and sexual indulgence. Under such cir- cumstances it is not uncommon for the disease to involve the ovaries, the Fallopian tubes, and even the peritoneum. Pelvic cellulitis is also an occasional occurrence. Gonor- rhceal ovaritis is characterized by deep-seated pelvic pains, aggravated by motion and pressure; by feverishness, gastric and other disturbances; by utero-vaginal discharge; and by heat and scalding in passing water. There is always great tenderness, with a sense of soreness, in the region of the affected organ. Care/ must be taken not to confound the disease with disease of the bowel or bladder. I he diagnosis of gonorrhoea from other affections, especially leucorrhoea, although most desirable, is frequently very difficult, and sometimes altogether impossible. The distinc- tion is particularly important on account of its medico-legal relations, females laboring under discharge of the genital organs being often suspected of having gonorrhoea, when, in fact, the disease is only of an ordinary nature. In general, the difficulty may be solved by the history of the case, the moral character of the woman, the nature of the discharge, and the presence or abscence of complications. In leucorrhoea, with which the disease is most liable to be confounded, there is seldom any discharge from the urethra, or scalding and smarting in micturition; in gonorrhoea, on the contrary, these two symptoms usually exist in a very marked degree. In leucorrhoea, the disease is mostly confined to the vagina CHAP. XVIII . GONORRHCEA IN THE FEMALE. 945 and uterus; the discoloration, although considerable, is seldom either great or uniform, and the vulvo-uterine canal is usually free from ulceration. In gonorrhoea the inflamma- tion always involves the labia and nymphoe ; the redness is of a fiery hue, and extensively ditfused, the parts having almost an erysipelatous aspect, and marked abrasions, excoria- tions, or superficial ulcers are nearly constantly found upon the neck of the uterus, as well as upon the vagina. Finally, in leucorrhoea the pain is comparatively slight, and there is no disease of the lymphatic glands of the groin, the reverse being the case in gonor- rhoea. In attempting to form an accurate diagnosis of these diseases, too much caution cannot be exercised, otherwise there will be great danger of occasionally involving the innocent. A thorough examination should always be made with the speculum, not once, but repeatedly, and the moral character of the woman duly considered. If the patient is very young, or of an age when there are usually no sexual propensities, it may be presumed that the dis- charge is the result purely of simple vaginitis, want of cleanliness, the presence of worms in the lower bowel, derangement of the digestive apparatus, or an anemic state of the system. All vaginal discharges are acrid, and intermixed with abraded epithelium; but neither the microscope, nor any chemical test at present known, is of any avail in deter- mining whether they are of an ordinary or of a contagious character. The treatment of gonorrhoea in the female must, unless there be some special contraindi- cation, be by active depletion until there is a marked diminution of the discharge and local distress. Copaiba, cubebs, and sandal wood oil, exert no specific influence in controlling the morbid action, unless the vulvo-vaginitis is associated with urethritis. The patient is confined to bed, and, if plethoric, freely bled at the arm, especially if the inflammation run very high, as denoted by the severity of the pain, and the sense of weight and full- ness in the pelvic region, together with the profuseness of the prof!uvia. The venesection should be followed up by a brisk cathartic of the compound calomel pill, or an infusion of senna and sulphate of magnesium ; and this, in turn, by antimonial and saline preparations, given every three or four hours, according to the exigencies of the case, along with ano- dynes to relieve suffering and promote sleep. The diet must be light, simple, and duly restricted in quantity. If the local action is unusually high, leeches are freely applied to the groins, perineum, and inside of the thighs. The vagina is washed out frequently with hot water, impreg- nated with some mildly astringent substance, as alum or sugar of lead; or, if the dis- charges are offensive, with permanganate of potassium, care being taken that the injections, whatever they may be, are not so strong as to cause pain. When the inflammation has been somewhat moderated, the opposed surfaces should be kept constantly asunder by means of a tent of patent lint, wet with a strong solution of alum, acetate of lead, or Gou- lard’s extract, substitution being effected not less than three or four times in the twenty- four hours. In this way the treatment may generally be very materially abridged. Dr. John S. Black has found great benefit in the treatment of gonorrhoeal vaginitis from the use of suppositories of alum and tannic acid, subsulphate of iron, and kindred articles. When the urethra is implicated, it should be thoroughly mopped once a day with a twenty grain solution of nitrate of silver. The solid nitrate is unnecessarily severe, if not inju- rious. The efficacy of injections in this complaint will be greatly influenced by the manner in which they are administered. The only instruments upon which any reliance is to be placed are Davidson’s syringe, and Foster’s vaginal douche, with either of which the operation may be performed very thoroughly. Any secretions that may be present must be washed away as a preliminary step, after which the medicated fluid should be thrown up and retained for at least fifteen or twenty minutes by slightly elevating the hips, so as to let it come as freely as possible in contact with the deeper portions of the vagina and the lower extremity of the uterus. Attention to this rule is indispensable. In the squatting posture the fluid runs out as fast as it is thrown up, and much of its good effects is, con- sequently, lost. When the inflammation has reached the subacute or chronic stage, the lotions may be dispensed with, and the tents smeared with ointment of nitrate of mercury diluted with ten, twelve, or fifteen parts of simple cerate. Under the influence of this application all dis- charge generally ceases in a few days. When ulcers exist upon the neck of the uterus, or upon the vulvo-vaginal mucous membrane, they should be gently touched every third or fourth day with the solid nitrate of silver, or, what is preferable, with very dilute acid nitrate of mercury. The same rule in regard to the continuance of the treatment, after all discharge has been arrested, should be observed here as in gonorrhoea of the male. The 946 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVI II. exhibition of copaiba, cubebs, and sandal wood oil is chiefly indicated when the urethra is much implicated ; for, as already intimated, the peculiar antigonorrhoeal virtues of these articles do not display themselves at all when the disease is confined to the vulva, vagina, and uterus. In uterine gonorrhoea, the proper plan is to detach the glairy mucus so liable to form in this complaint, several times a day, by means of a mop, or mop and forceps, and to paint the canal of the neck of the womb, very gently, every forty-eight hours, with a twenty grain solution of nitrate of silver. Injections of this substance, however weak, cannot be employed with safety, on account of their liability to enter the Fallopian tubes, and to occasion violent, if not fatal, peritonitis. In gonorrhoeal peritonitis the ordinary reme- dies will be required, especially leeches and fomentations to the abdomen, and full doses of opium. The abstraction of blood from the uterus and vulva will also be very serviceable. When the ovaries or Fallopian tubes are involved in the morbid action, absolute recum- bency should be enjoined with the application of leeches and blisters to the seat of the disease; followed, if the case be obstinate, by a gentle course of mercury. In the milder forms of these affections iodine and fomentations afford marked relief. Abscesses are very liable to form in the labium, in the more severe forms of gonorrhoea, most commonly in connection with the vulvo-vaginal glands, and should always claim early attention, as they are generally excessively painful, and may, if neglected, occasion serious structural lesion. Their contents are usually excessively fetid, and of a thick, purulent character. The nymphas sometimes suffer in a similar manner. Among the best applications are weak solutions of nitrate of silver, as ten grains to the ounce of water, leeches, and poultices, medicated with acetate of lead, and laudanum. Rest is an indis- pensable element in the treatment. Matter must be evacuated by early and free incisions. Buboes, arising during the course of the disease, are treated by rest, leeches, iodine, acetate of lead, and anodyne cataplasms. Matter is evacuated in the usual manner. If the resulting ulcers and sinuses are long in healing, the knife must be used along with cataplasms and weak solutions of nitrate of silver. SECT. IX VESICO-VAGINAL FISTULES. The bladder of the female is liable to various kinds of fistules, deriving their names from the organs with which they communicate, as vesico-vaginal, urethro-vaginal, vesico- uterine, vesico-utero-vaginal, and vesico-rectal. The most common cause of this affection is the accidental laceration of the parts during parturition, in consequence of the pressure of the child’s head, especially if the accoucheur has neglected to empty the bladder. It may also be produced by the maladroit use of instruments, inducing either direct rupture, or such an amount of contusion as to eventuate in gangrene and sloughing ; by penetrating wounds of the vagina and bladder; and by ulceration, whether occasioned by abscess, by simple, syphilitic, or malignant dis- ease, or by the pressure of a urinary calculus, a pessary, or any other foreign body. The different varieties of urinary fistules are represented in the adjoining cut, fig. 728, copied from Professor Thomas’s work on Gynecology. A great deal of diversity obtains in regard to the size, shape, and number of vesical fistules. Ihus, the opening may not exceed the diameter of a small shot, or it may be so large as to admit a pullet’s egg, or even a small orange. In its shape it is generally somewhat oval or circular, but occasionally it presents itself in the form of a transverse, oblique, or longitudinal rent, slit, or fissure. Its edges are usually well defined, rough, callous, and white, with a slight eversion of the vesical mucous membrane. The indu- ration often extends a considerable distance beyond the fissure, especially when this has been caused by sloughing, and it is, therefore, occasionally very difficult to pare the edges of such an opening. I he vagina in the neighborhood of the aperture is either perfectly sound or variously altered by disease, according to the nature of the exciting cause of the fistule, the violence of the resulting inflammation, and the acrid character of the dis- charges. It is not often that there is more than one opening. A singular eversion of the bladder occasionally takes place in vesico-vaginal fistule, the lining membrane passing across the abnormal aperture so as to form a tumor in the vagina. The protrusion, which is seldom considerable, is generally of so trifling a nature as not to require any special attention. When, however, the artificial opening is unusu- ally large, the whole bladder may project through it, and eventually even protrude at the vulva, as in the remarkable case mentioned in my Treatise on the Urinary Organs. CHAP. XVIII. VESICO-VAGINAL FISTULES. 947 A woman affected with vesico-vaginal fistule must necessarily be an object of the deepest commiseration. Incapable of controlling the contents of the bladder, the urine constantly escapes at the vagina, thus not only soiling her clothes, and giving rise to the most noisome odors, which no amount of cleanliness can entirely prevent, but chafing and fretting the parts with which it comes in contact, and thus rendering them unfit for the exercise of their appropriate functions. The escape of fluid is incessant when the opening is situated at the bas-fond of the bladder, and is always worse in the erect than in the recumbent posture. Fig. 728. Varieties of Urinary Fistules: 1. Urethro-Vaginal; 2. Vesico-Vaginal; 3. Vesico-Utero-Vaginal; 4. Vesico-Uterine. The existence of this affection is generally indicated by the escape of urine by the vagina; but the situation, shape, and extent of the fistule can only be ascertained by means of the speculum, the woman lying on her back, or, what is better, resting on her knees and fore-arms, with the head as dependent as possible, and the nates considerably elevated, a catheter being at the same time inserted into the urethra. In this way every portion of the vagina may be most satisfactorily inspected, and any opening, however small, easily detected. In some instances, the speculum is advantageously replaced by the finger, carried about in different directions, along the anterior wall of the tube, until its extremity comes in contact with the naked end of the catheter. When the aperture is very small, a long, slender probe should be used, or a colored fluid may be thrown into the bladder with a syringe. Treatment The treatment of this affection is palliative and radical; the former con- sisting in the employment of such means as are adapted to promote temporary comfort, while the latter are designed to effect the permanent obliteration of the abnormal opening. Frequent ablutions and injections with cold water, either simple or medicated, and the occasional use of chlorinated sodium, will prevent excoriation and noisome fetor, and a proper regulation of the diet with a soluble condition of the bowels, will go far in preserv- ing the general health, which, in such a condition, sometimes suffers most severely, the patient becoming nervous, dyspeptic, and hysterical. To guard against the incessant escape of the urine, and enable the poor patient to exercise occasionally in the open air, the vagina should be kept constantly filled with a hollow plug, or rubber bottle, en- veloped in oiled silk, and furnished with a tube and stopcock, in order that it may be inflated or emptied at pleasure. Or, instead of this, a reservoir, such as that referred to at p. 706, may be suspended from the vulva. The radical treatment of vesical fistule has been brought to a high degree of perfection, almost exclusively by the labors of two practitioners, Dr. Sims, and Dr. Bozeman, to the former of whom great credit is deservedly due for having led the way in this most laud- 948 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII . able enterprise. Previously to this, occasional cures bad been effected by different Amexi- can surgeons, especially by Hayward, Mettauer, and Pancoast. The operation of Dr. Sims was originally performed with silver wire, the ends of which were fastened with an ordinary shot, perforated at the centime. lie accordingly called his suture the clamp-suture. For the shot Dr. Bozeman substituted a broad piece of sheet lead, generally of an oval shape, as seen in fig. /29, about a third of a line in thickness, pierced by several apertures, and variously bent in order to adapt it accurately to the shape of the parts. Dr. Sims has of late years altogether discarded the use of the clamp, and now confines himself to the employment of the wire suture. Dr. Bozeman, I believe, still operates with the aid of his button. I have myself effected excellent cures both with and wdthout these aids, and am satisfied that the simple wire suture is, in the main, the very best that can be adopted. The button-suture may, however, be usefully employed in vesico-uterine and urethro-vaginal fistules, as it serves to support the edges of the fissure and pi-event undue traction. A certain amount of preliminary treatment is 'generally necessary, not protracted, but thorough, both as it inspects the parts and the system at large. The most absolute re- cumbency and cleanliness should be observed; the vagina should be frequently syringed with cold water; cold cloths should be kept constantly upon the vulva; the bowels and seci’etions should be properly x-egulated; the diet should be peidectly plain and simple; and large quantities of bland drinks should be used to dilute the renal secretion, and de- prive it of its aci’imony. Blood should be taken from the vulva, perineum, groins, and thighs, by means of leeches, if there be evidence of decided plethora, and the parts, if much inflamed, should be gently touched, evei-y other day, with a thii-ty-grain solution of niti-ate of silver until the disease has measurably disappeared. Any cicatricial bands that may exist in the vagina must be cai’efully and thoi’oughly divided. When the neck of the uterus is imprisoned in the bladder, an effort must be made to reinstate it in its natural situation, as well as to relieve it of inflammation, before attempting to close the fistule. For this purpose, the cervix is drawn down with a blunt hook while the fundus is dislodged from its position between the vagina and the rectum with a sponge mop, the woman resting upon her knees and arms, so as to bring the parts fully into view. When held in this way, a tent, such as that described on a px-evious page, is introduced, renewal being after- wards effected twice a day, preceded by injections of cold water, until the organ is disposed to maintain its place. The patient, fi-eed from all bodily constriction, and thoroughly influenced by an anaesthetic, may occupy one of two positions, the abdominal or the dor- sal. In either event, she is placed upon a suitable bed or table, covered with a a folded sheet and a soft oil cloth. In the abdominal posture, which I have myself always prefex-red, the head and shoulders being depi’essed, the nates may be elevated to any desirable height, and the light so ai'ranged as to fall directly upon the entii-e vesico-vaginal septum, the fistule, and the mouth of the uterus. The thighs are wddely separated, and supported by assistants. The duck-bill speculum of Dr. Sims is now introduced, fig. 730, showing the application of the instrument, the position of the nates, the appearance of the dilated vagina, and , , the situation of the uterus, bladder, and vesico-vaginal septum. If the light be insufficient, a small mirror may be used, the re- flection of which will generally render everything perfectly distinct, and enable the ope- Fig. 729. Bozeman’s Button. Fig. 730. Position of the Patient in the Operation for Vesico-Vaginal Fistule. CHAP. XVIII. VESICO-VAGINAL FISTULES. 949 rator to proceed without any embarrassment from this cause. In the dorsal method, the favorite one of the late Professor Simon, of Heidelberg, the patient is placed in an exag- gerated lithotomy position; that is, the breech is thoroughly exposed by flexing the knees nearly to a level with the chest, the head is slightly elevated, and the vagina is dilated to its fullest extent by two duck-bill speculums. To insure success, the edges of the fistule must be most thoroughly bevelled off at the expense of the vaginal mucous membrane, at the same time that the incision is carried freely through the muscular and mucous coats of the bladder, so as to form an ample surface for approximation and agglutination. It is impossible to lay too much stress upon the manner in which this part of the operation is performed. If the opening is circular, unusually large, or vertical, the edges should be sloped in such a way as to admit of being brought together transversely, otherwise complete union will be very difficult, if not im- practicable. The instruments required for paring the fistule are, a delicate tenaculum, long, slender, toothed forceps, a straight and angular knife, and a pair of scissors, represented in figs. 731, 732, 733, 734, and 735. The scissors are provided with very short, sharp- pointed blades, slightly curved on the flat. The anterior border of the fistule is pared first, and this is done most easily with the straight knife, the necessary quantity of sub- stance being excised in one piece. For refreshing the posterior margin the curved knife or scissors will be found most convenient. When the opening is very large this stage of the operation is sometimes impeded by the protrusion of the vesical mucous membrane, but the obstacle may usually be readily overcome by returning the part, and then filling the bladder temporarily with bits of sponge. Fig. 731. Fig. 732. Fig. 733. Fig. 734. Fig. 735. Fig. 736. The next step of the operation consists in introducing the sutures, the number of which must necessarily vary according to the extent of the fistule. The instruments required for this purpose are several needles, a needle-holder, a pair of long, curved forceps, and a small hook. The needles commonly employed in this operation are entirely too small and not suf- ficiently curved. They should be at least an inch and a half in length, stout, well tem- pered, moderately curved, like the ordinary suture instrument, and very sharp at the Instruments for Vesico-Vaginal Fistule. Needle-holder. 950 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. point. Unless they possess these qualities, the operation will be attended with great vexation and delay, and it will be found to be extremely difficult, if not impossible, to take deep, firm, enduring stitches, a matter essential to success. The best needle-holder, at all events the one which generally answers the purpose very well in my hands, is the instrument sketched in fig. 736. Fig. 737. Hook for Making Counterpressure. The first suture should be introduced at the centre of the fistule, the distance at which the needle is entered from its anterior edge being not less than one-third of an inch, as the object is to obtain a very firm hold. The instrument, pushed steadily on, is brought out of the submucous connective tissue of the bladder, counterpressure being made against its advancing point with a pair of forceps, or the hook repre- sented in fig. 737. The needle is then carried across the fissure, and entered at the posterior edge, which it traverses in a simi- lar manner as the anterior. Thus suture after suture is intro- duced, until the number is completed, the interval between each two being about three-sixteenths of an inch, as exhibited in fig. 738. The closure of the fistule, and the arrangement of the shot or button, constitute the third stage of the operation. This is easily done with the aid of an adjuster, represented in fig. 739. It consists of a strong rod, curved in the shaft, and set into a handle, its distal extremity being perforated and somewhat bulbous. The opposite ends of each wire are now passed through the opening in the instrument, and firmly held between the thumb and forefinger of the left hand, when the adjuster is care- fully slipped down and well pressed against the parts. Fig. 740 shows the appearance of the parts after all the sutures have been adjusted, and the edges of the opening approximated. The operation is finished by firmly twisting together the ends of the wires, and then cutting them off close to the fissure. Fig. 738. Application of the Sutures. Fig. 739. Suture-Adjuster. If the button is used, one of suitable shape and size is now selected and passed over the wires, as seen in fig. 741 ; its concave surface corresponding to the vesico-vaginal sep- tum, with which it is brought in close contact by means of the instrument represented in Fig. 740. Fig. 741. Adjustment of the Sutures. Application of the Button. the annexed cut, fig. 742, the angular and scalloped extremity of which admirably adapts it for that object. The crotchet is now slipped down over the approximated ends of each CHAP. XVIII. VESICO-VAGINAL FISTULES. 951 suture, as illustrated in fig. 743, and pressed firmly against the convex surface of the but- ton by means of a pair of forceps, to keep the button in place, and the edges of the wound thoroughly united. Finally, the operation is completed by clipping off the wires close to the crotchet, and turning down their short ends, as delineated in fig. 744. Fig. 742. Instrument for Securing the Button. Certain modifications of this operation are frequently necessary, growing out of the peculiar situation of the fistule, or the condition of the parts. Thus, as Dr. Bozeman has Fig. 743. Fig. 744. Slipping down the Crotchets. Suture completely Adjusted. so well pointed out, in the urethro-vaginal lesion the button must be rather long in the antero-posterior direction, very concave, and extended well forward in front of the urinary meatus, so as to support the catheter, its extremity being somewhat notched. The edges of the opening are brought together transversely; and the catheter, a gum-elastic one, is introduced before the sutures are adjusted, retention being maintained, if possible, until the cure is completed. In fistules involving the vesical trigone and the root of the urethra, or of the trigone and bas-fond, or of all these parts together, in which the anterior border of the opening is immovably fixed to the pubic arch, with the concavity presenting backwards, the button requires to be bent upon its convexity. When there is complete, or nearly complete, destruction of the urethra, an attempt should be made to lorm a new one by dissect- ing up suitable flaps from the surrounding structures, and uniting them at the middle line by sutures. To increase the chances of success, under such circumstances, an opening should be made in the bas-fond of the bladder to conduct away the urine as fast as it descends from the kidneys. In a case attended with great de- struction of the urethra and the neck of the bladder, treated, in 1881, by Dr. C. S. Muscroft, of Cincinnati, an operation was per- formed by which complete closure of the vulva was effected, with the exception of a small opening in the posterior part, near the commissure, for the discharge of the urine. For some time the pa- tient, a woman, twenty-three years of age, had no control over the bladder, but by degrees this infirmity diminished, and when she left the hospital, nearly one month after the operation, she was able to hold her water for two hours at a time. Considerable modification is required when the fistule extends into the neck of the uterus. The paring of the edges being effected in the usual manner, the button is carefully adapted to the shape of the parts, its posterior border being generally notched to accommodate the anterior lip of the cervix. A semicircular button is required when there has been so much loss of substance of the vesico-vaginal septum as to render it impossible to draw the anterior border of the fistule up to the posterior. The line of the perforations cor- responds with the former border, while the notch in the button projects over the an- terior lip of the neck of the uterus. Instead of using a button, the vivified edges may be approximated by the interrupted suture, as seen in fig. 745. Fig. 745. The Cervix slit up to ex- pose the Fistule above, with the Sutures in Position. 952 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. When the neck of the womb is lacerated, and buried in the bladder, the first tiling to be done is to restore the organ to its normal position in the vagina, in order that, after the cure is completed, the menstrual fluid may resume its natural outlet. To effect this, it is necessary to enlarge the fistule in the vesico-vaginal septum on each side, trans- versely, thus disengaging the viscus somewhat, and affording more space for paring the anterior lip of the cervix. In inserting the sutures into the posterior border, the vesical mucous membrane is pierced by the needle, which, being carried into the bladder through the fistule, is entered far in on the vesical side of the cervix, and brought out from behind forwards, the object of the procedure being to obtain such a hold upon the womb as to enable the operator to pull its neck downwards and backwards during the adjustment of the sutures, restoration of the displaced organ being impracticable in any other way. The button for this variety of fistule requires to be bent upon its convexity, and to be notched above for the support of the anterior border of the neck of the uterus. When the opening is uncommonly large, a double row of sutures may be employed, as originally practised by Simon ; one to lessen the tension, and the other to unite the edges of the fistule, the threads in the latter being invariably carried through the mucous mem- brane of the bladder. These appearances are well illustrated in fig. 746. Fig. 746. Simon’s Double Sutures in Position. During these various procedures, which must necessarily be more or less tedious and fatiguing, both to the patient and operator, great advantage will be derived from the use of several sponge mops, of various shapes and sizes, for wiping away the blood and secre- tions. The bleeding is usually insignificant, and readily stops of its own accord, or under the application of ice. The operation being over, a Sims’s catheter, fig. 747, is inserted into the bladder, a gum-elastic tube, about fifteen inches in length, having previously been CHAP. X V 111 . VESICO-VAGINAL FISTULES. 953 secured to its outer extremity, in order to conduct the urine into a large bottle lying in a hollow between the patient’s thighs. Dr. J. Goodman, of Louisville, Kentucky, has devised a self-retaining catheter, the use of which greatly facilitates the cure after this operation. It is about two inches in length, curved to the shape of the urethra, bul- bous at the vesical extremity, and surrounded by a button nine lines in diameter. The instrument need not be cleaned oftener than once a week, and has the additional advantage of permitting the patient to sit up or walk about at pleasure. Excellent cures, as I can testify from personal observation, are occasionally effected without the aid of any catheter whatever, the passage of the urine being left solely to the natural efforts of the bladder. After-treatment—Much of the success of this operation will depend upon the after-treatment. As soon as the. patient is put to bed, a anodyne is administered to allay pain and induce quiescence of the bowels, which should not, on any account, be disturbed under ten, twelve, or fifteen days. The diet should consist exclusively of animal broths, potato, bread, crackers, custard, rice, and tea, with water as the common drink. Opium is given twice a day in as large doses as can be borne ; the urine is rendered bland and unirritant by the liberal use of diluents ; and the patient is not permitted, even for a moment, for any purpose whatever, to assume the erect posture, although she may, if she prefer it, lie on either side. The catheter is removed as often as may be necessary to keep it clear of blood, mucus, and calculous matter, once a day generally sufficing. The vulva and orifice of the vagina are syringed night and morning with tepid water, a large bed-pan being placed under the nates during the operation. Undue inflammation is treated on general principles. Both the part and the system are occasionally endangered, after this operation, by erysipelas. In a patient under my charge several years ago, although more than ordinary care had been bestowed upon the preliminary treatment, a most violent attack of this dis- ease took place within a few days, commencing on the right buttock, and gradually spread- ing over the upper part of the thigh, perineum, and vulva, from which it speedily extended to the vagina, causing large deposits of lymph, with a strong tendency to cohesion. The constitution suffered very much, and at one time I was not without serious apprehen- sion in regard to the ultimate issue of the case. Notwithstanding all this, however, the woman made a good recovery, although several months elapsed before she fully regained her strength. Peritonitis has occasionally occurred after this operation, and it is well enough always to have an eye to the possibility of such an event; so that, if it arise, it may be promptly combated. It rarely appears before the third day, or after the sixth or eighth. A case has been reported by Paul Hourteloup, in which the accidental division of the left utero-ovarian artery, in paring the edges of the fistule, was followed by fatal hemor- rhage. The flow was controlled for several days by a pair of screw-forceps, but its recur- rence proved speedily disastrous. The sutures should not, as a rule, be removed before the tenth day ; if taken out sooner, the adhesions may give way, and thus necessitate a repetition of the operation. The patient being placed in the same posture as in the first instance, the wires are clipped with a pair of curved scissors, and gently drawn away. Recumbency is observed for several days longer, and distention of the bladder is avoided until the new cicatrice is sufficiently strong to resist the pressure and traction of the surrounding parts. Any little apertures that may remain in the line of the sutures may usually be promptly closed with the aid of nitrate of silver. When the operation fails, whether in whole or in part, as it not unfrequently does, even in the hapds of the most skilful surgeon, further interference must be postponed until the parts and system have perfectly recovered, otherwise failure will again be inevitable. Of 186 cases of this operation reported by Bozeman, Brown, and Simon, ten died. In extreme cases, when the more ordinary resources fail, other expedients may be em- ployed, in order to enable the poor sufferer to eke out her wretched existence. Of these only two, elytroplasty and episiorraphy, deserve special mention. .Elytroplasty—Elytroplasty, an operation devised by Jobert de Lamballe, in 1834, and variously modified by contemporary and succeeding surgeons, has become in great degree obsolete, other and more simple methods having superseded it. Its object, as in rhino- Fig. 747. Sims’s Catheter. 954 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. plasty, is to substitute new for lost tissue, by taking the flap either from one of the buttocks or from the posterior wall of the vagina, and attaching it by sutures to the edges of the fistulous openings, previously well pared. The operation, besides being difficult of execu- tion, is extremely liable to be followed by failure on account of the great trouble expe- rienced in preventing the contact of the urine. Velpeau gave preference to the vaginal flap; and Leroy, in addition, prolonged the incisions so as to embrace a portion of the mucous membrane of the vulva. Episiorraphy When, in consequence of the total, or nearly total, destruction of the vesico-vaginal septum, the case is utterly hopeless, the sufferer may be made compara- tively comfortable by closing the vagina, so as to compel it to subserve the purpose of a subsidiary reservoir for the urine and the menstrual fluid. Two methods may be adopted to effect this end. The one, originally practised by Vidal de Cassis, in 1833, consists in paring the inner surfaces of the great lips, and uniting them with a suitable number of interrupted sutures, introduced at a great depth, close to each other, and retained until complete consolidation has taken place, which will seldom be under ten days. Despite every precaution, however, a small opening, admitting of the escape of more or less urine, generally remains at the upper angle of the wound just below the urethra, thereby mar- ring the result of the operation. For this reason, the vaginal method, devised by Pro- fessor Simon, in 1855, and described by him under the name of kolpokleisis, is decidedly preferable. It simply consists in removing a broad strip of the mucous membrane from the periphery of the inferior extremity of the vagina, and in tacking together the raw sur- faces with interrupted sutures, in the same manner as in the other procedure. When the operation is properly executed the result is generally very gratifying, many of the woi'St Fig. 748. cases of incontinence being thereby effectually relieved. Instead of occluding the vagina in the manner above described, and burying the mouth of the uterus in the bladder,"Dr. .Bozeman attaches the cervix to the remnant of the vaginal septum, thus rendering the organ subservient to closing the fistulous opening. Before this can be done successfully, Simon’s Method of Obliterating the Vagina. CHAP. XVIII. VESICO-RECTAL FISTULES. 955 it is indispensably necessary, except in women whose genital organs are very much re- laxed, to drag down the womb daily by means ol‘ toothed forceps, or a double hook, until it can be easily retained in its new situation, when the parts are properly vivified and tacked together in the usual manner. This procedure, it is obvious, offers a great advan- tage over episiorraphy, inasmuch as it preserves the vagina, and leaves the mouth of the uterus free for the discharge of its ordinary functions. The after-treatment in these different methods must be conducted upon general princi- ples. A most important point is to keep the bladder empty by the frequent insertion of the soft catheter. The subjoined cut, fig. 748, from Simon, affords an excellent idea of the arrangement of the sutures in this operation. A uretero-vagincil or uretero-uterine fistule is an occasional occurrence, the rent ex- tending from the one or other of these organs into the ureter. Cases of this kind have been reported by different observers, as Berard, Emipet, Baker, and Campbell; and are to be treated upon general principles. To lay down specific rules for meeting such con- tingencies would be an endless task. SECT. X VESICO-RECTAL FISTULES. Vesico-rectal fistules are generally caused by wounds, ulceration, abscess, or malignant disease. The characteristic sign is an interchange of the contents of the two contiguous reservoirs, the urine passing into the bowel, and the feces into the bladder. Owing to this circumstance, the parts are sore and irritable, and the general health is more or less disordered in consequence. Moreover, the constant introduction of fecal and other matter into the bladder is liable to give rise to calculous concretions, and to retention of urine. The more simple forms of this affection often disappear of their own accord. In all cases the bowels should be maintained, for days together, in a perfectly quiescent state by morphia, opium, or laudanum, and the rectum should be washed out several times in the twenty-four hours with warm water, or, if the discharges are fetid, with a very weak solution of chlorinated sodium, or carbolic acid. The recumbent posture should be carefully observed; the diet should be of the most bland and simple character; and drinks of every description should be used as sparingly as possible. As the case progresses, the closure of the fistule may often be greatly promoted by the constant retention of a soft catheter, to conduct off the urine as fast as it reaches the bladder, and thus prevent it from passing into the bowel. If nature fails to accomplish her purpose, a cure may not unfrequently be effected by the use of nitrate of silver, acid nitrate of mercury, or the actual cautery, applied with the aid of an anal speculum. In very obstinate cases, especially when the abnormal opening is situated very low down, the edges may be pared, and united by suture, as in vesico-vaginal fistule. The anus should be widely dilated during the operation by means of blunt hooks. When this pi'ocedure does not afford the requisite room, the best plan is to divide, as a preliminary step, the sphincter muscles. One of the most remarkable cases of vesico-vagino-rectcil fistule on record came under my observation in a woman, twenty-seven years of age, the accident having occurred during a protracted labor. For the first twelve months the urine dribbled off constantly by the anus; but, after that period, she was able to retain it for half an hour or even an hour at a time, especially when in the erect posture. The rectum, which thus served the purpose of an accessory reservoir for the urine, was unusually tender and irritable, and the anus constantly inflamed and excoriated. The orifice of the urethra was natural, but all attempts to pass an instrument, even the smallest pocket-probe, proved abortive. Menstruation was performed with great regularity, although rather sparingly, and the fluid, which was of the natural color, was discharged by the anus. Finding it impossible to restore the vagina, I introduced a large curved trocar into the urethra, for the purpose of reestablishing the natural channel for the urine. The opera- tion was performed without difficulty, the woman being under the influence of chloroform, and a self-retaining catheter was immediately inserted into the bladder. By wearing this, off and on, for several weeks, the passage was completely restored to its former size, the urine being discharged only five or six times in the twenty-four hours, and then always in a full stream. The woman had, in fact, the most thorough control over the bladder, the general health was excellent, and not a drop of urine escaped by the anus. The men- strual fluid also passed off' by the bladder. 956 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. SECT. XI. LACERATION OP THE PERINEUM. Laceration of the perineum, usually a casualty of parturition, in consequence ot the large size and rapid descent of the child’s head, or the maladroit use ot instruments, occurs in various degrees, from the slightest division of the skin and mucous tissues, to the union of the vagina and rectum into one cavity. In the latter case, there is, of course, more or less involvement of the recto-vaginal septum, the rent, perhaps, reaching up from six to eighteen lines. Owing to the laceration of the sphincter muscles ot the anus, an accident which always necessarily attends the worst forms of the lesion, the woman has seldom any control over her bowels. This accident, in all respects so deplorable, is most frequent in first labors in strong, robust women, in whom the parts, in consequence ot their resistance nearly alway offer a great obstacle to the passage of the child’s head. In former times when it was the custom to bleed such women more or less copiously during, or a short time before, labor pains set in, such an occurrence was exceedingly uncommon; now that the forceps have taken the place of the lancet and are applied in every fifth or sixth case, it is exceedingly frequent. The treatment of this affection varies according to its extent and character. The more simple forms often promptly recover spontaneously, especially if proper care be bestowed upon them soon after their occurrence, in the way of rest, thorough approximation of the limbs, and cleanliness, assisted by light diet and a confined state of the bowels. Instead, however, of trusting the case to nature’s efforts, the best plan, as a rule, is to sew the parts up at once, immediately after the woman has recovered from the fatigue and worriment of her labor. When the rent is extensive, the quilled suture must be employed, the stitches being introduced very deep, and retained until there is a certainty of complete adhesion of the opposed surfaces. A similar plan of treatment is adopted when the case has been neglected, but, in addition to this, it will be necessary, before arranging the ligatures, to see that the edges of the chasm are properly refreshed. This is usually easily done with the bistoury and toothed forceps, aided with curved and straight scissors of different sizes. The raw surfaces should not, on an average, be less than two inches in length by nine to twelve lines in width. The borders of the recto-vaginal septum are also well pared, and carefully united, as a preliminary step, two stitches usually sufficing for the purpose. In sewing up the perineal portion of the fissure, at least five or six stout silk ligatures will be necessary, the first being inserted at the verge of the anus, and the last at the base of the labia, through their substance. The hold should be very firm that there may be no danger of premature separation ; and the two lower sutures should be buried in the tissues, otherwise a pocket or pouch will be sure to form on each side for the lodgment of blood or pus. In performing the operation, the patient, brought fully under the influence of anassthe- sia, is placed upon her back, as in the operation of lithotomy, the bowels having been thoroughly cleared out the night before. For sewing up the recto-vaginal septum the best instrument that I know of is the one represented at p. 470, in the section on staphy- lorraphy. The ligatures for the perineal fissure are readily introduced with the aid of the admirable needle devised by Dr. Ellwood Wilson, or a long needle in a fixed handle. The eyelet should be large, so that the thread may be easily reinserted above, after trans- fixion has been effected on the opposite side. The ends of the ligatures are then separated, and secured over two pieces of bougie, or Bozeman’s buttons, the superficial portions of the wound being brought together with a few points of ordinary interrupted suture. If there be much tension, the operator may now divide the sphincter muscle of the anus, from an inch to an inch and a half exterior to this opening, the incision beginning about three lines in front of the coccyx, and extending some distance outwards and backwards, the gap being left to fill up by granulation. Such an expedient, however, will seldom be required, and I have not myself been obliged to resort to it in any of my cases. I he operation being over, the patient is placed in bed, her knees resting over a pillow, and being tied together, to prevent any strain upon the perineum. Half a grain of mor- phia is at once given, in order to relieve pain and lock up the bowels, which should not be moved for at least ten or twelve days. The diet should be concentrated, and brandy freely used if there is evidence of debility. For the first three or four days, the parts are covered with cold water-dressing, and a syringeful of carbolized water is occasionally thrown into the vagina. The sutures are not disturbed, on an average, under a fortnight, or until there is reason to believe that the union is perfect. Strict recumbency is main- tained for at least a week longer. The urine is di’awn off twice or thrice a day by the nurse. The accompanying cuts, from Savage, fig. 749, and fig. 750, explain themselves. CHAP. XVIII. LACERATION OF THE PERINEUM. 957 When the sphincter muscles of the anus are completely torn through and the rent ex- tends high up into the rectum and the vagina, the patient should be subjected to a thor- Fig. 749. Fig. 750. Denudation for Kepair of Perineum. Surfaces Denuded and Sutures in Position. ough course of treatment to prepare her fully for the operation. Unless this be done, and the subsequent management be conducted with the greatest possible care and judgment, Fig. 751 Jenks’s Operation of Colpoperineorrhapliy. failure and chagrin will be almost inevitable. Dr. T. Gaillard Thomas, whose experience in so large in colpoperineorrhaphy as to entitle him to speak as an authority, states that at least two weeks should thus be spent, and the bowels during this time should be moved regu- larly twice daily with some mild laxative, as the compound rhubarb or compound cathartic pill, to clear the track of scybalous and other crude matter, active purgation being of course guarded against. The diet should consist of meat and broths, oatmeal mush, 958 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. potatoes, bread, and other nutritious articles. Milk should be avoided. During the first few days after the operation, the patient should be sustained entirely on animal broths, and the bowels should be kept perfectly quiet with anodynes until the end of this period, when they should be moved by a gentle laxative, or an enema, administered by the medi- cal attendant himself or by the nurse, lest harm should be done. During the progress of the cure a small tube may occasionally be inserted into the rectum to facilitate the dis- charge of gas. Of the various operations of colpoperineorrhaphy now before the profession, the most ingenious perhaps is that of Professor Jenks, of Chicago. “ After denuding a tongue- shaped extension up the posterior vaginal wall,” says Thomas, “ Jenks approximates the raw surfaces by catgut sutures, runs down upon each of these a perforated shot, passes down upon this a piece of hard rubber tubing two and a half inches long, and puts at the end of this another shot which he compresses firmly. Upon removal of the compressed shot, the tube, uncompressed shot, and suture can all be readily withdrawn.” Fig. 751 illustrates the sutures in question. PERINEAL BANDAGE. The perineal bandage is a contrivance of great value for retaining dressings upon the vulva, perineum, and anus, as well as for affording support in prolapse of the uterus and rec- tum. It consists, as the adjoining cut, fig. 752, sufficiently indicates, of two distinct pieces, a circular and a perpendicular, the former passing round the hips, and the latter over the perineum and vulva, where it is provided with a pad, covered with oiled silk. It is then split in two, each strip being brought up in front, and attached to the circular girth. SECT. XII RETROUTERINE HEMATOCELE. In this form of sanguineous tumor, first accurately described by Nelaton, the blood upon which it depends is poured out into the subperitoneal connective tissue of the neck of the uterus, from which it gravi- tates around the rectum and the upper extremity of the vagina, as shown in fig. 753. It usually takes place under the influence of inordinate straining during parturition, excessive sexual ex- citement, difficult menstruation, or external violence, and may acquire such a bulk as to break through its confines into the peri- toneal cavity. Generally, how- ever, it is comparatively small, and eventually disappears through the agency of the absorbents. The disease, which bears the strongest resemblance to a throm- bus of the vulva, is most common in females laboring under a vari- cose condition of the utero-pelvic veins, habitual constipation of the bowels, and morbid growths of the uterus and its appendages interfering with the free return of the blood. The hemorrhage may proceed from different sources. Most commonly it is derived from the veins of the broad liga- ments, or from the rupture of a Graafian vesicle during its extreme congestion at the menstrual period. It may also be caused by a reflux ot blood from the uterus, as when Fig. 752. Perineal Bandage. Fig. 753. Retro-Uterine Hematocele: a representing the Tumor; 6, the Uterus; c, the Rectum; d, the Bladder. CHAP. XVIII. PELVIC CELLULITIS. 959 the mouth of that organ is occluded by some obstruction ; and cases have been recorded in which it emanated from injury of the Fallopian tube. Age exerts an important influence upon its production. Of 34 cases analyzed by Voi- sin, 20 were between twenty and thirty years old. I am not aware that it has ever been observed before the age of puberty. Its favorite period is evidently of the greatest sexual vigor. The diagnosis is commonly obscure. The most reliable sign is the existence of a tumor at the sides and back of the neck of the womb, distinguishable by the finger in the vagina and rectum, free from pain, and the seat of more or less fluctuation, especially if the examination be made soon after the occurrence of the accident. The fundus of the uterus is generally tilted somewhat forward toward the pubes, while the neck of the organ is inclined proportionately backward, and sensibly diminished in length. The affections with which it is most liable to be confounded are, retroversion of the uterus, pelvic abscess, extrauterine fetation, and dropsy of the ovary; but from these it may usually be readily distinguished by the history of the case, the median position of the tumor, and the suddenness of the attack. The treatment of retrouterine hematocele is generally very simple ; for, unless the tumor is of unusual bulk, it commonly soon disappears spontaneously, particularly if the woman be kept at rest in the recumbent posture and upon light diet. If symptoms of inflammation arise, as indicated by pelvic pains and constitutional disturbance, leeches, fomentations, purgatives, and other antiphlogistics will be required. The sudden disap- pearance of the tumor, followed by great tenderness in the hypogastrium and depression of the vital powers, should lead to the suspicion of its rupture and the escape of its con- tents into the peritoneal cavity. When the case is obstinate, refusing to yield to ordinary measures, the best plan is to evacuate the tumor with a large trocar, carried through the rectum or vagina, the sac being well washed out immediately after with tepid carbolized water, lest suppuration should occur. The canula, which should generally be withdrawn on the completion of the operation, may occasionally be advantageously used for breaking up the clotted blood, so as to promote its more easy escape. It is proper to add that puncture of a hematocele has occasionally been followed by serious hemorrhage, pyemia, and other bad results. SECT. XIII.—PELVIC CELLULITIS. The connective substance of the pelvis, the broad ligaments of the uterus, and the recto- vaginal cul-de-sac is liable to inflammation, known as pelvic cellulitis. The phrase “ pelvic abscess” is also very generally employed, as the inflammation not unfrequently terminates in suppuration. The disease, which is of a phlegmonous character, often in- volves the uterine appendages, is not confined to any particular period of life, occurs both in single and in married females, although much more frequently in the latter than in the former, and is produced by a great variety of causes, among which the most common are external injury, as a blow, kick, or fall, and violence inflicted by the passage of the child’s head in difficult labor. It may also be caused by excessive sexual intercourse, by suppression of the cutaneous perspiration, and by an extension of inflammation from the uterus, vagina, vulva, bladder, or rectum. The most common seat of the disease is the connective tissue of the pelvis. Lying-in females are its most frequent subjects. Of 61 cases observed by Dr. McClintock, of Dublin, nearly one-half occurred after the first labor. The disease is generally ushered in by bold and well-marked symptoms. , The pain, at first dull and heavy, soon assumes a violent, throbbing, pulsatile character, and is always increased by motion and pressure; it generally begins low down in the pelvis; but as the disease proceeds it radiates about in different directions, and is often very severe in the iliac, suprapubic, and anal regions. The whole hypogastrium is sometimes ex- quisitely tender. Gradually swelling sets in, easily detectable by the finger in the vagina and rectum, hard at first, but soft and fluctuating if the disease has made considerable progress. If the quantity of matter, upon which its presence mainly depends, is at all large, the tumor may encroach sufficiently upon the vagina, uterus, and rectum to occa- sion serious displacement or obliquity of these parts. Not unfrequently a distinct swelling may be observed in the iliac region or in the lower portion of the hypogastric. Defeca- tion and micturition are attended with more or less difficulty, progression is painful, if not impossible, and the woman, as she lies in bed, usually retracts her limbs to relieve the abdomen of its tension. The attendant fever is variable. In general, it is well marked, 960 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. with a distinct vesperal exacerbation ; the pulse is hard, full, and frequent; the skin is hot and dry; the urine is scanty and high colored; the appetite is impaired; the thirst is considerable, and the sleep is disturbed. Although such is the course ot events generally in this disease, cases not unfrecjuently occur in which its approaches are extremely stealthy and insidious. Instead ot pain, there is, perhaps, merely a sense of uneasiness and fullness in the pelvic region ; the gene- ral health is disordered, but there is no decided febrile disturbance; and the discovery of the swelling in the side, the vagina, or the rectum, may be purely accidental. M hen the attack is consequent upon parturition, the characteristic symptoms may not make their appearance under several weeks, or until the patient is considered as perfectly convales- cent. The matter that forms during the progress of the disease generally escapes, unless evacuated artificially, through the rectum, the vagina, or the colon. Occasionally it passes off externally, through the wall of the abdomen, and cases have occurred in which it burst into the bladder, the peritoneal cavity, and even into the uterus, as in the remarka- ble instances related by Dance and Wainright. The diagnosis is generally sufficiently easy. The most important circumstances are, the history of the case, the peculiar situation and character of the pain, and the presence of a tumor, generally readily detectable by the finger in the vagina and rectum, or by the eye and finger, as when the matter points in the iliac region. The affections with which it is most liable to be confounded are, peritonitis and inflammation of the ovary, or ovary and uterus. It may also be simulated by neuralgia of the pelvic viscera. In case of doubt the exploring needle is inserted. The formation of matter is sometimes indicated by rigors. The prognosis is generally favorable, provided the case is properly managed. If it be misunderstood, the matter may escape into the abdominal cavity and speedily destroy life by the induction of peritonitis. When the abscess is allowed to open spontaneously, great, if not irreparable mischief may be occasioned by the burrowing of the pus, and by the establishment of numerous sinuses, perforating, perhaps, the vagina, the rectum, or even the bladder. The treatment is sufficiently obvious. The object, in the early stage of the disease, is to prevent the formation of matter, by antiphlogistic measures, especially rest in the re- cumbent posture, and the application of leeches to the perineum, vulva, and liypogas- trium, along with medicated fomentations. If the patient is strong and plethoric, blood is freely taken from the arm, and the system rapidly brought under the full influence of antimonial and saline medicines. The lower bowel is emptied with enemas, but active purging must be avoided, as it would tend to irritate the affected parts. A laudanum injection generally affords great relief. As soon as the abscess points, a large incision is made into it, if possible, at its most dependent portion, to afford free vent to the pent-up fluid, which should on no account be permitted to burrow, otherwise troublesome, if not incurable, sinuses and fistules will be sure to follow. When the abscess opens spontane- ously, the aperture should be enlarged with the probe-pointed bistoury, that the matter may escape as fast as it is formed. Cleanliness is promoted by the frequent use of the syringe charged with tepid water and some antiseptic fluid. The cure is often tedious. Change of air, tonics, and a full share of alcoholic stimulants will be required when there is much prostration. SECT. XIV SEPARATION OF THE PELVIC SYMPHYSES. Separation of the pelvic symphyses is liable to be produced by external injury, as when the body is jammed violently between two hard and resisting objects ; but the affection which I am about to describe is not caused in this way, but by a process of inflammation and softening occasioned during pregnancy, apparently, as a consequence of the pressure ot the child’s head. The affection has not been noticed, so far as my information extends, by systematic writers on surgery; it is referred to by some of the older obstetricians, but Mr. John Burns, of Glasgow, was the first to give any detailed account of it. I he disjunction may be limited to one articulation, or it may attack all, either simul- taneously or successively. The pubic symphysis, according to my observation, suffers more frequently than either of the sacro-iliac. The separation sometimes occurs during a first pregnancy, and I have noticed cases in which it showed itself in several consecu- tive terms. It seldom makes its appearance until the latter months of gestation. One attack does not necessarily predispose to another, unless the conception take place in rapid succession before the parts have recovered their natural tone. CHAP. XVIII. IMPOTENCE AND STERILITY. 961 The pathology of the disease is still undetermined. The probability is that the affec- tion essentially consists in inflammatory softening, by which the cartilages are gradually disintegrated and broken down, so as to be incapable of holding the bones in their natural relations. The ligaments are, doubtless, also invaded, but to what extent is, of course, merely a matter of conjecture. The symptoms are usually well characterized. The most prominent are, pains of a dull, aching nature in the region of the pelvis, increased by pressure, walking, and turning in bed, an unsteady, waddling gait, a sense of weakness in the lower extremities, great diffi- culty in progression, and inability to stand upon one leg. The slightest exertion causes fatigue and suffering; the feet are spread out in walking, and it is often impossible to maintain the erect posture without some support for the hands. A feeling of uneasiness and wyeight, as if a bar wefe sti’etched across the pelvis, is sometimes experienced. The articulations are tender on pressure, the back aches, and pains extend along the thighs, groins, perineum, and pelvis. The bladder is occasionally irritable, and now and then there is considerable leueorrhoea. The general health is often disordered, but there is sel- dom any fever. When the separation exists in a marked degree, the pelvic bones may be moved upon each other, and the patient is unable to walk or support herself in the upright posture. There is no discoloration or swelling of the skin, except when there is a ten- dency to suppuration. In some cases, the disjunction is so great that the point of the finger may readily be pressed into the affected joints, especially the pubic. These symptoms generally come on during the latter months of pregnancy, but occasionally they are not noticed until several days after delivery. The disease may be mistaken for rheumatism, scrofula of the sacro-iliac symphysis, sprains, and contusions. Errors will be best avoided by a thorough examination of the parts, and a careful consideration of the history of the case. The prognosis is favorable. A long time may, however, elapse before a complete cure is effected. Abscess constitutes a serious complication ; death has been known to occur from an extension of the disease to the peritoneum. Pelvic cellulitis sometimes arises during the progress of the case. The most appropriate remedies are rest in the horizontal posture, the application of leeches to the affected joints, and an occasional laxative with a full dose of Dover’s pow- der at bedtime. The local distress is generally promptly relieved by the use of a well padded belt, worn in such a manner as to afford firm support to the pelvic bones. With the aid of such a contrivance the patient is often able at once to sit up and walk about with little or no inconvenience. When the disease has reached the chronic stage, the cure will be accelerated by the employment of sorbefacient liniments, chalybeate tonics, the cold shower-bath, and exercise in the open air. If matter forms, it must be speedily evacuated. SECT. XV IMPOTENCE AND STERILITY. Impotence and sterility in the female are subjects of too much importance to be wholly overlooked in a treatise of this kind. When we consider how often the practitioner is consulted respecting them, and what amount of happiness or misery is involved in a cor- rect answer, their gravity will be sufficiently apparent, both in a surgical and a medico-legal point of view. The affections which give rise to impotence and sterility in the female are, like the analogous affections of the male, divisible into two classes, the curable and incurable. A woman who is incapable of copulating must necessarily be sterile; for, although her re- productive organs, properly so called, as the ovaries, Fallopian tubes, and uterus, may be perfect, yet, if the seminal fluid cannot reach its destination, conception cannot occur. On the other hand, she may be fully competent to perform the sexual act, and yet be incapable of offspring. Most of the causes of impotence in woman are of a mechanical character, referrible to certain conditions of the labia, the vagina, or the uterus. The labia may be firmly ad- herent to each other, in consequence of accident or disease; the vagina may be closed, extremely contracted, double, congenitally absent, or obliterated by inflammation ; and the uterus may be procedent, lying on the outside of the pelvis, between the thighs. Besides, there may be various morbid growths, both benign and malignant, occupying these organs, or obstructing the vulva, and thus interfering with penetration. Great deformity ol the pelvis and of the thighs may render copulation impracticable, by preventing the ap- proaches of the male. The existence of a hymen, however strong and resisting, would not be a complete barrier to the sexual congress. Vaginismus is frequently an effectual 962 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. obstacle to copulation, the vagina being so exquisitely sensitive as not to tolerate the con- tact of the male organ. Enormous distention of the abdomen, such, for example, as occurs in some forms of ovarian dropsy, or ascites, may be a cause of impotence, and a similar impediment might be produced by an inordinate inguinal, labial, or femoral her- nia. Some of these cases are curable, others are not. I he necessary treatment will readily suggest itself from what has been said respecting it in different parts of the work. A woman may be able to copulate, and yet not conceive. Various causes may con- spire to produce such a result i as, 1st, absence, adhesions, stricture, or obliteration of the vagina, or a cul-de-sac of this canal above the neck of the womb, whereby the seminal flu?d is prevented from reaching its destination ; 2dly, an imperforate hymen ; 3dly, absence, malposition, laceration, inversion, occlusion, or any serious disease whatever of the uterus ; 4thly, congenital deficiency, obliteration, or morbid adhesions of the Fallo- pian tubes; 5thly, absence, disease, or degeneration of the ovaries; 6thly, imperfect menstruation and absence of sexual desire; and, lastly, an acid condition of the mucus of the vagina and uterus, rapidly depriving the spermatozoa of their vitality. Ulceration of the neck of the uterus, profuse leucorrhoea, and excessive sexual indulgence may be included among the curable causes of sterility. No conception can happen unless there is actual contact of the semen with the ovum ; hence, whatever prevents this occurrence is a cause of sterility. If this condi- tion exists, it is not necessary that the female should experience any particular enjoy- ment ; indeed, both sexual desire and gratification may be absent, and yet impregnation take place. The recent progress of uterine pathology, as developed by Bennet, Simp- son, Tilt, Sims, and others, clearly shows that sterility, existing probably in one woman of every ten, is due, in the great majority of cases, to some mechanical impediment to the passage of the semen, often perfectly remediable by surgical intervention. Among the more prominent and frequent of these causes are the various malpositions of the womb, as anteversion and retroversion, various curvatures, hypertrophy of the anterior and pos- terior lips, with abnormal narrowness of the canal of the neck of the organ, and occlusion of the mouth of the uterus, whether by tough, inspissated mucus, morbid adhesions, or neoplasms. The proper mode of treating these affections has already been pointed out. The researches of Donne and others have shown that the spermatozoa lose their vitality very soon in acid mucus; and the ova furnished by the female, doubtless, gene- rally share a similar fate. Married life is often rendered miserable by the inability of the woman to copulate, by various diseased conditions of her genital organs, or of the structures with which they are more immediately associated. Whatever the cause of the trouble, known under the name of dyspareunia, from a Greek word signifying ill-mated, may be, it must be carefully in- quired into, and, if possible, removed, as a cure cannot be effected in any other way. Many such cases, from a wrant of proper treatment, become the subjects of unjust divorce, or of incalculable domestic affliction. Various mental states may give rise to sterility and prevent sexual enjoyment, as dis- like for the husband, a want of congeniality of the two sexes, and habitual intemperance. The confirmed use of opium destroys the sexual appetite, and renders women barren by interfering with the process of ovulation. Abundant proof has been furnished in recent times of the fact that excision of both ova- ries, while it necessarily renders a woman sterile, does not, in any degree, impair any of the characteristics of her sex, as the nutrition of her system, the graces of her mind or person, or the sexual sensory powers. The popular belief that a woman without ovaries is not a woman is untenable. SECT. XYI AFFECTIONS OF THE MAMMARY GLAND. I he mamma is liable to inflammation, abscess, hypertrophy, neuralgia, and various kinds of tumors, both innocent and malignant. The latter, in fact, appear to have a kind of preemption right to this organ. MAMMITIS. Inflammation of the breast, technically termed mammitis, or mastitis, is chiefly observed during lactation, in consequence of suppression of the cutaneous perspiration or retention of the milk, causing overdistention of the lactiferous ducts. It may also arise from too CHAP. XVIII. ABSCESS OF THE MAMMA. 963 free living, neglect of the bowels and secretions, and from the effects of external violence. It generally comes on within the first fortnight after parturition, beginning in the form of one or more ovoidal lobules, hard and tender to the touch, somewhat deep-seated, and not exceeding the volume of an almond. As the inflammation progresses, other lumps appear, and, gradually coalescing, at length involve the whole breast, glandular structure and connective tissue as well. The organ is now exceedingly large, hard, and heavy, ex- quisitely painful, and intolerant both of manipulation and pressure. The skin is hot, dis- colored, tense, and glossy, pitting, perhaps, here and there slightly under the finger. The secretion of milk is either arrested, or, at all events, much diminished, and great difficulty is experienced in emptying the organ, the choked-up ducts being seemingly indisposed to part with their contents. Well marked constitutional symptoms are always present at this stage of the disease. The patient is hot and feverish, or alternately hot and chilly, the tongue is dry and coated, the pulse is full and frequent, the bowels are constipated, and the urine is scanty, high colored, and loaded with urates. If permitted to proceed, the inflammation soon passes into suppuration, the event being announced by the ordinary local and constitutional phenomena, especially throbbing, an erysipelatous blush of the skin, and rigors alternating with flushes of heat. The treatment of acute mammitis is strictly antiphlogistic, early and vigorously enforced. If the patient is very plethoric, blood is taken from the arm, or by leeches from the seat of the disease, the bowels are moved by active purgatives, vascular action is controlled by tartar emetic and sulphate of magnesium in combination with aconite, and the lightest possible diet is enjoined, with an avoidance of fluids of every description, thirst being allayed by the use of ice. The breast is supported with an appropriate bandage, and the surface is kept constantly wet with warm water-dressing, medicated with acetate of lead and laudanum. If suppuration be threatened, an emollient poultice, if not too heavy, will generally be found to be very grateful. Pain is allayed by anodynes, conjoined with dia- phoretics, especially if there be dryness of the skin. The breast should be relieved at least thrice a day of milk, either by suction with the mouth or by a suitable pump, the child receiving its nourishment from the sound organ. A speedy check may often be put to an incipient mammitis by rubbing the affected organ thoroughly several times a day with warm oil and laudanum, or mild ammoniated lini- ment, the friction being made in the direction of the lactiferous ducts, that is,from above downwards towards the nipple, by the nurse, as she stands behind the patient, and sup- ports the posterior surface of the breast with one of her hands. This mode of treatment, which is particularly insisted upon by Dr. S. C. Foster, of New York, generally exerts a powerful effect upon the indurated gland, softening it in a short time, reducing the swell- ing and promoting the flow of milk by relieving the lacteal ducts of congestion. When the inflammation is unusually severe, and attended with great heat, pain, and swell- ing, no local remedy exercises a more powerful or more controlling influence in checking the morbid action than pounded ice, applied in a bladder or an elastic bag, spread over the affected organ, over a folded cloth wrung out of cold water. The ice rapidly carries off the heat, relieves suffering, and prevents the formation of matter. Dr. Hiram Corson, of Pennsylvania, deserves much credit for introducing this mode of treating acute mammitis to the notice of the profession and for insisting upon its unquestionable advantages. When the disease has lost its acute character, sorbefacient liniments and unguents may advantageously be employed ; or, what is often much better, strapping of the breast with adhesive plaster, on the same principle as in chronic inflammation of the testicle. Each strip should be three-fourths of an inch to an inch in width, and long enough to extend once and about a third around the organ, the application being commenced at the base, and continued by circular and vertical turns, until the whole is completely enveloped, a suitable opening being, of course, left for the nipple. The dressing will require renewal about every forty-eight hours. The local treatment in these chronic cases is generally greatly promoted by a properly regulated diet, and by an occasional cathartic of black draught, or blue mass and colocynth. ABSCESS. When mammitis passes into suppuration, the matter always collects in the form of an abscess, which may be situated either in the interlobular substance of the gland, in the cellulo-adipose tissue beneath the skin, or in the connective substance behind the organ, the frequency of the occurrence being in the order here stated. The symptoms denotive of the event are, an increase of pain, which is throbbing, deep-seated, and continued, a 964 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. dusky or purplish appearance of the skin, a sense of fluctuation, especially if the matter has already accumulated in considerable quantity, and rigors or chilly feelings, alternat- ing with flushes of heat, and followed by copious sweats. When the pus is situated at an unusual depth, its presence is often indicated by an cedematous state of the subcutaneous connective tissue. The matter which is formed in this disease is generally of a thick, cream-like consist- ence, and of a whitish or pale yellowish color. When the inflammation has been very high, it is apt to contain flakes of lymph and pure blood, the latter being usually in a state of coagulation. Milk is almost always a prominent ingredient. Pven when it exists in so small a quantity as to be undiscoverable by the naked eye, its presence may, generally, be readily detected with the aid of the microscope. The quantity of pus varies from a few ounces to upwards of a quart, the average being from four to eight ounces. From a week to a fortnight is the time required by the abscess to work its way to the surface. The treatment of mammary abscess consists in an early and free incision, for the two- fold purpose of relieving pain and saving structure. The edges of the wound are pre- vented from closing by the use of the tent or drainage-tube. The most suitable application for the first few days is an emollient poultice, or the warm water-dressing. All rude squeezing, with a view of promoting the evacuation of the pus, must be avoided, as it is calculated not only to produce pain, but to aggravate inflammation. When the treatment of mammary abscess has been neglected or mismanaged, the matter is extremely apt to burrow, dissecting the lobules of the glands from each other, and also, in many cases, from the surrounding parts, thus causing extensive havoc, and the formation of numerous sinuses ; sometimes as many, perhaps, as half a dozen. Such cases are always attended with great suffering, both local and constitutional. Until lately, the treatment used to be as cruel as it was generally tedious and unsatisfactory, the object being to trace out the passages with the director and knife, with a view, as was alleged, of healing them from the bottom, a tent being maintained in them for the pur- pose. Within the last few years, a more scientific mode of management has been exten- sively pursued in this country, in consequence of the recommendation of Dr. Foster. It consists simply in the application of compressed sponge, confined by means of an appro- priate bandage, aided by a suitable diet, and attention to the bowels. The sponge, freed of dirt, perfectly soft, elastic, and large enough to cover the entire breast, is thoroughly dried, and then effectually compressed by keeping it for twenty-four hours under a heavy weight, as for example, a common letter copying-press. Thus prepared, it is bound upon the affected organ over a piece of patent lint, to prevent irritation of the skin, by means of a roller passed several times around the chest, above and below the sound breast. It is then saturated with tepid water, which has the effect of expanding it towards the dis- eased structures, pressing the walls of the sinuses together, and at the same time forcing out their contents and absorbing them. The sponge is changed once in the twenty-four hours. A little pain generally attends the first application, but this usually disappears in fifteen or twenty minutes, and does not recur afterwards. The improvement under this treatment is most rapid, the worst cases generally recovering in a few weeks. If the gene- ral health is much impaired, it should be conjoined with the use of tonics, a nourishing diet, and exercise in the open air. In addition to these measures, the cure will be ex- pedited if the child be weaned, as suckling of the sound breast keeps up vascular excite- ment in the one that is inflamed. In my own practice, I have usually succeeded, without difficulty, in relieving such cases by systematic compression with adhesive strips, or, what is better, with strips of ammoniac and mercurial plaster, applied quite firmly, and in such a manner as not to interfere with the discharges. Indeed, I have often effected excellent cures simply by wrapping up the breast in the plaster, without cutting it into strips. A mammary abscess is sometimes prevented from closing by the presence of foreign substance. In the case of a young married woman, communicated to me by Dr. Mastin, of Mobile, a long and tortuous sinus existed, which resisted, for many months, all known methods of treatment, owing to the presence of a deeply buried and long-foi'gotten di’ain- age tube, the removal of which was speedily followed by a permanent cui’e. The genei'al health had been greatly impaired by the proti'acted discharge and by constitutional irri- tation. Ihe chronic abscess of the breast is often a very troublesome and annoying affection, the moi-e so because of the difficulty occasionally experienced in the diagnosis. Patients have repeatedly been sent to me from a gx-eat distance under the supposition that they were laboring under malignant disease of the mamma, when the only ailment was a chronic CHAP. XVIII. LACTEAL ENGORGEMENT. 965 abscess. What is still worse is that the organ has occasionally been extirpated in such cases, as I have myself known it to be in several instances. Such a procedure cannot be too severely reprehended, especially as there is not the slightest excuse for it, the use of the exploring needle always promptly revealing the true nature of the disease. Although the chronic mammary abscess is occasionally of a strumous nature, especially when it attacks, as I have repeatedly known it to do, young, unmarried females, it will generally be found to be the result of ordinary inflammation, occurring during suckling, and proceeding in a very slow and stealthy manner, in consequence of some defect in the constitution, or of some obstruction in the lactiferous ducts. The disease, as a rule, takes place in the breast which the child has been unable to use on account of an inflamed, chapped, or retracted nipple. Sometimes the exciting cause is a blow or contusion, per- haps so trivial as at the moment not to atti’act any attention. The disease usually begins in the form of several hard lumps, which, gradually coales- cing, at length unite into one solid mass, of irregular shape, and of firm consistence ; sometimes involving only a portion of the breast, and at other times the entire organ. Occasionally the glandular structure escapes completely, the morbid action being confined exclusively to the connective tissue around, behind, or in front of the breast. By and by, a process of softening begins, and, steadily progressing, a large accumulation of pus occurs, pressing upon the parts in every direction, and fluctuating distinctly under the finger. Marked enlargement of the subcutaneous veins usually attends, especially when the dis- ease is of long standing, but there is no discoloration of the skin, and seldom any severe pain ; merely, perhaps, a sense of weight and uneasiness. The general health is not ma- terially affected, and there is no involvement of the surrounding lymphatic glands. The disease may last for months. The treatment of chronic mammary abscess is by evacuation, and support of the breast by the ammoniac and mercurial plaster, aided by compress and bandage. Unless this pre- caution be used, there will be danger of hemorrhage from the rupture of the weakened vessels of the wall of the abscess. In a case communicated to me by Dr. Walter, of Nazareth, bleeding came on a week after opening a large swelling of this kind, and was so Copious as almost to exhaust the patient. It was at length checked by the pressure of a common spring truss. When the matter has been evacuated, recovery will be pro- moted by attention to the diet and bowels, by exercise in the open air, and by the use of tonics and alterants. The cure is generally perfect. GANGRENE. The mammary gland is singularly exempt from gangrene. Such an occurrence, indeed, is possible only in very unhealthy females, or in women who, in addition to scrofulous or syphilitic disease, are suffering, at the time of the inflammatory seizure, under an impov- erished state of the blood. A few cases are upon record in which gangrene of this gland was occasioned, in middle-aged femnles, by the protracted use of ergot. In erysipelas and carbuncle the connective tissue around the gland sometimes mortifies, the mamma itself generally escaping. The treatment of this affection, however induced, is to be conducted in the same manner as in gangrene in other parts of the body. LACTEAL ENGORGEMENT. Lacteal engorgement of the mamma must not be confounded with abscess or the lacteal tumor, properly so called. It is simply, as the name signifies, an accumulation of milk in the lacteal ducts, and is usually caused by an imperfect evacuation of their contents. The breast, thus affected, may exceed many times its natural bulk, and contain an enor- mous quantity of fluid. In a case observed by Dr. Charles R. Cleveland, in a woman, tw'enty-twro years of age, the right gland, three days after delivery, measured forty-two inches in circumference by twelve inches and a half in length, and the left thirty-six by ten. Both organs were of a firm, dense consistence, free from pain, tenderness, or fluc- tuation, and traversed by numerous large veins. The integument was stretched to its utmost, the arms felt benumbed from the pressure of the tumors upon the axillary nerves, and the pulse could hardly be perceived at the wrist. A gallon of milk was removed with the aid of a pump within ten hours. The breasts had been unusually large and flabby from early girlhood. The treatment is by suction with the breast pump, cicuta plasters, purgatives, a dry diet, and the exhibition of sorbefacient medicines, as cicuta, belladonna, and iodide of potassium. 966 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XV III. SYPHILITIC AFFECTIONS. The fact that the breast is liable to syphilis in its tertiary form is a discovery of modern times, due to the researches of the Trench and Italian surgeons, especially Maisonneuve, Richet, Verneuil, Lancereaux, and Ambrosoli, the two latter ot whom have met with it in both sexes. The affection, constituting what is known as syphilitic mastitis, occurs in twm distinct forms, the circumscribed and the diffuse, the former presenting itself, as the name implies, in small, hard, more or less numerous nodules, and the latter as a genual induration of the gland. The tumors are of a gummy character, similar to those that are met with in the connective tissue, the testicle, and the different internal organs. The malady seldom makes its appearance before the second or third year after the primary affection, and generally attacks both breasts at the same time, or in more or less rapid succession. The disease with which syphilis of the breast might be confounded are carcinoma and adenoma, from both of which, however, it may generally be readily distinguished by the history of the case, as the existence of syphilis in other parts of the body, the absence of pain and axillary involvement, and the symmetrical character of the affection, both glands, as was originally remarked by Sauvages, usually suffering simultaneously. The ulcer, consequent upon the softening of the gummy tumor ot the breast., has hard, undefined edges, with a tendency to the formation of deep sinuses, and the discharge of an unhealthy, whitish, mucus-like appearance and consistence, entirely different from that of a carcino- matous ulcer. An adenoma of the breast is generally of uniform hardness, of slow deve- lopment, and without any disposition to softening, so common in syphilis. The effects of treatment will often do more to clear up the diagnosis than anything else. The treatment of syphilitic mastitis is conducted upon the same principles as in specific orchitis, the iodides and bichloride of mercury being the principal internal remedies, and iodine, leeches, acetate of lead, and cataplasms the most important local ones. Any mat- ter that may form must be early evacuated. Strapping the breast with ammoniaeal and mercurial plaster is often serviceable. Ulcers must be treated with mild, unirritating applications. NEURALGIA. Neuralgia of the breast may occur at any period after puberty, but is most common in young females from the age of fifteen to thirty. It is characterized by exquisite pain, darting through the part like electricity, and extending generally to the corresponding shoulder and axilla, and sometimes down the elbow' to the fingers. The suffering, which resembles that of tic douloureux, and which often observes a regular periodicity, is very much increased prior to menstruation, and is sometimes so severe that the patient is una- ble to lie upon the affected side, or bear the weight of the bedclothes. The disease, which may last for years, is met with mostly in persons of a nervous, irritable temperament, with deficient menstrual secretion. The morbid action is commonly confined to several of the mammary lobules, which either retain their natural bulk and appearance, or, what is more common, they are con- verted into small, solid tumors, distinctly circumscribed, movable, and highly sensitive to the touch. Occasionally these swellings seem to be seated in the connective tissue rather than in the glandular structure; they seldom exceed the size of a marble, an almond, or a w'alnut; they never suppurate, and they sometimes disappear spontaneously. More or less disorder of the general health usually attends ; the patient looks pale and thin, is remarkably susceptible to atmospheric impressions, and nearly always suffers under marked derangement of the menstrual function, the discharge being unusually scanty, and accompanied with a great deal of pain. In most of the cases that have fallen under my observation, the disease w'as associated with neuralgia in other parts of the body. The treatment is to be conducted upon ordinary antineuralgic principles. The gene- ral health having been amended by a proper regulation of the diet and the use of purga- tives, the patient is placed under the influence of quinine, or if there is evidence of ane- mia, quinine and iron, in union with arsenic, strychnia, and aconite, cannabis Indica, or stramonium, steadily and persistently continued, with an occasional intermission, until a decided impression has been made upon the complaint. Sometimes the exhibition of colchicum and morphia proves highly beneficial; and I have seen cases in which nothing appeared to answrnr so well as antimonial and saline preparations, with aconite. The CHAP. XVI II. HYPERTROPHY OF THE MAMMA. 967 most suitable local remedies are anodyne liniments and plasters, preceded, if there is con- siderable tenderness and swelling, by leeching. The breast must be well supported and protected from pressure. The menstrual function must receive due attention. HYPERTROPHY. General hypertrophy of the mamma, fig. 754, from Erichsen, is not common, nor is it, as might be supposed, confined entirely to the female sex. I have repeatedly seen both breasts of the male enlarged many times beyond their normal bulk, and not a few cases are recorded where they freely, and for a long time, secreted milk. The affection, which is entirely dis- tinct from the swelling that is so commonly asso- ciated with amenorrhcea, sometimes occurs during pregnancy, and disappears soon after delivery, but it generally begins at an early period of life, and goes on progressively increasing until the breast acquires an enormous bulk. Of this, an interesting case came under my observation in 1857, in a col- ored girl, nearly seventeen years of age, a patient of Dr. Iianly, of this city. The hypertrophy in- volved both organs, but not in an equal degree, the right being more than twice the volume of the left, and weighing, by estimate, upward of fifteen pounds, its length exceeding fifteen inches. They were of a very firm consistence, considerably nodulated, and very tender on manipulation. The subcutaneous veins were enormously enlarged. The hypertrophy had commenced without any assignable cause, when the girl was twelve years of age. When I first saw her she had been confined a fortnight, and I was in- formed that her breasts had much increased in size both during and since her pregnancy. Her general health had become much impaired, and she was ex- cessively emaciated. Dorsten gives a case of this kind, in which the left breast weighed sixty-four pounds, and Bouyer successfully extirpated both glands, the patient losing thereby one-third of the weight of her entire body. The true nature of this disease is not accurately determined. In some cases the organ retains its normal structure, which is mostly excessively hypertrophied. In another class of cases it is of the character of true ade- noma, there being not only hyperplasia of the glandular elements, or great development of new lobules, but a corresponding increase in the quantity of the interacinous connective and adipose tissues. In a third class of cases, again, the hypertrophy depends upon an inordinate development of the adipose tissue. Under such circumstances the fatty matter is largely deposited among the lobes and ducts of the organ, and piled, in immense masses upon its anterior and lateral aspects, very little, even in such cases, generally lying behind the breast, between it and the pectoral muscle. The affection is most common after the decline of the menses, in women in whom the procreative powers have naturally been rather weak. The growth is slow and painless, and is characterized by a soft, doughy consistence, by a sense of weight, by abnormal enlargement of the subcutaneous veins, and by an unimpaired condition of the general health. In a case related by Dr. John C. Warren, which, however, is somewhat equivocal, the weight of the breast, after extirpa- tion, was eight pounds, and was due chiefly to an increased development of the interlobu- lar adipose tissue. The treatment of mammary hypertrophy is generally conducted upon empirical princi- ples. The use of sorbefacients would necessarily suggest itself in such a disease, but it does not appear that it has hitherto been of any marked benefit. The most suitable arti- cle would be iodine, administered internally, and applied to the affected organ, either in the form of tincture or of ointment. Gentle and protracted ptyalism might be service- able. Occasionally benefit has accrued from the steady and persistent exhibition of chloride of ammonium, in doses of ten to twenty grains, thrice a day. Whatever reme- Fig. 754. General Hypertrophy of the Mammary Gland. 968 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. dies be employed, special attention should be paid to the improvement of the general health, which is often much impaired. The breast should be well supported, to take off weight and tension. Strapping the organ carefully with ammoniac and mercurial plaster would probably exert a more powerful sorbefacient influence than any other local means, although I am not aware that it has ever been fairly tested. Extirpation should be resorted to when the tumor, refusing to yield to treatment, is so large as to cause severe suffering and inconvenience, gradually, but effectually, undermining the general health. ATROPHY. Atrophy of the mamma is a natural effect of old age. When the menstrual function ceases, the gland begins to diminish in volume, and the wasting gradually progresses, until, at length, the whole organ is reduced to a soft, flabby mass, of a dirty, grayish tint, in which it is often difficult to detect any of the natural structures, except the lactiferous ducts, which are seldom completely effaced. Sometimes the gland shrinks early in life, particularly in married females who do not nurse their offspring. Atrophy of this viscus occasionally results from the effects of neuralgia, and the use of certain medicines, as iodine and hemlock. The lesion presents little of surgical interest. When it occurs in young females, as a consequence of the use of certain medicinal agents, neuralgia, or habitual pressure, immedi- ate measures should be adopted for its arrest, otherwise the organ may be irretrievably lost. , FISTULE. During lactation, a milk duct is sometimes included in a wound of the breast, and, un- less the edges are very closely approximated, a lacteal fistule may remain. The same consequences may be produced by a rupture of the canal from the inordinate accumulation of milk. A more common occurrence is the formation of accidental outlets, from the irri- tation of multilocular abscesses. These passages are often of considerable depth, tortuous, numerous, lined by an adventitious membrane, and attended with a great deal of indura- tion of the surrounding parts. The nature of the affection is generally easily determined by the character of the discharge and a careful examination with the probe. The disease will usually disappear of its own accord, as soon as lactation is over, and frequently even long before that event. If the case is troublesome, a cure should be attempted by the application of compressed sponge, conjoined, if necessary, with stimu- lating injections. CALCAREOUS CONCRETIONS. Calcareous concretions are met with in the breast, either in its substance or in the lac- tiferous ducts ; they are commonly small, not exceeding an ordinary pea, and are observed chiefly in connection with fibrous and other tumors. I have seen these bodies only in two instances, in females far advanced in life. They were of a whitish color, irregularly spherical in shape, and of a hard, solid consistence, like dry mortar. A case lias been described by Berard, in which the walls of a cyst of the mamma were converted into a complete osseous shell. Unless these concretions prove a source of inconvenience or annoyance, they should be let alone, especially if the patient has not passed the child-bearing period, as an opera- tion might be attended with serious injury to the lactiferous tubes. APOPLEXY. I he breast is liable to apoplexy, consisting in an effusion of blood into the con- nective tissue, resembling an ecchymosis produced by a blow or leech-bite. Generally there is only one such spot, but there may be several, coming on a few days before the menstrual period, and disappearing within the first week or two after; although some- times they continue for more than a month. The disease seems to depend upon some sv mpathetic action between the uterus and the breast, causing a great determination of blood to the latter, eventuating in the rupture of some of its smaller vessels. It is most common in girls suffering from amenorrhoea and dysmenorrhoea, and is, apparently, now and then, vicarious of the menstrual function. The affected parts are always of a dark, livid hue, and are exquisitely tender on pressure, the pain sometimes shooting down to the ends of the fingers. CHAP. XVIII. CYSTS OF THE MAMMA. 969 The treatment consists in sorbefacient applications, especially if some time has elapsed since the occurrence of the disease. When the effusion is recent, it will generally promptly disappear under cold saturnine and opiate lotions. CYSTS. Cysts of the breast may be classified, in accordance with the mode of their develop- ment, as retention, or duct cysts, and cysts of new formation; or they may more appro- priately be described, according to the nature of their contents, as lacteal, oily, serous, and hydatid cysts. a. Lacteal Cysts—The breast, in consequence of the occlusion and distention of some of its lactiferous ducts or sinuses, is liable to an inordinate accumulation of milk, form- ing a distinct swelling, commonly known as the milk tumor or galactocele. It is gene- rally of a globular or ovoidal shape, and is capable of acquiring a large bulk, as is evident from some of the reported cases. Thus, in one related by Dr. Willard Parker, in a woman thirty-five years of age, three quarts of fluid were evacuated at the first operation, and half that quantity in a week afterwards. In an instance recorded by Scarpa, the breast measured thirty-four inches in circumference, and gave vent, on being punctured, to upwards of a gallon of pure milk. In these cases of enormous volume, the milk, in- stead of being retained in a dilated duct or sinus, is poured out into the connective tissue of the gland, which is thus gradually condensed into a kind of cyst. The swelling usually begins within the first month after delivery, and often attains a large bulk in a few weeks. It is attended with a peculiar sense of distention, without any decided pain, distinctly fluctuates under the finger and enlarges during sucking. On cutting into it, the contents are found to be of a whitish color, and of the consistence of milk, cream, or whey. The general health is unimpaired. When the tumor is unusually voluminous, there is always marked enlargement of the subcutaneous veins. A case has been recorded by Wormald, in which a small cystic tumor of the mamma was filled with what appeared to be pure oil, that coagulated into a substance resembling lard, intermixed with crystals of margarine. I have myself met with an example of mammary cyst partially filled with oil and a substance like curds, the result evidently of degenerated milk. There is a form of milk tumor of the breast, in which the contents are of a solid char- acter, bearing a close resemblance to butter, and hence called the bntyroid tumor. It consists of a cyst, inclosing a yellowish, concrete substance, of the appearance of butter, cheese, or casein, and due to altered milk, the more fluid portions of wrbich are absorbed, while the solid are retained, and thus gradually assume the properties here assigned to them. The occurrence is very uncommon, and the diagnosis must necessarily be obscure. The treatment of the milk tumor should be conducted upon the same principle as that of any other cystic formation ; that is, either by the injection of some stimulating fluid, as dilute tincture of iodine, by the seton, or by the tent, care being taken that the result- ing inflammation do not run too high. When the tumor is solid, the proper operation, of course, is excision. (3. Serous Cysts.—Serocystic tumors of the breast are sometimes met with; chiefly in married females between the twentieth and fortieth years. The affection is strictly of a benign character, and never recurs after thorough removal. Its progress, always very tardy, is seldom attended with any decided disorder of the general health, the chief inconvenience caused by the morbid growth arising from its weight and bulk, which are sometimes enormous. The disease is due either to obstruction with retention of the contents of a single duct, or to interstitial new formations whereby a portion of numerous tubules is compressed and obliterated, and the remainder dilated by its accumulated secretion and converted into more or less globular sacs. In the former event the cyst is single and isolated; in the latter multiple, the gland being often literally stuffed with them. Two distinct forms of cystic disease of the breast are met with, the unilocular and the multilocular. In the former, the cyst, as the name implies, is single, and composed of a membrane which bears a very close resemblance to the peritoneum, its inner surface being perfectly smooth and glossy, and lined with squamous epithelium, while the outer is inti- mately connected to the surrounding parts. Occasionally the cyst is intersected by mem- branous bands, separating it into a number of distinct compartments, of varying size and shape. When this is the case, the cyst is said to be multilocular. Various fluids are found in these sacs. Generally they are of a serous nature, more or less viscid, coagula- 970 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. X V 111 . ble, of a saline taste, and of a limpid, or pale yellowish appearance; but cases occur in which, from the admixture of hematin, they are of a reddish, olive, brownish, claret, or blackish hue. Not long ago, I saw an instance in which the fluid was of the color of the tincture of iodine. Sometimes, again, the fluid is of a lactescent nature, whey-like, or mucoid. Finally, there are cases in which it contains eholesterine, flakes of lymph, and other substances. Cysts of the character now described often attain a large bulk, and are capable of holding from twenty to sixty ounces of fluid. Very frequently, again, the cysts are multiple, their number, perhaps, ranging from a few dozens to many hundred. When this is the case, they are generally very small, their volume varying from that of a hemp-seed to that of a pigeon’s egg. Their shape is usually spherical, ovoidal, or conical. When young, they are smooth, transparent, elastic, vas- cular, closely adherent, and filled with a clear, watery fluid, slightly saline in taste, and but faintly coagulable by heat, alcohol, or acid. Their parietes, however, are liable to become opaque and thickened, when the contained fluid may be lactescent, bloody, oleaginous, glairy, or gelatinous. Different cells of the same tumor often have dissimilar contents. The morbid mass is sometimes entirely composed of cysts; at other times a considerable proportion of solid matter is interposed between them, commonly of a tough, fibrous nature. The characters of the multiple form of this disease are well seen in fig. 755, from a preparation in my cabinet. Single or multiple cysts, uncombined with a contracted state of the connective tissue, are most common in young adults during the period of activity or evolution of the mammary gland, whence they are sometimes termed evolution cysts. The cyst is not unf'requently blended with condensed and thickened interstitial tissue, the two elements being more or less intimately intermixed with each other. This is especially true of the multiple or poly- cystic variety, of long standing, in females after the decline of the menses. The cysts, under such circumstances known as involution cysts, are very thick, dense, opaque, and occupied either by solid or semisolid formations. Such tumors often grow quite rapidly, and are capable of acquiring a very large bulk. The diagnosis of cystic disease of the mammary gland is often obscure, especially in its earlier stages. The chief signs of distinction are, the gradual and steady growth of the tumor, the absence of pain and of lymphatic involvement, a sense of fluctuation, more dis- tinct at some points than at others, the natural appearance of the integument, and the integrity of the general health. In some cases a serous or bloody fluid constantly flows from the nipple, or may be made to escape by gentle pressure, an occurrence which must be regarded as of great value in a diagnostic point of view1. Any doubt that may exist may usually be promptly dispelled by a resort to the exploring needle. When the mass is of a fibrocystic character, one part will be hard and inelastic, the other soft and fluctu- ating. When the tumor is large and old, it sometimes manifests a disposition to ulcerate, but, in general, as it goes on increasing, the skin gradually accommodates itself to its size. The treatment varies. The unilocular form of the disease sometimes disappears under the steady use of discutient remedies, as a strong solution of chloride of ammonium, or a mixture of equal parts of alcohol and spirit of camphor, with a small quantity of Goulard’s extract. Sometimes, again, a cure may be effected with the seton, the injec- tion of iodine, or the insertion of a tent. When the cyst is old, unusually large, or par- tially filled with solid matter, nothing short of excision will answer, and there is the more reason for its performance when there is a probability that the tumor has completely annihilated the glandular structure of the organ. The only remedy, when the growth is multiple or multilocular, is thorough ablation. y. Hydatid Cysts—Hydatids seldom infest this gland, at least in the females of this country. In the examination of a great number of breasts, I have not met with more than two cases. They always belong to the class of echinococci, and are most common between the ages of twenty-five and forty. Varying in volume between a currant and a cocoanut, they may occur in any portion of the organ, the proper substance of which they generally completely destroy. They are of a globular figure, and present themselves Fig. 755. Cystic Disease of the Breast. CHAP. XVIII. FIBROUS TUMORS OF THE MAMMA. 971 either in clusters, or as bodies perfectly distinct from each other. When of considerable size, it is not uncommon to find within the old hydatids young ones, hanging by narrow footstalks, and having precisely a similar configuration and structure. The contained fluid is generally thin and limpid, but it may be thick and glairy, like the white of an egg. In the older hydatids, especially such as are partially dead, there is sometimes an admix- ture of blood, pus, albumen, or curdy matter. These bodies may exist either alone, or in connection with other morbid products ; and, when bulky and numerous, are productive of extraordinary enlargement of the breast, cases now and then occurring where the organ weighs from eight to ten pounds. As in the ordinary cystic tumor, so in this, the diagnosis is often very difficult, if not impossible. In its earlier stages, the disease is liable to be confounded with scirrhus; afterwards, when it has attained a large bulk, with encephaloid. The most important signs are, the tardy progress of the case, the unimpaired state of the general health, the absence of lymphatic involvement, the natural appearance of the skin, and the globular or ovoidal shape of the tumor, together with its large size and want of adhesion to the sur- rounding structures. The pain is usually much greater than in mere cystic disease, although there is sometimes none at all, and there is but little fluctuation, except when the tumor has acquired a large bulk, when it is always well marked. There is nothing, however, of a truly diagnostic character in any case, except the escape of some of the contents of the tumor. The only remedy for the hydatid tumor is thorough excision, performed as soon as possible after the establishment of the diagnosis. The operation is not followed by relapse. BENIGN TUMORS. Under this head may be included fibroma, myxoma, and adenoma, the last two being characterized by a tendency to recur after removal, without, however, infecting distant organs. Lipoma, although met with as a paramammary growth, does not occur in the gland itself; there is not a single instance, confirmed by minute examination, of pure chondroma on record; and only a few examples of neuroma and angioma have been ob- served. 1. FIBROUS TUMORS. The mammary gland is a frequent seat of fibrous growths, either in the form of diffused fibrous transformation or as circumscribed, partial neoplasms. In the first variety the interstitial connective tissue is condensed into a firm, contractile, fibrous substance, im- parting to the touch the sensation of atrophic scirrhus, which it sometimes closely re- sembles in its coarser features. In its earlier stages the acini and tubules are little, if at all, changed, but, as the disease progresses, they wither and finally disappear. In some cases, and particularly in elderly females, there is a secondary development of cysts. In another class of cases the connective tissue shrinks, the glandular elements disappear, the nipple retracts, and the breast is converted into a small, indurated mass. In the second variety of fibrous tumor the changes in the glandular connective tissue are limited to circumscribed portions of the mamma, particularly at its circumference, where one or more small, firm, dense, lobulated nodules are developed, which are usually termed adenomas or adenoid tumors, as they contain gland structures, the proportion of which varies in different specimens. These mammary glandular tumors, as they are sometimes termed, are not, however, in the strict sense of the term, adenomas. Of many specimens of so-called adenoma which I have had subjected to microscopical examination, in none was there any epithelial hyperplasia. In all the point of departure of the neoplasm was the connective tissue, and in nearly all acini and ducts were present in a very abundant fibrous tissue, which was evidently obliterating, by its pressure, the lumen of the tubes. In a few instances the glandular elements had entirely disappeared, the mass being com- posed either of succulent, rapidly growing connective tissue, or a dense, firm, compact, fibrous substance, creaking under the knife, and occasionally containing calcareous de- posits. If, when glandular elements are present, it be deemed desirable to recognize their existence, such tumors may be termed adenoid fibromas, but as these elements are merely included normal, and not new, developments, to avoid confusion, it is best to speak simply of a fibroma, reserving the term adenoma for those rare growths in which there is a new formation of genuine, regularly constituted acini and ducts. The pure fibrous tumor of the mamma, whether single or multiple, is firm, elastic, 972 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. bossed, or lobulated, and movable, notwithstanding that it is more or less adherent to the portion of the gland from which it immediately arises. It is commonly situated immediately beneath the surface at the upper and outer part of the breast, and rarely exceeds the volume of a walnut. When cysts are present, thereby constituting cystic fibroma, the tumor grows more rapidly than the pure variety, is liable to sudden increase, is soft and fluctuating over the large bosses, and fungates and discharges by the nipple once in about every seven cases. The subcutaneous veins sometimes enlarge, but there is hardly any pain, and no involve- ment of the neighboring lymphatic glands. The disease usually arises without any as- signable cause. The prognosis is favorable. There is a variety of cystic fibrous tumor of the breast in which the structure is more complicated, rapidly proliferating connective tissue projecting into and filling the dis- tended ducts, in the form of vascular, papillary, fimbriated, dendritic, or cauliflower-like vegetations, or of polypoid, lobed, spheroidal, rounded, or flattened masses, thereby giving rise to proliferous fibroma, or, as it is termed by Virchow, intracanalicular papillary fibroma. The section displays, a smooth, dense, glistening, fibrous tissue traversed by variously shaped fissures, tortuous spaces, or clefts representing the altered ducts, upon separating the walls of which the vegetations are disclosed. In a specimen in my cabinet, the appearances of which are rudely represented in fig. 756, removed from a married, but sterile, female, thirty-three years of age, each breast was filled with small, tough masses of proliferating connective tissue, of a rounded form, from the size of a filbert to that of a common hickory nut, hard, and almost inelastic. The disease had been in progress for upwards of three years, and was attended with considerable enlarge- ment of each gland, but there was an entire freedom from pain, lymphatic involvement, and disorder of the general health. The organs were perfectly movable, and numerous nodules could be felt in their substance in every direction. The nipples were badly developed, but not more retracted than they often are in women who have never borne children. Upon making a careful examination of the nodules above described, I found that they all consisted of a kind of cyst, inclosing a mass bearing a striking re- semblance to a cauliflower, being composed of fibrous membrane, of a white, glistening appearance, thin, and semitransparent, folded like the ruffles of a shirt, and studded with an immense number of small deli- cate excrescences, looking very much like the warts which are so often met with upon the penis. They all adhered by a broad base or stem, and were made up each of a number of minute granules, resembling the eggs of certain insects. Under the miscroscope, the stems were seen to consist of fibrous tissue in various stages of development, continuous with that of the gland itself, while the granules were made up, for the most part, of rounded bodies, presenting a delicate, fibrillated stroma, inclosing small, ovoidal, and spindle-shaped cells in varying proportions. The hard part of the mamma, that in which the nodules were developed, was composed of bundles of very dense fibrous tissue, wavy, and extremely distinct. Fat cells were here and there discernible in its meshes. The only reliable remedy for fibroma is excision, but such a measure will only be re- quired in the event of the morbid growth being very large, painful, or inconvenient by its weight. Removal of the entire breast is seldom necessary. As a rule, indeed, the operation should be limited to the parts more immediately involved. Sorbefacient appli- cations, and the exhibition of iodine, are of no avail. Compression might be tried in the earlier stages of the disease with a better prospect of success. 2. MYXOMATOUS TUMORS. Myxoma of the breast is uncommon, Dr. S. W. Gross having been able to collect only ten examples, confirmed by minute inspection. The growth is solitary, round, or ovoid, occasionally lobular, and seated towards the outer border of the upper hemisphere of the gland of middle-aged, married subjects. It is very liable to inflammation, ulceration and fungous protrusion, but it is not attended with enlargement of the superficial veins, in- Fig. 756. Proliferous Fibroma of the Mamma, exhi- biting its Lobulated Arrangement and two Dilated Ducts, containing the New Growths laid open. CHAP. XVIII. SARCOMA OF THE MAMMA. 973 volvement of the axillary glands, or retraction of, or discharge from, the nipple. On account of the recurring tendency of the disease, the entire breast should be sacrificed. 3. ADENOMATOUS TUMORS. Pure adenoma of the mammary gland is not only one of the rarest, but it differs from all other neoplasms of this organ in its extraordinary tendency to undergo cystic degene- ration, and in invariably presenting a bossed configuration, as represented in fig. 757, from Bryant. Dr. S. W. Gross finds that “ the diagnosis of adenoma is based upon its hard and heavy feel, its nodular outline, its inti- mate attachment to the breast even when of moderate volume, its mobility upon the chest, its slow and equable growth, its increase by the addition of small, compact nodules, its occur- rence in married and prolific women toward the thirty-fifth year, the limited discoloration and adhesion of the skin, the ulceration late in the disease, the freedom from retraction of the nip- ple, the enlargement of the subcutaneous veins, and the involvementof the lymphatic glands. If a tumor which presents these features has been preceded by a discharge from the nipple, there should be little difficulty in arriving at a correct conclusion as to its true nature.” As the disease recurs in at least one-half of all cases, the entire breast should be extirpated. MALIGNANT TUMORS. The most common malignant diseases of the mamma are sarcoma, scirrhus, and ence- plialoid. Melanosis, and colloid are extremely infrequent. 1. SARCOMA. Sarcoma of the breast is essentially an affection of early life, being most common in young married females, although it is now and then observed in impubic girls and in women after the decline of the menses. Occurring in two varieties of form, the circum- scribed and diffused, it is usually made up of small round or spindle cells, or of both elements variously intermixed, or, as sometimes happens, combined with giant or myeloid cells, and may, therefore, be classified in accordance with the preponderance of one or the other of these elements, although, from a clinical point of view, it may appropriately be separated into the firm and soft, the latter including the myxomatous and cystic varieties, which differ from each other widely in their progress and in the degree of their malig- nancy. The circumscribed sarcoma, which is rarely soft, generally forms at the circum- ference of the gland or in one of the outlying lobules, but presents no features by which it can be distinguished from adenoma or fibroma. It is most common soon after marriage or impregnation, between the ages of twenty and thirty, and evinces little disposition to recurrence. To this tumor certain pathologists apply the name of adenoid sarcoma, but as the glandular structure is not only not of new formation, but often disappears through the compression exerted upon it by the rapidly proliferating new formation, the term should be abolished. The diffused variety of the affection most commonly arises in the centre of the breast, in the neighborhood of the nipple, is composed of small connective elements, and has a much softer consistence than the circumscribed tumor. It is often combined with cystic dilatation of the milk ducts, the cysts themselves being either barren or filled with solid or semisolid masses of the new tissue. The diffused, soft, medullary neoplasm is most frequent towards middle age, although it has been observed in impubic girls, grows rapidly, attains enormous bulk, undermines the general health, returns after extirpation in two-thirds of all cases, and gives rise to secondary deposits in the pleura, lungs, and other viscera in 57 per cent, of all examples. It is distinguished from encephaloid carci- noma, to which it scarcely yields in respect to malignancy, by its more rapid develop- ment, mobility, greater volume, freedom from suffering and lymphatic involvement, and the presence of marked enlargement of the subcutaneous veins. The cystic form of the Fig. 757. Adenoma of the Mamma. 974 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. affection is not so malignant as the pure medullary tumor, but numerous instances are recorded of repeated repullulation and metastasis to internal organs. "W ithout dwelling upon the general features of these neoplasms, which are fully discussed in the first volume, it appears to me that the whole subject will be placed in a more satisfactory light by the narration of typical cases of the different forms of sarcoma. A healthy, robust, married lady, thirty-two years of age, came under my care with a circumscribed, movable tumor, seated deep in the breast above and internal to the nipple. She had first noticed it, seven months previously, as a nodule of the size of a pea, which gradually increased, and was the seat of frequent neuralgic pains, which were aggravated in wet weather. After removal it was found to be a globular, deeply-lobed, firm, elastic mass, about one inch in diameter, inclosed in a distinct capsule, and presented, on section, a uniform grayisli-white, tough, fibrous structure, which, on minute examination, was found to be composed of a very abundant fasciculated spindle-celled tissue, through which numerous acini and tubules, some undergoing obliteration, were interspersed. The tumor, in fact, was a fibrous sarcoma, and has shown no disposition to return, although two years have elapsed since its extirpation. In striking contrast with the above case is that of a soft, medullary, small spindle- celled sarcoma, or fibroplastic tumor, in which round, oval, and giant elements, however, were present, but not in any great number. It forms, so far as I am aware, the most extraordinary example of recurrence on record, and forcibly illustrates the importance of reexcision so long as the disease continues to appear at its original site, or, in other words, so long as it retains its local character, and does not infect the general system. The patient, an unmarried female, with small breasts, forty-five years of age, in March, 1857, became affected with a swelling in the left gland, which was partially excised the follow- ing October. During the next sixteen months two more operations were performed, and in May, 1859, when the case fell into my hands, I removed the entire breast, along with a fourth tumor. The disease soon reappeared in the cicatrice, and in three months and a half again required the use of the knife. In September, 1861, I performed the twenty- third and last operation, a number having previously been performed by Dr. Aseh, one of my former clinical assistants. Altogether fifty-two tumors were removed ; all of a soft, spongy, brain-like consistence, very vascular, and from the size of a small almond to that of a pullet’s egg. They generally recurred at or near the former cicatrice, within a few weeks after extirpation, and speedily assumed a fungating disposition, with a thin, fetid discharge, but no disposition to bleed. There was little or no local suffering; the woman’s general health was all along excellent; there was no lymphatic involvement; menstrua- tion was going on well; and she always rapidly recovered from the effects of the use of the knife. Upwards often years have now elapsed since the last operation, and, thus far, the cicatrices are all in a sound condition, soft, and of a whitish aspect. Small round-celled sarcoma of the breast usually runs a very rapid course, and must be regarded as the most malignant of all neoplasms in this situation, excepting encepha- loid carcinoma, to which it bears a most striking resemblance in its gross appearances as well as in its clinical history, but from which it may be distinguished by the features already alluded to and by its minute structure. It grows very rapidly, attains enormous bulk, and finally softens, ulcerates, and protrudes fungous masses, liable to frequent hem- orrhages. Local and general infection commence early; recurrence after extirpation is almost invariable; and the entire duration of life sometimes does not exceed six or eight months. In the case of a lady, thirty-five years of age, whom I saw with Dr. Addinell Ilewson, a tumor ot this kind attained, in the course of four months from the time of its first appearance, a weight of nearly six pounds and a volume equal to an ordinary adult head, its basal circumference being twenty-three inches. To the touch it was elastic and movable, its surface was bosselated, and at one point, where the integument was stretched and discolored, there was an indistinct sense of fluctuation. There was no lymphatic involvement, the subcutaneous veins were not enlarged, the nipple was natural, and the suffering, which interfered with her rest, was ascribable to the tension and wreight of the growth. Microscopic examination of the soft, pulpy, medullary mass, disclosed an ex- quisite example of small round-celled tissue, the intercellular substance being amorphous. At several points it had undergone softening and cystoid degeneration, the cavities being occupied with mucoid contents. Two months subsequently the disease recurred in the cicatrice, and in six w’eeks, when it was of the volume of a small fist, it was again removed by Dr. Hewson. The patient soon afterwards was seized with the most violent and obstinate sciatica; rapid emaciation ensued; another tumor formed at the cicatrice between nine and ten weeks after the second operation; and she succumbed one month CHAP. XV III. SARCOMA OF THE MAMMA. 975 later, apparently exhausted by the combined effects of neuralgia and loss of sleep. The entire duration of life from the first manifestation of the disease was hardly nine months. No post-mortem inspection of the body could be obtained. Cystic sarcoma, which is of comparatively common occurrence, and an entirely distinct affection from cystic fibroma, previously described, but analogous to cystic sarcoma of the testicle in its mode of production and clinical history, is characterized by the presence of numerous cysts, due to dilatation of the lactiferous ducts, a portion of which has been compressed by the rapidly proliferating interstitial new formation. The cysts are either occupied with fluid, or, as more frequently happens, filled with papillary, foliated, or other forms of solid masses of the new growth, thereby giving rise to proliferous cystic sarcoma in the strict acceptation of the term. The tumor, thus constituted, is most common in middle-aged subjects, is capable of attaining colossal dimensions, its outline is usually irregular and lobulated, while its consistence is unequal, distinct fluctuation, perhaps, being apparent at some points. Its progress is slow, but, after it has acquired a certain bulk, it increases rapidly, softens, ulcerates, and throws out fungous masses. When it is composed of a soft, round-celled basis, the danger of return after extirpation, numerous instances of which are on record, and of infection of internal organs, is much greater than when it is of a fibrous nature. In 1871 I removed a proliferous cystic fibro-sarcoma of the breast of a lady, forty-eight years of age, who had first noticed a small lump, above and external to the nipple, fifteen years previously. Latterly the swelling had increased rapidly, but it was free from pain, and only inconvenient from its bulk and weight. To the touch it was uniformly smooth, firm, and somewhat elastic, except towards its axillary margin, where it was lobulated, with an obscure sense of fluctuation, and an attenuated and discolored state of the integument. It was perfectly free from adhesions, and there was no lymphatic involvement in the axilla or elsewhere ; but the subcutaneous veins were greatly enlarged. When cleared of fat, the mass, which was finely and largely lobulated, and contained in a distinct capsule, weighed four pounds and a half, and was of the volume of a child’s head. The section, which was attended with the escape of a straw- colored, viscid fluid, disclosed a smooth, succulent, glistening, striated yellowish-white structure, with numerous points of a gelatinous-looking substance, which was composed of fibrous tissue in various stages of development, and rich in spindle cells. Interspersed throughout it were dilated acini, lined with cylindrical epithelium, around which the spindle elements were very abundant. This rapidly growing tissue had projected papilli- form, polypoid, lobulated, dendritic, and cauliflower-like masses into the dilated ducts, which were of a tough consistence, and either of a yellowish-white or of a gelatinous ap- pearance. The majority of the vegetations displayed the same minute features as the main growth, with the addition, at rare intervals, of small patches of gland tissue. Others were composed almost entirely of white, wavy fibrous tissue, while those which had a gelatinous look showed spindle cells, with oil globules and granular matter. The cysts formed by the distended milk ducts were for the most part single, of large size, many being of the capacity of a hen’s egg, and filled with solid vegetations, the remainder being occupied by a straw-colored or pinkish mucoid fluid. The similarity of the mass in its gross features to the proliferous fibroma, previously described, was most sticking. The patient remains perfectly well, ten years after the operation. Of myxomatous and 'pigmentary sarcoma, I have never seen any examples in the mamma. They do not, however, differ in their clinical history from the soft, medullary form of the affection, and, like it, may be combined with cystic growths, the dilated lac- tiferous ducts being filled with the new formation, and thus giving rise to a variety of cystic sarcoma. The presence, in the one, of a net-work of anastomosing cells in a gela- tinous tissue, and, in the other, of round or spindle-celled elements impregnated with melanin, suffices to distinguish them from other tumors. The treatment of sarcoma of the breast is conducted upon the same principles as that of carcinoma. The only remedy is the knife, carried far beyond the apparent limits of the disease, and the sooner it is resorted to the better will be the chance of prolonging life and even of effecting a radical cure. In the fibrous and large spindle-celled tumors, local recurrence, much less secondary internal deposits, is not to be anticipated, and the same is true, in great measure, of the cystic formations, although the prognosis in these cases is not so favorable. In the other forms of the affection relapse may be ex- pected, but even under such circumstances the patient should not be thought beyond the pale of surgical interference, particularly if the tumor be of slow growth, and occurs at an early period of life. 976 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. 2. SCIRRHUS. Scirrhus of the breast is most common soon after the decline of the menses, in married females. The average age in 642 cases analyzed by Dr. S. W. Gross, was 48 years. It is extremely rare before the age of thirty. I have repeatedly seen the disease after seventy. Sir Astley Cooper met with an instance at eighty-six. On the other hand, it may occur at a very early period. The youngest case I have ever seen was in a woman of twenty-seven. Of 30,000 female bodies brought to the Vienna Pathological Institute from 1817 to 1879, 366 had been affected with cancer. Of these cases the disease in 46 occurred in both breasts, in 161 in the right, and in 144 in the left, no mention being made of its situation in the remaining 15. Unmarried females occasionally suffer from it, but much less frequently, relatively speaking, than women who have borne children. Its origin is generally spontaneous, although it is often referred by the patient to the effects of a blow, contusion, or some other external violence. It has been known to occur in four or five members of the same family, and occasionally it coexists with scirrhus in other parts of the body. Now and then it arises in the mammary gland of the male. The disease is usually confined to one breast, and the right, as stated above, suffers somewhat more frequently than the left. When both glands are affected, the attacks are always consecutive, never simultaneous. The affection occurs in two varieties of form, the tuberous and the infiltrated. The former usually begins insidiously, in the axillary border of the gland, as a small circum- scribed lump, hard and irregular to the touch, and somewhat tender on pressure. As the disease progresses, the whole organ becomes involved, assuming a firm and knobby char- acter, movable, and the seat of occasional pain, of a sharp, lancinating, darting nature. Advancing still further, the tumor gradually contracts adhesions to the surrounding parts, especially to the pectoral muscle, so that eventually it can no longer be lifted up, or pushed about. In the mean time the nipple is retracted; the skin is puckered and dis- colored ; and presently ulceration sets in, leaving one or more circular sores, with hard, depressed, angry-looking edges, and a foul, sloughy base. The discharge is thin, ichorous, offensive, and often so acrid as to erode the healthy skin. Gi'adually the irritation extends to the neighboring lymphatic glands, which either become white, firm, and tumid, or they are rendered preternaturally soft and vascular, having often a bloodshot appearance. Fig. 758. Fig. 759. Scirrhous Tumor of the Breast, exhibiting a section of the re- tracted Nipple. Retraction of the Nipple in Scirrhus. The retracted and fixed appearance of the nipple is well shown in fig. 758, from a patient at the College Clinic. It often begins early in the disease, and is produced by the manner in which the lactiferous tubes are drawn towards the contracting growth, an effect admirably exhibited in fig. 759. Eczema of the nipple and areola is occasionally, as was first noticed by Paget, observed as a kind ot precursor of carcinoma of the mammary gland. The occurrence, however, CHAP. XVIII. SCIRRHUS OF THE MAMMA. 977 is uncommon, and I do not know that it is entitled to any special clinical significance. When long continued it may act as an exciting cause of the disease. On dissection, the mamma is found to be inelastic, firm, dense, and crisp, like cartilage, which it also resembles in color; sometimes it is of a dry, fibrous texture, like the interior of an unripe pear, and of a light grayish tint, interspersed with yellowish lines, probably the remains ot lactiferous ducts. A very characteristic appearance is the concavity pre- sented by the cut surfaces on section. The volume of a scirrhous breast is extremely variable. When the patient is very fat, the tumor is generally proportionately large, owing to the presence of an extraordinary quantity ol adipose matter. The morbid mass itself, carefully divested of extraneous substance, seldom exceeds the size ot a large orange. There is, however, a form of the disease, known as atrophic scirrhus of the breast, in which the tumor is generally not larger than a small walnut, including both normal and abnormal tissues, which appear to be shrivelled up into one solid mass, of remarkable hardness and density. It is most common in advanced life, and often remains stationary, or nearly so, for years together, Fig. 760. Fig. 761. Section of a Scirrhous Nodule. although eventually it is not less fatal than ordinary mammary carcinoma. Atrophy of the breast sometimes occurs very rapidly, as in the course of a few months, and that, too, occasion- ally when the organ has been of unusually large bulk. The wasting process, under such circumstances, seems to involve every portion of the diseased gland simultane- ously, and to proceed in a steady and persistent manner until the organ is reduced to the merest nodule, hardly the size of a common hickory-nut. The malady, as already stated, usually commences in a few lobules; but, as it progresses, the whole organ is converted into a firm, solid mass, with a rough, tuberculated surface. In the annexed sketch, fig. 760, taken from a specimen in my cabinet, a large number of nodules are seen, the largest of which, hard and crisp, like cartilage, and of an oblong, spherical shape, scarcely equal the size of a pullet’s egg. Fig. 761 exhibits a section of one of these bodies. Scirrhus of the breast sometimes remains quiescent for a considerable length of time, when, taking, as it were, a fresh start, it rapidly assumes the characters above assigned to it. When removed, it is almost certain eventually to return, either at the cicatrice, or in the contiguous lymphatic glands. The tumor is occasionally invaded by gangrene, even before ulceration has commenced. In a case of this kind which came under my observa- tion a few years ago, and which is described in the chapter on the general history of scir- rhus, the morbid growth was lifted completely out of its bed, the cavity being afterwards filled up with healthy granulations, although the disease returned subsequently in the neighborhood of the original affection and proved fatal. The symptoms of scirrhus of the breast are usually characteristic. Its lump-like origin in the body of the organ, its slow but steady progress, the great hardness and compara- tively small volume of the tumor, the sharp, lancinating pain, the retraction of the nipple, the gradual adhesion of the breast to the surrounding structures, and the ultimate involve- ment of the neighboring lymphatic glands, as those of the axilla and subclavicular region, are phenomena which it is impossible to misinterpret. The nature of the scirrhous ulcer is also peculiar. It has an excavated appearance, as if a portion of the tumor had been punched out, with afoul bottom, and steep, everted edges. The discharge is thin, sani- ous, fetid, irritating, and more or less abundant. Hemorrhage sometimes occurs, but seldom to any extent. Retraction of the nipple generally exists in a marked degree, and often begins at an early period of the complaint. Along with this there is nearly always a deep groove or gutter around the base of the nipple, a sign which, like the retraction Scirrhous Mamma laid open to show its Lobulated Structure. 978 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. itself, is almost characteristic of the nature of the disease. Enlargement of the lymphatic glands, seldom present before the end of the sixth or seventh month, is commonly very conspicuous after the occurrence of ulceration, especially in the axilla. In the more severe forms of the disease, it generally affects those also of the subclavicular region and even those of the neck. Swelling, pain, and numbness of the corresponding extremity always attend the malady in its latter stages, and greatly augment the suffering, the limb becoming perfectly stiff and useless, and feeling like a mass of lead. Ibis occurrence, according to my observation, is most frequent in women who have experienced a relapse after excision of the breast, and is then apt to be proportionately severe. The swelling and hardness generally involve the entire limb, from the top of the shoulder to the tips of the fingers, and greatly intensifies the patient’s suffering. I lately attended an elderly lady who had had two operations per- formed for her relief, and whose limb, enor- mously increased in size, was for nearly six months a source of the most distressing pain, weight, and numbness. The immediate cause of this condition is the pressure that is ex- erted upon the veins and lymphatic vessels by the enlarged axillary glands. The annexed drawing, fig. 762, taken from a clinical case, exhibits the condition of a scirrhous breast in the advanced stage of the disease, after the occurrence of ulceration. The tumor was of unusual volume. The general health is variously affected. In most cases it remains comparatively good until ulceration begins,when it usually rapidly declines, the body becoming emaciated, and the countenance exhibiting that peculiar sallow, cadaverous appearance so denotive of the carcinomatous cachexia. The pain, in the latter stages of the disease, is generally atrocious, depriving the patient both of ap- petite and sleep. The duration of the disease is far from being uniform. Left to itself, it generally ter- minates fatally in thirty-one months, as a general average. Occasionally death takes place much sooner; and, on the other hand, instances occur in which it does not destroy life under ten, fifteen, twenty, or even twenty-five years, although such an event is ex- tremely uncommon. When ulceration has once fairly begun, the health is rapidly under- mined, and the patient usually perishes in a few months. The immediate cause of this event is either sheer exhaustion from excessive pain, loss of sleep, and want of appetite, or pneumonia, hydrothorax, or pulmonary oedema. The most rapidly fatal cases gener- ally occur in young females. Roux met with an instance in which death took place in three months from the commencement of the attack. In old women the disease often remains quiescent for many years, especially when the tumor is uncommonly small. During the progress of the disease secondary scirrhous growths sometimes appear; gen- erally in the skin and connective tissue of the breast, or in the parts immediately around, in the form of tubercles, varying from the volume of a small shot to that of a pea, exceedingly firm and solid, slightly movable, very tender on pres- sure, and the seat of sharp, pungent pain. They often exist in large numbers, as in fig. 763. In one case I counted upwards of fifty. Occasionally they occur both over the mammary gland as well as at some distance from it. In an instance recently under my care, in a female upwards of fifty, whose breast had been the seat of an enormous scirrhus, of nearly two years’ standing, tubercles of this kind appeared a few weeks before death upon the cor- responding side of the trunk near the spine, shoulder, neck, and head, and also upon the upper part of the opposite arm. Sometimes these second- Fig. 762. Ulceration of a Scirrhous Breast. Fig. 763. Secondary Scirrhous Nodules. CHAP. XVIII. ENCEPHALOID OF THE MAMMA. 979 ary formations show themselves upon the scars left by the bites of the leeches applied for the relief of the pain and the inflammation of the breast, as in a case under my charge not long ago in a woman, forty years of age. She had labored under scirrhus upwards of a year, when nine leeches were applied, the bites of which became affected in this way. As these secondary growths increase in size they project beyond the skin, and exhibit a red, vascular, angry appearance, denotive of the worst consequences, and, of course, impera- tively forbidding surgical interference. A very singular condition of the common integument, consisting in a dark-colored, brawny alteration, occasionally occurs in the latter stages of scirrhus, both upon the breast and in the parts immediately around it. The induration is generally very great, the skin feeling as hard as marble, and there are cases in which it is accompanied by a remarkable contraction of the affected structures, not unlike what is so often witnessed in the scars of burns and scalds. The cause of this change, which sometimes involves a large portion of the chest, reaching, perhaps, as high up as the clavicle and shoulder, and finally extend- ing down even over the arm, is the infiltration of carcinomatous cells, converting the skin and subcutaneous connective tissue into a substance of the color and consistence of the rind of bacon. Hence it is generally known as the lardaceous degeneration of the skin. Its presence is always denotive of a highly vitiated condition of the system, with a rapid downward tendency. Cases, again, occur in which the skin over the indurated gland exhibits a peculiar striated appearance, the individual lines extending outwards from the nipple like so many radii. The appearance is evidently due to distention of the lymphatic vessels by carci- nomatous material, and is a sign of unusual malignancy. In the more severe forms of the disease thus characterized, the surface is raised into numerous hard, whitish ridges, higher at some points than at others, and so closely aggregated as to render the tissues as firm and inelastic as a board. I have repeatedly witnessed this injected condition of the cutaneous absorbent vessels at a very early period of scirrhus. In a case recently under my care, one of the best marked of the kind I ever saw, the patient was only thirty-five years old. 3. ENCEPHALOID. In comparison with scirrhus, encephaloid of the mamma is a rare disease. Of 22 cases analyzed by Dr. S. W. Gross, 20 per cent, occurred before the fortieth year, and 80 per cent, after that age, the youngest subject having been twenty-nine, and the oldest sixty- nine years of age. It is not possible to tell with any degree of exactitude the proportion which the cases of encephaloid bear to those of scirrhus. Dr. S. W. Gross asserts, how- ever, that it is as one in about fifteen. The symptoms are commonly well marked. Ordinarily the disease begins, without any assignable cause, as a small tumor in the substance of the gland, which generally increases with frightful rapidity, often acquiring the bulk of a large fist or even of a foetal head in the course of a few weeks. Like scirrhus, it is at first movable, but eventually it is firmly united to the surrounding structures, which it is sure in time to involve and contaminate. The pectoral muscle, in particular, is liable to suffer in this manner. The lymphatic glands are not affected quite as frequently as in hard carcinoma. The tumor is usually knobby or tuberculated, and of varying degrees of consistence, being firm and incompressible at one point, soft at another, and perhaps fluctuating at a third. The nipple is retracted in about one-third of all cases. The subcutaneous veins are rarely greatly enlarged ; the pain is comparatively slight; and the parts are generally singularly tolerant of manipula- tion. Ulceration sets in at variable periods ; rarely before the ninth month or later than the twelfth. The resulting sore is deep and excavated, and it does not fungate as in sarcoma. The general health usually suffers at an early period; the patient loses flesh and strength, and the countenance exhibits a sallow, withered appearance, denotive of the profound impression which the disease is making upon the system. The pulse is small, frequent, and irritable ; the appetite fails ; sleep is interrupted by the pain and the dis- charges ; night-sweats set in, and thus the case steadily progresses, from bad to worse, until life is worn out by exhaustion. Sometimes the immediate cause of death is hem- orrhage. In some cases the patient perishes from hydrothorax, pneumonia, pleurisy, or pulmonary oedema. The period at which life is worn out varies, on an average, from six to twelve months. The diagnosis of encephaloid is, in general, too well marked to admit of error, especially if the disease has taken a fair start. The great size, rapid growth, and comparative soft- ness of the tumor, the absence for a long time of severe pain, and the early constitutional 980 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVI II. involvement, will always serve to distinguish it from other carcinomatous diseases ot the mammary ilute tincture of iodine is sometimes beneficial. Itching of the skin may he relieved by zinc or an ointment composed of chloral and camphor. By means ot these measures, judiciously employed, the patient may often live in great comfort for months and even years. Gradually, however, the vital powers give way, the countenance assumes the peculiar sallow expression, so indicative of the carcinomatous cachexia, and she finally expires in a state of complete exhaustion. In regard to the use of the knife, as a means of relief in carcinoma of the breast, the greatest possible contrariety of opinion exists. While some are altogether opposed to it under any circumstances, there are others who do not hesitate to resort to it in every case, and at almost every stage of the disease, either as a curative or as a palliative measure. They argue that it is better to operate even if it afford only temporary relief, than to abandon the patient to her fate; and, on the other hand, they positively assert that extirpation is occasionally followed by a complete cure, or, if not a complete cure, by such a protracted immunity from disease as virtually to amount to that. It has been a question with surgeons whether extirpation of a carcinomatous breast does, on an average, tend to shorten or prolong life. The subject has been examined by different observers, but the most reliable statistics are those that have been supplied by Dr. S. W. Gross, who finds that the average duration of life in carcinoma of the breast, allowed to pursue its natural course, was 27 months, whereas in those subjected to the knife it amounted to 39 months, thus showing a difference of one year in favor of the latter. Not only does extirpation add twelve months of life, but it actually leads to a radical cure in a certain proportion of cases. Thus, of 524 cases of scirrhus, encephaloid, col- loid, and atrophying carcinoma in which the result is known, analyzed by Dr. S. W. Gross, 57, or 1 in 9|, survived over three years without local or general recurrence after the last operation, or died of some intercurrent malady under the same conditions, 53 being still alive at the date of the last reports. “The average duration of life after ope- ration,” says Dr. Gross, “ was six years and five months, and the disease had existed, on an average, for seventeen months and a half before surgical intervention, so that the mean duration of life was seven years and ten months. Of the cases which ran a natural course only 1.5 per cent, survived six years ; while of the cures 31.57 per cent., or nearly one-third, were free from disease at the end of six years. Of these, 4 were well for between ten years and one month and ten years and ten months; 2 for between eleven years and one month and eleven years and nine months ; 1 for twelve years; 1 for thir- teen years and eight months; 1 for fourteen years and seven months; and 1 for fifteen years and seven months.” “ In the final cures the operation was performed when the affection had already existed, on an average, for seventeen months and a half. Hence, it was not practised early, or at a period which is best fitted for securing immunity from reproduction ; nor was it by any means always complete. Thus, of fifty-three cases in which the extent of the operation is noted, the breast was amputated in twenty-five; the breast was amputated and the axilla was cleaned out in sixteen ; the tumor alone was excised in ten; and extirpation with the removal of infected glands was resorted to in two. Of the entire number, the sixteen in which the breast and the lymphatic glands were completely removed are alone to be regarded as having been subjected to thorough operations.” “ In connection with the fifty-seven cures there are two interesting points which are of the first importance in influencing the prognosis after surgical interference. In nine instances there was repullulation. In six there was one relapse; in two there were two reproductions, respectively, in twelve months and four years; and in one there were three recurrences in four years. In these three cases the subjects were free from disease for three and a half, four and a half, and twelve years after the last operation ; so that, as in sarcoma of the mammary gland, recurrent tumors should be freely extirpated as soon as they appear. The second practical point is, that glandular implication is not a bar to operation. In eighteen, or nearly one-third, of the fifty-seven permanent recoveries, infected axillary glands were removed ; in several of these cases there were nodules in the skin, and the upper layer of the great pectoral muscle was excised. The results of operations indicate, moreover, that infection of the lymphatic glands is more frequent by 11 per cent., when the breast alone is removed, than when the glands are simultane- ously extirpated, and that glandular involvement is witnessed four months earlier after the former than after the latter procedure.” Extirpation is occasionally performed simply with a view to bodily palliation, as when the system is racked with pain, and worn out from the want of appetite and sleep. Or, CHAP. XVIII. TREATMENT OF CARCINOMA OF THE BREAST. 983 it may be, the patient is rapidly sinking under the effects of hectic irritation and the pro- fuse and foul discharge which so often accompanies an open carcinoma. The very air she breathes is poisoned by the effluvia of her apartment. No one will deny that the removal of a breast, in such an event, would not be proper, even if it should be attended with some risk to life. The tumor is excised ; pain and discharge cease; appetite and sleep return ; even hope is temporarily revived. The most promising conditions for a favorable issue, as it respects the prolongation of life, are, the tardy growth of the tumor, the appearance of the disease after the fiftieth year, the partial enlargement of the gland, the normal condition of the nipple, the absence of lymphatic involvement, and the complete integrity of the general health. Interference with the knife is out of the question when there are extensive ulceration of the tumor, great involvement of the lymphatic glands, firm adhesions, secondary for- mations in the skin or in some internal organ, extraordinary rapidity of development, and well-marked evidence of the carcinomatous cachexia. In such an event an operation would only inflict additional suffering upon the patient, and tend to bring surgery into discredit. The period of recurrence after operation varies. The cases most favorable for pro- longed immunity are those in which the disease is purely local, where there is no consti- tutional involvement, and where the patient has passed the fiftieth year. Of 203 cases analyzed by Dr. S. W. Gross, 03 per cent, relapsed in three months, and only 11.65 per cent, after one year, the average period for all cases having been rather more than five months. The suffering consequent upon repullulation is said by some highly respectable authori- ties to be less than when the disease is permitted to pursue its natural course. The statement does not coincide with the results of my experience. The disease, after removal, in the great majority of cases, returns either at the original wound, in the skin in the neighborhood of the cicatrice, in the axillary, subclavicular -or cervical glands, or in some internal structure, as the pleura, lung, liver, or uterus. Hence, the aim of the surgeon should be to remove all the tissues which long experience has shown are particularly obnoxious to recurrent growths, an aim which can only be reached by extirpating the entire breast with its investing skin and fat, dissecting the fascia off the pectoral muscle, and opening the axilla with a view to its exploration and the removal of any glands which were not palpable before interference. By adopting these rules, there is no reason why the number of radical cures should not be greatly increased. Reexcision should be practised so long as the disease continues to appear at its original site; or, in other words, so long as it retains its local character, and does not infect the general system. Finally, I am not an advocate for removing carcinomatous breasts with caustics. Independently of the cruel pain which attends and follows their application, there are few cases in which, unless the disease is exceedingly limited, they do not leave more or less of the morbid structures intact, and, consequently, in a condition for speedy outgrowth. The knife is always a more certain remedy, and in these days of anaesthetics there is no valid reason why it should ever give way to escharotics. Some surgeons are favorable to the employment of these substances on the ground that their application is accompanied with less hemorrhage than excision; this may be true, but it is equally true that there never need be much bleeding, however large or vascular the tumor may be, if proper care is exercised in its extirpation. I do not think, however, that caustics should be altogether condemned in the treatment of carcinoma of the breast; for cases do occur in which they may advantageously be used as palliatives, for allaying fetor and for improving the condition of the ulcerated surface. They are particularly adapted to the latter stages of the disease, when the period for extirpation is past, and when all that can be done is to render life a little more tolerable. The best articles for the purpose are the Vienna paste, butter of antimony, and chloride of zinc, applied while the patient is anaisthetized, and followed, if there be much pain, by a full anodyne. As to the ecraseur, as a means of removing a carcinomatous mammary gland, no sur- geon who has any self-respect could be induced to employ so barbarous an instrument for such a purpose. I can certainly not conceive of any case that would justify it. 984 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. DISEASES OF THE NIPPLE AND ITS AREOLA. The nipple and areola are liable to inflammation, syphilis, morbid growths, and malig- nant disease. Women during their confinement, particularly if it be a first one, are extremely liable to suffer from inflammation of the nipple, speedily terminating in ulceration and con- stituting what is ordinarily known as sore nipple. The sores have generally the appear- ance of superficial fissures, cracks, or abrasions, attended with a thin, serous, or sero- sanguinolent discharge, and excessive pain, usually of an itching, smarting character. Occasionally the ulceration extends to a great depth, partially separating the nipple from the breast, and thus greatly augmenting the suffering. The affected parts are red and inflamed, the breast feels tender and hard from the accumulation of milk, and the seba- ceous follicles around the nipple are irritated and sensibly enlarged. The disease usually appears within the first few days after delivery, in consequence of the application of the child’s mouth, which never fails to aggravate it. The treatment consists in the application of collodion, in thoroughly emptying the breast at least three times a day with the pump, and in the use of an active purgative, along with a light, dry diet, the object being a partial suppression of the milk. If both nipples are affected, the child should be compelled to suck with the aid of a heifer’s teat, until the parts are cicatrized. Protection from the pressure of the clothes is afforded by means of an appropriate glass. When collodion fails to afford relief, various astringent remedies may be employed, as weak solutions of alum, zinc, or copper, in union with tannic acid. Nitrate of silver, in the proportion of two grains to the ounce of water, sometimes answers a good purpose. Yellow wash, prepared with one-fourth of a grain of bichloride of mercury to the ounce of water, makes an excellent application for superficial chaps of the nipple, but caution must be observed in its use. Occasionally nothing affords such prompt relief as the ointment of nitrate of mercury, diluted with ten, twelve, or fifteen times its weight of simple cerate. A strong solution of borax, thickened with brown sugar, and rendered stimulating with brandy, is a favorite domestic x*emedy, from which I have frequently derived great benefit. In most cases, the foundation of this disease is laid during pregnancy, from a want of proper attention to the parts. In general, all difficulty may be successfully prevented by the avoidance of pressure, and the use of some astringent wash, as alum and tannic acid, for the purpose of hardening the nipple. The nipple is often very short, imperfectly developed, or flat and retracted, much to the annoyance both of the mother and child. Of the numerous plans that have been sug- gested for elongating it when thus affected, perhaps the most effectual is the application of a large bottle with a long neck, in which the air has been rarified with hot water. The water having been poured out, and the mouth of the bottle placed over the nipple, a vacuum is formed as the bottle cools, which thus establishes a powerful and equable suc- tion, thereby materially elongating the parts without any serious inconvenience to the mother. Most of the suction tubes and pumps, properly so called, do more harm than good in these states of the nipple. This treatment may often be advantageously employed during the last six or eight weeks of pregnancy, so that the nipple may be sufficiently developed by the time of birth. Syphilis of the nipple may exhibit itself either as a primary or secondary affection, in the form of a chancre or of a broad condyloma. Chancre may be communicated by a sore or a mucous tubercle upon the lip or tongue of the child in the act of sucking, forming an ulcer which exhibits the characteristics of the initial lesion of syphilis upon the geni- tal organs, passing through the same stages, attended with involvement of the axillary lymphatic glands, and followed, eventually, by constitutional symptoms, perhaps of the worst kind. The treatment is conducted upon the same general principles as in syphilitic disease of other tissues. Tumors of the nipple and areola are of uncommon occurrence, the most frequent being the sebaceous and pendulous cutaneous growths. The sebaceous tumor, developed from the glands which are so abundant near the base of the nipple and upon the surface of the areola, is readily distinguished by its tardy growth, its superficial situation, its great mobility, its rounded and spherical form, its freedom from pain, and its soft consistence. Russell has described a tumor in this situation which contained a pultaceous material mixed with hair, and which appears to belong to this category; while Billroth met with a partially calcified atheroma in the male areola of the volume of a hen’s egg. A pendu- lous tumor sometimes forms upon the areola, generally in close contact with the nipple, CHAP. XVIII. DISEASES OF THE BREAST IN THE MALE. and occasionally even within its substance. It is generally attached by a narrow pedicle, which eventually may acquire a length of several inches. The structure of the tumor, which varies in volume from a cherry to that of a walnut, exhibits nothing of a definite character. In many cases it consists, apparently, simply of a hypertrophied condition of the skin and connective tissue, inclosing a few long, slender vessels. In other cases, more especially when the tumor takes its rise in the nipple, it is composed, in addition to dermoid and connective substances, largely of glandular and papillary matter, the sur- faces, in this event, having a reddish, tuberculated aspect, not unlike that of a strawberry. In another class of cases, the morbid growth is mainly of a mevoid structure, consisting principally of enlarged convoluted veins, or it is composed of smooth, muscular fibres, there being at least two examples of leiomyoma of the nipple on record. Finally, the pendulous mass may be composed of myxomatous tissue, as in the rare and interesting case of a woman, twenty-one years of age, alluded to by Virchow, in whom the neoplasm, which was of two years’ growth and of the volume of the fist of an infant, sprung from a warty excrescence just by the side of the left nipple. For the sebaceous tumor, the only remedy is enucleation. In the pendulous growths the knife should be carried around the base of the tumor, so as to include a portion of the sound skin. Unless this be done, speedy recurrence will almost be inevitable. Hence, ligation of the pedicle, as advised by some surgeons, is decidedly objectionable. Of the malignant affections of the nipple and areola, by far the most common is epithe- lioma, of which I have met with a number of characteristic examples. In a maiden lady, forty-seven years of age, whom I recently saw in consultation with Dr. Stubbins, the morbid action commenced in the form of a hard tubercle in the areola, from which it gradually extended over the whole of the mammary gland. The nipple was remarkably hard and firm, erect, and at least three-quarters of an inch in length. The skin around was occupied by a superficial ulcer, fully the size of the palm of a large hand, and the seat of a thin, sanious, fetid discharge, which had made its appearance about six months previously. The pain was of a gnawing, dragging nature, and so severe at night as to interfere with sleep. The breast, naturally very small, was firmly bound down to the pectoral muscle, and felt like a very hard, solid substance. All the tissues around this organ, as well as over it, were greatly swollen and indurated, from the infiltration of inflammatory new formations and epithelial matter. The lymphatic vessels of the skin had a peculiar knobby appearance, their course being indicated by well-defined purplish lines. Several of the subclavicular lymphatic glands were enlarged, but those in the axilla were perfectly sound. The corresponding arm was swollen, oedematous, and of a mottled hue. The general health was good. I)r. Rogers, of New York, in 1866, reported a case of epithelioma of the mamma, in which the disease originally appeared as a warty excrescence in the skin at the side of the nipple. It rapidly increased in size, and in the course of twelve months attained the bulk of a small orange. The woman was seventy years of age. DISEASES OF THE BREAST IN TIIE MALE. The mammary gland of the male, although merely a rudimentary organ, is liable to the same diseases, benign and malignant, as that of the female, but only, as experience has shown, in very rare instances. The most frequent affections here, according to my obser- vation, are hypertrophy, induration, and neuralgia, which, indeed, are generally associ- ated, and are sufficiently common to render them objects of great practical interest. In 1859, not less than three cases of these diseases were at the same time under my care at the College Clinic, all the patients being young men otherwise in good health. In each the organ was very hard, decidedly enlarged, remarkably tender on pressure, and the seat of sharp, darting pains, liable to frequent exacerbations. Occasionally both glands are involved. The treatment of these several affections must be conducted upon the same principles as in cases of mammary neuralgia or irritable breast in the female. The result, however, is generally anything but satisfactory; for, although temporary amelioration may soon follow, it is only after a long time, and after frequent relapses, that permanent relief is obtained. The most trustworthy remedies are quinine, arsenic, and strychnia, with a minute quantity of bichloride of mercury, aided by occasional leeching, and the use of sorbefacient and anodyne plasters. Abscesses sometimes form in the mammary region of the male, either in the substance of the gland immediately below the integument, between the gland and the pectoral mus- 986 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII . cle, or beneath the latter, especially when the suppuration has been provoked by external violence, as a fall or blow. The diagnosis is generally easy, and the treatment sufficiently obvious. The breast of the male has been found to be enormously hypertrophied, forming a large, heavy mass at the front and side of the chest. It is also occasionally the seat of adenomatous, fibrous, cystic, sebaceous, and sarcomatous tumors. The sarcomatous growths sometimes ulcerate, throwing out fungous, cauliflower-like excrescences, which, indepen- dently of their alarming appearance, are more or less painful, and the seat of a fetid discharge. The proper remedy is extirpation. Of the carcinomatous diseases of the male breast, the most common is scirrhus ; encepha- loid is very infrequent, and the same is true of melanosis and colloid. Hard and soft carcinomas pursue the same course here as in the other sex ; they are most common in elderly subjects, and are generally easily distinguished by their external characters. A well-marked case of open scirrhus of the left mammary gland, in a man, seventy years of age, was recently shown to me by Dr. W. H. Webb. The ulcer was nearly two inches in diameter, very painful, and the seat of a thin, bloody, fetid discharge. Marked involve- ment of the axillary lymphatic glands existed. In another case, in a man fifty-six years old, whom I saw with Dr. S. W. Gross, the gland was very hard, shrivelled, and very firmly adherent, the disease having commenced eighteen months previously without any assignable cause. The nipple was retracted, ulcerated, and the seat of a thin, sanious discharge, along with sharp, darting pain. The general health was good, and there was no axillary involvement. In a third case, that of a man fifty-eight years old, the tumor, which was about the volume of a billiard-ball, was of a spherical shape, very hard, ulcer- ated, and the seat of sharp, stinging pain. The disease had been in progress about twelve months. One of the axillary glands was enlarged and indurated. The general health was unimpaired. Extirpation is nearly always followed by a recurrence of the disease, although usually not so soon as when it affects the female breast. In a remarkable case of melanosis of the male breast, in a man, eighty-two years of age, kindly communicated to me by Dr. William L. Newell, of New Jersey, the malady had taken its rise near the left nipple, in an old wart-like excrescence, which, in a fit of delirium, the patient had picked off eight months previously to his death. About four weeks prior to this event, the morbid growth had attained the volume of a large fist, and was attached by a pedicle nearly an inch and a half in diameter; it was of a black color, lobulated in shape, and of a soft, brain-like consistence. Ulceration gradually set in, and in a short time the whole tumor sloughed away, followed by a copious, black, and most offensive discharge. Secondary growths now appeared in the neighborhood of the original disease, and one also, about the size of a walnut, at the inferior angle of the left scapula. The whole mai’eh of the disease was painless, and the man died from sheer exhaustion, occasioned by the profuse discharge. I recently saw, in a man, thirty-five years old, a patient of Dr. Cullen, of Camden, New Jersey, a secondary carcinomatous formation in the left mamma, consequent upon the existence of a large encephaloid tumor of the corresponding axillary lymphatic glands. Numerous subcutaneous carcinomatous tubercles existed upon the abdomen, chest, neck, and shoulders. DISEASES OF THE BREAST IN THE INFANT. New-born infants are subject to a peculiar intumescence of the breast, consisting in inflammation of the glandular structure of the organ and of the surrounding cellulo-adi- pose tissue, the nipple, which is usually a good deal enlarged, forming the centre of the swelling. The part feels excessively hard, and is exquisitely tender on pressure. Under an erroneous supposition that the disease is caused by an accumulation of milk, the breast is often rudely squeezed; a circumstance which never fails to aggravate the morbid action. If improperly managed, suppuration may occur, as I have witnessed in a number of cases. Both breasts are sometimes involved. The disease generally appears within the first fortnight; sometimes, indeed, within the first few days, or at so early a period as to induce the belief that it is congenital. As it advances, the part becomes excessively painful, and the child is feverish and restless. The disease, in its incipient stages, generally readily yields under the use of sweet oil and laudanum with a little ammonia, applied warm, and rubbed on frequently with the bare finger. In the intervals the surface should be constantly covered with a thick layer of flannel saturated with a solution of chloride of ammonium, in the proportion of one CHAP. XVIII . GENERAL DIAGNOSIS OF MAMMARY TUMORS. 987 drachm to eight ounces of water and two of vinegar. When the disease is obstinate, or already far advanced, a leech may be applied, followed by a teaspoonful of castor oil. In the event of suppuration, an early puncture is made. AFFECTIONS OF THE MAMMARY REGION. The mammary region is subject to cystic tumors, either congenital or acquired, single or multiple, simple or compound. Their contents are variable, but, in general, they are strictly serous, and of a pale straw or amber color. Their volume ranges from that of a pea to that of an adult head; they fluctuate distinctly under pressure, are free from pain, and often grow7 with great rapidity. The most remarkable instance of congenital cyst of this region that I have ever wit- nessed occurred in a male infant, only three weeks old. The tumor was of a globular shape, and measured thirteen inches in circumference at its base; it was somewhat lobulated, soft, elastic, fluctuating, and translucent, like a hydrocele, the skin being perfectly sound, but traversed by several large veins. It was occupied by nearly a pint of yellowish, serous fluid, saline in taste, and readily coagulable by heat arid acids. A cure was readily effected by the use of a seton, consisting of a few silk threads retained for forty-eight hours. Tlie inflammation consequent upon the operation soon yielded to the use of satur- nine lotions and a dose of castor oil, and the little patient made an excellent recovery. Such a tumor might be laid freely open, and mopped with tincture of iodine, or stuffed with carbolized lint. The fatty tumor of the mammary region is uncommon. The only instance I have ever seen of it occurred in a sea-captain, in whom it was as large as an adult head. The growth is generally situated behind the gland, between it and the pectoral muscle, but cases occur in which it lies in front. The tumor is sometimes of enormous bulk. Thus, in a case observed by Sir Astley Cooper, it was thirty-one inches in circumference by ten and a half in length, and weighed upwards of fourteen pounds after removal. The difficulty of distinguishing such a tumor is strikingly exemplified in a case related by Brodie. A lady, he remarks, had a growth in her breast, concerning which she obtained the opinions of some of the leading surgeons of that day. “ One thought that it was fungus hematodes, another believed that it was something else, and another could not say what it was. At last it was decided to cut down on the tumor, and then it was found to be a great mass of fat.” It was situated behind the breast, which it had pushed out in such a manner as to give it an unnaturally prominent appearance. Mr. Birkett, of London, in 1868, showed me a fatty tumor in the museum of Guy’s Hospital, which had grown in front of the breast for fifty-two years, and which, by its pressure, had nearly destroyed the glandular tissues. The only remedy is extirpation, and, in performing the operation, care must be taken not to inflict any serious injury upon the breast. Other morbid formations, as sarcoma, keloid, epithelioma, and chronic abscesses, are liable to occur on various parts of the mammary region, but, as they present nothing peculiar, they require no special notice here. GENERAL DIAGNOSIS OF MAMMARY TUMORS. The diagnosis of the affections of the mammary gland is not only exceedingly important but often very difficult and embarrassing. Many a breast has been sacrificed under the supposition that it was affected with carcinoma w hen it was merely laboring under chronic abscess or induration dependent upon neuralgia, inflammation, or lobular hypertrophy. The diseases that are most liable to lead to error in diagnosis are, among the benign, chronic abscesses, neuralgia, hypertrophy, adenoma, myxoma, and fibrous tumors ; among malignant, scirrhus, encephaloid, and sarcoma. There is no possibility of confounding an acute abscess with any other disease. Its occurrence during early lactation, its rapid progress, the severity of the concomitant pain, the great swelling, the sympathetic disturbance of the system, and, lastly, the discolora- tion of the skin and the sense of fluctuation as the matter nears the surface, are always sufficient to distinguish its true character. In chronic abscess most, if not all, of the above symptoms are wanting. The disease, usually beginning in several hard nodules, is the work of weeks, if not months ; there is an increased size of the organ but no swelling, properly so called; the part has no un- natural heat; there is no discoloration of the skin, not even when the attack is of long 988 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. standing ; instead of pain, there is merely a sense of soreness or of weight; the general health is not materially disordered. Marked enlargement of the subcutaneous veins generally exists, especially in protracted cases, and may, unless great caution is exercised, be mistaken for that which so constantly attends confirmed enceplialoid. Neuralgia occurs early in life, generally from the eighteenth to the thirtieth year, and is usually associated with dysmenorrhoea and neuralgia in other parts ol the body, especially of the chest and abdomen. The breast is not materially, if at all, enlarged, but it is ex- quisitely tender on pressure, and several small nodules, hard, circumscribed and perfectly movable, are imbedded in its substance. They occasionally acquire a considerable bulk, especially if some of them coalesce. The general health is more or less impaired, and the patient is very nervous, often hysterical, and remarkably susceptible to atmospheric im- pressions. The nipple and axillary glands remain unchanged. Hypertrophy, especially when not exaggerated, might be mistaken for scirrhus or enceplialoid. The extraordinary bulk of the tumor, the natural appearance of the nipple, the absence of lymphatic involvement, and the lobulated character of the breast, together with its pedunculated configuration, caused by the manner in which it is dragged away from the chest, readily distinguish general hypertrophy from other affections. The sub- cutaneous veins are always excessively enlarged and tortuous. The sero-cystic tumor, most common between the twentieth and fortieth year, is charac- terized by the tardiness of its progress, by a sense of fluctuation, by the absence of pain and lymphatic disease, by the natural appearance of the nipple, and by the unimpaired state of the general health. In the multilocular form of the affection the diagnosis is sometimes very obscure, especially in its earlier stages; there is less distinct fluctuation than in the unilocular cyst; and the tumor has a more solid and heavy feel. Hydatids of the breast are very uncommon, and their diagnosis does not differ materially from that of the sero-cystic growth. More or less fluctuation necessarily exists; and, when the tumor is occupied by several bodies of this kind, a distinct fremitus, or friction sound, not unlike the creaking of new sole leather, may sometimes be elicited by rubbing the surface with the finger. When ulceration occurs, the microscope may detect the booklets of broken-down echinococci in the discharges. The lacteal tumor is recognized by its globular or ovoidal shape, its fluctuating feel, its rapid development, and its supervention upon delivery. Instead of pain there is a sense of distention or of uneasiness, and the general health is unimpaired. The tumor often acquires a large bulk in a short time. Fibrous and adenomatous tumors are not always easily distinguishable either from each other or from other affections. In general, however, their slow development, small size, the absence of adhesions and of lymphatic involvement, the normal appearance of the nipple, the firm, elastic character of the swelling, and the integrity of the general health, will suffice to determine the diagnosis. Both of these growths are peculiar to young sub- jects. In the adenomatous tumor, the morbid mass is always remarkably nodulated, and, consequently, feels as if it consisted of numerous bosses connected by fibrous tissue. The myxomatous growth, most common in middle life, is characterized by its soft con- sistence, limited discoloration of the skin, and by the occasional occurrence of deformity of the nipple, superficial adhesions, ulceration, dilatation of the subcutaneous veins, and en- largement of the axillary glands. Of the malignant affections of the mammary gland the only ones requiring any special notice, in a general diagnostic point of view, are scirrhus, encephaloid, and sarcoma. There are no reliable signs of colloid. The tumor is hard, inelastic, heavy, globular, or ovoidal, somewhat smooth upon the surface, and tardy in its growth, but capable of attaining a large bulk. The diagnosis is based mainly upon the principle of exclusion. I he different diagnosis of scirrhus and encephaloid will be most easily understood if exhibited in tabular form. SCIRRHUS. 1. Increases slowly, and is occasionally almost stationary. 2. The breast is seldom much enlarged, except when there is an unusual quantity of fatty matter around it. 3. The tumor is hard, firm, incompressible. 4. Retraction of the nipple is an early and pro- minent feature. ENCEPHALOID. 1. Extends rapidly, and never stops in its ca- reer. 2. Great bulk is one of the characteristic fea- tures of enceplialoid. 3. The breast is soft and elastic, feeling, at cer- tain points, as if it contained a fluid. 4. The nipple often retains its natural appear- ance, even late in the disease. CHAP. XVIII. GENERAL DIAGNOSIS OF MAMMARY TUMORS. 989 SCIRRHUS. 5. The breast, early in the disease contracts firm and extensive adhesions to the sur- rounding parts. 6. The axillary lymphatic glands are always seriously involved during the progress of the disease. 7. There is no marked enlargement of the sub- cutaneous veins. 8. The pain is sharp, or lancinating, and begins early in the attack 9. The ulcer has an excavated appearance, with steep, sharp, everted edges, and a foul bot- tom. 10. The discharge is thin and sanious, or sero- sanguinolent, and never very copious. 11. There is seldom any decided bleeding, ex- cept when a vessel of considerable size is eroded. 12. The general health rarely suffers seriously until late. 13. Secondary scirrhous tubercles frequently form in the skin of the breast in the last stage of the disease. 14. The patient lasts, on an average, twenty- seven months. ENCEPHALOID. 5. Adhesions also form early, and they are very extensive. 6. The glands rarely suffer until after ulcera- tion sets in. 7. The vessels under the skin are sometimes greatly enlarged, and sometimes very tor- tuous. 8. The pain is dull or ohtuse, and seldom con- siderable, until ulceration begins. 9. The ulcer presents similar appearances, and is liable to bleed. 10. Is always very abundant, bloody, or sero- sanguinolent, like the washings of meat, and of a nauseous, almost insupportable odor. 11. Hemorrhage is frequent, and often very co- pious and exhausting. 12. Early constitutional involvement and carci- nomatous cachexia. 13. Similar appearances are witnessed in ence- phaloid in the early stage of the disease. 14. Death usually occurs in eight or ten months. Soft, medullary, small-celled sarcoma is very liable to be confounded with encephaloid carcinoma, from which, however, it may be differentiated by its occurrence in young girls and in young, robust married women, by its remarkably rapid progress, by the enormous bulk which it attains in a short time, by its uniformly soft and apparently fluctuating feel, by its freedom from lymphatic involvement, adhesion to the subjacent tissues and retrac- tion of the nipple, by the marked enlargement of the subcutaneous veins, by its tendency to ulceration, and, finally, by the shorter duration of life. Cystic sarcoma, most common towards the thirty-third year in females, at first grows slowly, but afterwards increases rapidly, forming a colossal, irregular, lobulated, movable tumor, the consistency of which is very unequal. The distinction between ordinary solid tumors of the breast and the malignant forma- tions to which this organ is liable, although not always very easy, may generally be satis- factorily established, provided the exploration is conducted with the requisite care and attention. The chief diagnostic differences are the following :— Non-malignant mammary tumors are most common from the twentieth to the fortieth year; they are irregular in shape, lobulated, of unequal consistence, more or less movable, tardy in their development, and seldom tending to ulceration. There is no retraction of the nipple; the skin retains its natural color, but is often sensibly attenuated, there is no enlargement of the subcutaneous veins, except in extensive hypertrophy or cystic disease; the axillary and infraclavicular glands are unaffected; there is frequently a feeling of weight and distention, but seldom any actual pain ; and the general health is little, if at all impaired. In cystic affections, there is always some degree of fluctuation, and the insertion of the exploring needle is followed by an escape of serous or sero-sanguineous fluid. Non-malignant tumors incommode by their weight and bulk, but seldom prove fatal. In malignant growths the symptoms are completely reversed. The disease, especially in scirrhus, is seldom observed until after the fortieth year, and always advances rapidly. The tumor, of extraordinary hardness, and of uniform consistence, soon loses its mobility, and, gradually approaching the surface, ultimately breaks out into an open, intractable ulcer. The skin is discolored and indurated; the nipple is retracted; the axillary lym- phatic glands are more or less implicated; the pain, at first slight and occasional, soon becomes constant, and is of a sharp, lancinating character; the health suffers severely; and the countenance exhibits the peculiar carcinomatous cachexia. The disease is in- variably fatal, the period at which death occurs varying from twelve months to two years and a half. Rapidity of growth and inordinate bulk should always excite suspicion of malignancy, especially if associated with great enlargement of the subcutaneous veins and marked failure of health. A bloody, sanious, or ichorous discharge from the nipple is generally a sign of ill omen. When ulceration exists, a particle of the diseased structure may be clipped off, and examined microscopically with a view to the detection of carcino- matous structure. 990 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. EXCISION OF THE BREAST. A certain amount of preliminary treatment is always necessary in excision of this organ. In most cases, there is marked disorder of the secretions, which should, there- fore, be carefully corrected; the diet should be properly regulated ; and the bowels should occasionally be opened by a mild laxative, as blue mass and rhubarb, or the compound cathartic pill. The operation itself is generally a very easy and simple affair. It is only when the organ is much enlarged by disease, or when it is very vascular, that it is likely to prove annoying and embarrassing, especially if there is not a sutficiency of assistants. During its performance, the patient may either sit up or lie down; the latter posture I always prefer, as it gives us better control over the parts, at the same time that an anaesthetic may be administered with greater safety. In most cases, it will be necessary to remove a portion of integument, particularly if the breast is at all large, or if there is ulceration of the skin, either actual or impending. Hence the incisions, as shown in fig. 765, should usually be elliptical; and it will be well, if possible, always to make them in the direction of the fibres of the great pectoral muscle, as this will tend to facilitate both the liberation of the organ and drainage after the operation. The surgeon, however, is not always able to control this matter, owing to the peculiar condition of the parts, and he will, therefore, occasionally be obliged to make his incisions very oblique, or, indeed, almost perpendicular. In all cases, except when the growth is of a malignant nature, when it is rarely possible, an attempt should be made to save enough integument for the easy closure of the wound. The integument being properly stretched, and the arm held off nearly at a right angle from the body, the knife is thrust through the skin and cellulo-adipose tissue, and carried around the diseased mass in such a manner as to include every particle of it, the lower incision being always made first. The dissection is then performed in the direction of the fibres of the pectoral muscle, which should be thoroughly exposed by the removal of its aponeurotic envelop. If any arteries of considerable size spring, they should immediately be compressed by the finger of an assistant, and carefully tied as soon as the operation is over, together with any of the smaller branches that might afterwards become a source of hemorrhage. When the tumor is inordinately vascular, it may be prudent to ligate each vessel as soon as it is divided, but this is generally an awkward and unneces- sary proceeding. Before the parts are approximated, the wounded structures are ex- amined with the greatest care, in order that not the slightest particle of the morbid sub- stance may be left. The adjoining sketch, fig. 766, affords a correct illustration of the position of the patient in this operation, of the lines of the incisions, and of the mode of separating the morbid mass. In carcinomatous and sarco- matous tumors, the adjacent tissues, although apparently healthy, are, as a rule, infiltrated with cells. Hence all such growths should be thoroughly ex- tirpated, by including the breast, and its investing skin and fat in a circular incision, and by dis- secting the fascia off the pectoral muscles. Copious hemorrhage will be most likely to attend either of these operations when they are performed on account of bulky, cystic fibromas, adenomas, and sarcomas, and large carcinomas which have formed strong and extensive attachments to the subjacent and surrounding structures; even then, however, it may always be readily controlled by the pressure of assistants, until the morbid mass is completely liberated. If any of the lymphatic glands in the axilla are involved, they should be dealt with in Fig. 765. Fig. 766. Excision of the Breast. CHAP. X V 111. BANDAGES FOR THE BREAST. 991 the same manner as the breast itself, either by an extension of the outer angle of the incision, or by an incision immediately over the affected structures, which are then generally readily enucleated with the finger or the fingers and the handle of the scalpel. This is often the most difficult and dangerous part of the operation, especially when these bodies are much enlarged, very numerous, thoroughly matted together, or closely hugged by the axillary artery, nerves, and vein. If, in such an event, the point of the knife be used, very serious mischief will be likely to be done. The number of lymphatic glands in the axilla is much greater than is generally imagined. In one instance, in a case of scirrhus of the breast in a woman, forty-five years old, I counted as many as forty-eight, from the volume of a small pea to that of a partridge egg. They were very hard, dense, almost cartilaginous, and very easily enu- cleated. My rule of practice, after excision of the mammary gland, formerly was to keep the wound open for four or five hours after the operation, lest secondary hemorrhage should arise, and thus necessitate the removal of the dressing, the surface being covered, in the interval, with a light, soft cloth, frequently wet with cold water. Of late years, however, I have usually closed it as soon as all bleeding has ceased, and this, as a general rule, will be found to be the preferable method. In dressing the wound, care should be taken to use only a few stitches, and to press the flaps well down with long, narrow strips of ad- hesive plaster, aided by a compress and bandage, carried around the upper part of the chest. A tent or drainage-tube should always be inserted into the most dependent part of the wound, to facilitate the discharge of bloody serum, of which there will always be more or less after such a severe and extensive operation. The arm should be supported in a sling, or what will be better, secured to the side and front of the chest; the treatment should be gently antiphlogistic; and the dressings should not, as a general rule, be dis- turbed until the end of the third day, except in very hot weather, when it may be neces- sary to remove them much sooner. Any tendency to bagging during the after-treatment should at once be counteracted by a free incision at the most dependent portion of the flap. Experience has shown that re- tained secretions soon become a source of irritation, provoking fever, erysipelas, pyemia, and phlegmonous abscess. I saw, not long ago, a patient perish from this cause within four days after the operation. An enormous quantity of thin, foul, offensive matter had accumulated under the flap, causing rapidly destructive pyemia. In the more thorough operation, the large wound may be materially lessened by sutures and adhesive strips. The dressing consists of an oiled compress, which is substituted by a poultice in forty-eight hours, to favor the granulating process. When the wound is healed, the parts should be well protected with a thin satin quilt, or a tanned rabbit skin, especially during cold weather ; all pressure from the clothes should be prevented; and the corresponding arm should be constantly carried in a sling, to re- lieve the chest and shoulder of the weight of the limb. Very few women perish from the effects of this operation in private practice. Among hospital subjects, however, a fatal termination is by no means uncommon. The rate of death is about 10 per cent, for partial operations ; 7.69 per cent, for removal of the entire breast and its coverings ; and it should not exceed 10 percent, from amputation of the breast and extirpation of the axillary glands. The chief danger is from erysipelas, which occasionally occurs despite the greatest care both of the patient and of the surgeon. I have lost only two patients from this cause out of more than two hundred from whom I have excised the breast. Both were uncommonly fat, and both were impressed with the con- viction that they would not recover from the effects of the operation. Death may also arise from pleurisy, pneumonia,-pyemia, and diffuse suppuration. Fat, portly women, with large breasts, do not bear the operation as well as the more common class of subjects ; very nervous ones also sometimes run great risk. In general, however, the case proceeds favorably ; much of the wound often unites by the first intention; and the cicatrization is usually completed in from three to four weeks. BANDAGES FOR THE BREAST. The breast, like other organs, demands, when diseased, proper rest and support. The duty of the surgeon is very imperfectly discharged if he do not attend to these important points. For ordinary purposes the organ may be easily sustained with a light silk hand- kerchief, thrown around the opposite shoulder, and so arranged as to make equable pres- 992 DISEASES OF THE FEMALE GENITAL ORGANS. CHAP. XVIII. sure. When greater nicety is required, a special apparatus may be used, consisting of a silk or gum-elastic web, adapted to the shape and size of the gland, and secured to the Fig. 767. trunk by shoulder-straps and a body-piece, the mode of construction and application being similar to those of the suspensory bandage for the scrotum. A beautiful contrivance of this kind is made in this city at the Nurses’ Home. Strapping of the Breast. Fig. 768. Sling for the Breast. Sometimes the object may be advantageously attained by means of two broad adhesive strips, carried loosely across the breast, as in fig. 767 ; or by splitting a piece of old linen into two tails, one of which is fastened around the body, while the other is passed over the shoulder thus supporting the organ in the form of a sling, as exhibited in fig. 768. CHAP. XIX. GUNSHOT WOUNDS. 993 CHAPTER XIX. DISEASES AND INJURIES OF THE EXTREMITIES. GUNSHOT WOUNDS. Gunshot wounds of the extremities are of frequent occurrence in time of war, and commonly require much judgment for their successful management, as they involve every possible grade of injury from the most insignificant scratch to the most appalling mutila- tion. The collapse is often so great as to cause death, either immediately or within a very short period after their receipt, the system, perhaps, never making the slightest effort at reaction. In the inferior extremity the shock and danger to life are always proportion- ately greater than in the superior, gunshot wounds and fractures sharing, in this respect, the same fate as common wounds and fractures. These effects increase in a marked de- gree as the injury approaches the trunk, precisely as in amputations, those of the foot and leg being attended with much less risk than those of the thigh and hip. During the war in the Crimea, the ratio of mortality after amputations for gunshot lesions was, in round terms, 14 per cent, for the foot, 22 for the ankle-joint, 30 for the leg, 50 for the lower third of the thigh, 55 for the middle third of the thigh, and 8G for the upper third of the thigh, all amputations of the hip-joint having proved fatal. Gunshot injuries of the extremities may, very properly, be arranged under the follow- ing heads, according to the nature of the parts involved: 1st, Wounds simply or mainly of the muscles; 2dly, wounds of the vessels; 3dly, wounds of the nerves; 4thly, wounds of the joints ; and, 5thly, wounds of the bones. 1. Wounds of the Muscles. — Gunshot wounds of the muscles, or simple flesh wounds, are not, generally, of themselves dangerous, even when of large extent, but they may readily become so when they occur in a person of intemperate habits or im- paired constitution, or even when the health was excellent at the time of the injury, from exposure, fatigue, or improper management. Erysipelas will then be very liable to arise, fol- lowed by high excitement, and by the formation of large abscesses, the pus often burrow- ing extensively among the surrounding structures; ordinarily, however, such injuries will, for the most part, do well, the patient making a rapid recovery with a good use of the limb. Of upwards of three hundred cases of flesh wounds of the upper and lower extremities which I saw after the battle of Bull Run, very few died. Indeed, most of the men were able in a short time to return to duty. Shell wounds of the muscles are usually more dangerous than wounds made with rifle balls. In the hospital at George- town I saw a man, aged thirty-eight, who died at the end of seven days from a frightful wound on the outside of the thigh, at least ten inches in length by four in width, caused by the bursting of his musket. As an offset against this case, I may mention one which occurred during the Mexican war, in a young private of the 2d Kentucky Regiment, who made an excellent recovery, although it would be difficult to conceive of a more terrible flesh wound. Here the muscles of the right hip and of the outer and back part of the thigh, as low down as the popliteal space, were almost entirely torn away by a shell, which at the same time denuded the head of the femur and the femoral artery, the pulsations of which were distinctly perceptible at the inner side of the limb. Not- withstanding this horrible mutilation, rapid recovery took place, and when I saw the man, three months after the accident, the parts were nearly cicatrized, without much impairment of function. Flesh wounds of the shoulder and back, inflicted by gunshot, are not, in general, dangerous. Of twenty-six men belonging to one of the Kentucky regiments, who were injured in this situation at the battle of Buena Vista, in 1847, not one died. The ball in nearly all had penetrated the deltoid muscle, and, passing upwards over the shoulder, lodged in the neck and back, from which it was afterwards extracted. The treatment of such injuries resolves itself into the removal of foreign matter, and the use of water-dressing, with rest and elevation of the limb, and attention to the diet, bowels, and secretions. The eschars, if there be any, will usually separate in five or six 994 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. days, followed by healthy granulations, and there will seldom be any necessity for dilat- ing the parts, unless there should be excessive tension, as when they are invaded by erysipelas, or when matter forms and threatens to burrow among the neighboring structures. 2. Wounds of the Bloodvessels—The large vessels suffer much less frequently in gunshot wounds than might at first sight be supposed, their great resiliency enabling them to glide out of the way of the flying missile. An instance has been recorded by Mr. Guthrie in which a ball passed between the femoral artery and vein without dividing either. The fact is, this class of injuries is comparatively exempt from copious hemor- rhage. It is only when a large artery or vein is perforated that the patient, unless promptly succored, will be likely to bleed to death. To this, however, there is occasion- ally an exception. Thus Larrey mentions the case of a soldier who, struck on the infe- rior third of the thigh by a ball, experienced one severe hemorrhage, which was never repeated. The limb soon became cold, the popliteal artery ceased to beat, and the ex- tremities of the divided vessel could be felt when the finger wras pressed into the wound. Perfect recovery ensued. At the siege of Antwerp a case occurred in which both femo- rals were severed by a shell, and yet there was hardly any bleeding, although there was extensive destruction of the soft parts. Sometimes a vessel, instead of being opened, is merely contused and slightly lacerated, the ball grazing its coats, which, inflaming, may ultimately give way, and thus lead to troublesome, if not destructive, hemorrhage. Such an event, which it is not always in our power to foresee, but which may reasonably be anticipated when the missile has passed in the direction of a large artery without having occasioned any serious bleeding, is most liable to occur from the sixth to the eighth day, and is always greatly to be deplored, inasmuch as, arising at a period when it is not ex- pected, it may prove fatal before the necessary assistance can be rendered. It is, there- fore, highly proper, in all such cases, to keep the limb for several days constantly encir- cled with a tourniquet, the use of which should be fully explained to the patient and his attendants, so that there may be no serious loss of blood in the absence of the surgeon. A vessel, grazed by a ball, does not always, unless devitalized, give way under the effects of its injuries; on the contrary, the wounded part is often successfully repaired, or the canal at the site of the mischief is permanently obliterated by the formation of a clot of blood. The causes of secondary hemorrhage in gunshot wounds of the extremities are; 1st injury inflicted upon the vessel by the missile, or by a sharp spicule of bone ; 2dly, the, premature detachment of the clot, in consequence of sudden and violent bodily exertion, attended with great increase in the force and rapidity of the heart’s action ; and, 3dly, a want of plastic power in the blood, dependent upon the hemorrhagic diathesis, or the effects of an inadequate supply of vegetable food. The period at which the bleeding thus occa- sioned sets in varies, on an average, from five to twenty days. The treatment of a wounded artery consists in exposing it at the seat of the injury, and applying two ligatures, one above and the other belowr the opening. This should be done as speedily as possible after the accident, before there is any considerable inflamma- tion or swelling. Tying the vessel at its cardiac side alone will not suffice; unless it is secured also at its distal extremity, hemorrhage from the recurrent circulation will be in- evitable. The operation should be performed even when all bleeding has ceased, espe- cially if the patient is obliged to be transported to any distance. Venous hemorrhage may generally be effectually arrested by compression ; the ligature should be employed only in the event of its failure. When the wound involves the principal artery and vein of a limb, amputation will generally be required, in anticipation of the mortification which is so liable to occur in such an event from the interruption of the circulation. The operation, in fact, is some- times demanded even when only one of these vessels is severely injured. 3. Wounds of the Nerves—Unless the nerve is very large, a gunshot w'ound of it wrill not be likely to eventuate in any trouble, beyond a slight temporary paralysis or loss of sensation. Under opposite circumstances, however, the mischief may be very great; for then there may be, in addition to these effects, danger of mortification from the interrup- tion of the nervous fluid, just as a limb may perish from the want of blood when its main artery has been divided. The mortification, in such a case, may be direct, that is, it may be caused by the mere suspension of the nervous power of the parts, or indirect, through the medium of inflammation ; the latter being the more common. Occasionally a gunshot wound of the nerves is followed by severe neuralgia, lasting, perhaps, for years, if not during the remainder of life. CHAP. XIX. GUNSHOT WOUNDS. 995 In the English army in the Crimea, only 23 eases of gunshot wounds of the brachial plexus and larger nerves, as the median, ulnar, and sciatic, are reported to have occurred; of which 9, or 41 per cent, of the whole, proved fatal. The cause of death in 5 of the cases was tetanus. Partial division of the nerves was sometimes followed, especially in the upper extremity, by total loss of sensation and power, which, although occasionally recovered from, often ended in atrophy, or atrophy and contraction of the muscles, with permanent disability of the limb. Valuable light was thrown upon many of the more remote effects of gunshot injuries of the nerves by the observations of Dr. S. Weir Mitchell and his colleagues, Dr. Morehouse and Dr. Keen, during the late war, at the Army Hospital for Diseases of the Nerves, in this city. Among the more remarkable of these effects, some of which had previously escaped attention, are the changes which the skin and its appendages undergo from the impairment of their nutritive functions. The skin is shrunken, glossy, discolored, par- tially deprived of cuticle, and so exquisitely sensitive as to render it intolerable to the slightest touch. These phenomena are particularly conspicuous in the hands and fingers ; they also occur, although less distinctly, in the feet and toes. The skin looks as if it were tightly stretched; little spots, or patches, of a reddish, purple, or bluish color, exist upon its surface; and it is not uncommon to meet with minute cracks, fissures, and vesi- cles, similar to those observed in eczema. Conjoined with these affections are generally loss of hair and incurvation of the nails, the latter being often so remarkable as to be almost pathognomonic of this class of injuries. Ulcerations, of an obstinate, painful cha- racter, often exist at the edges of the nails, and add greatly to the patient’s suffering. A curious circumstance, first noticed by the above observers during our late war, is that the subjects of a gunshot wound, involving the nerves of the arm, axilla, or neck imme- diately fall to the ground, without losing consciousness. The shock thus occasioned is doubtless due to the connection which naturally exists between the axillary plexus and the inferior cervical ganglion, which also furnishes the inferior cardiac, or principal inhi- bitory nerve of the heart. The joints are often swollen, stiff, tender, and painful; the tissues around are indu- rated, from interstitial deposits ; and troublesome, if not permanent, ankylosis frequently ensues. Among other phenomena noticed by Dr. Mitchell is a remarkable burning pain in the hands and feet, especially on the palmar surface of the former, and the dorsum of the latter; coming on at a variable period after the receipt of the injury, lasting for a longer or shorter time, and generally referred to the skin or superficial structures. It varies in degree from the most trivial burning to exquisite torture. It is aggravated by exercise, by dependency of the part, and by exposure to heat and dry air, but relieved by cold and moisture. When these affections exist in a high degree, they are always attended with marked disorder of the constitution, loss of sleep and appetite, derangement of the secretions, irritable temper, and excessive impressibility to atmospheric vicissitudes. They may be caused apparently by the most simple hardly less than by the most severe injuries. In many cases they follow upon the most trivial contusions. It is not always easy to decide upon the proper course of treatment in gunshot wounds of the nerves. In the milder cases, the same plan should be adopted as in common flesh wounds. If the nerve is completely, but irregularly, divided, or much contused and lacerated, the safest procedure will be to cut off its ends smoothly, and to tack them nicely together with the silver-wire suture, hoping for ultimate reunion through the agency of plastic matter; but if the intervening space is considerable, such treatment would, of course, be improper. If the main nerve of a limb is completely severed, amputation may be required, especially when the injury is complicated with lesion of an important vessel; but, even then, the surgeon should greatly hesitate before he undertakes so terri- ble an operation. For the more remote effects of these injuries much may be done by attention to the general health, the use of tonics and alterants, change of air, and the correction of the secretions. The burning pain and hyperesthesia of the skin are most effectually relieved by thorough vesication, first with liquid ammonia, and afterwards with cantharides, along with hypodermic injections of morphia, and cold-water dressing. Dr. Mitchell has found all other means, both local and constitutional, perfectly inert and unreliable. In some of his more obstinate cases he was obliged to employ as many as six, eight, or even ten blisters before he was able to make any very decided impressions upon the disease. 4. Wounds of the Joints.—The gravity of gunshot wounds of the joints has been 996 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. recognized by all practitioners, military and civil, since the invention of firearms. The principal circumstances influencing the prognosis are the size and complexity of the articulation, the extent of the injury, and the state of the system and previous health of the patient. A gunshot wound of a ginglymoid joint is, in general, more dangerous than one of a ball-and-socket joint, and a gunshot wound of the hip, knee, and ankle, than one of the shoulder, elbow, and wrist. The structures around the articulation often suffer severely, thus adding greatly to the risk of limb and life. Of 65 cases of gunshot wounds of different joints, related by Alcock, '33 recovered, but of these 21 lost each a limb. Of the 32 that died, no operation was performed upon 18. Gunshot wounds of the smaller joints often do well, although they always require long and careful treatment. Lesions of this kind involving the shoulder are frequently amenable to ordinary means. If the ball lodge in the head of the humerus, as in fig. 769, it should be extracted without delay, its retention being sure to excite violent inflammation in the soft parts, and caries or necrosis in the bone, ultimately necessitating amputation, if not causing death. If the bone is at all shattered, the proper operation will be resection. Gunshot injuries of the elbow generally do well under resection ; it is only when there is extensive lesion of the soft parts, along with great comminution of the bones, that amputation will be likely to be required. Similar remarks are applicable to gunshot injuries of the wrist and car- pal joints. Gunshot wounds of the hip, knee, and ankle joints are always to be considered as serious accidents, very liable to be followed by loss of limb and life. The danger is a hundredfold increased when there is severe involvement of the articular extremities of the bones, as in fig. 770. Gunshot wounds of the knee are the most dangerous of all. Of upwards of forty cases of this kind in the French hos- pitals in the Crimea, in which an attempt was made to save the limb, all, except one, proved fatal. Of nine cases which occurred in India, not one was saved. Guthrie never saw a gunshot wound of the knee-joint, at- tended with severe injury of the bones, recover without removal of the limb; the experience of Lai'rey was of the same nature; and Esmarch declares, as the result of his observa- tion in the Schleswig-Holstein cam- paigns, that all lesions of this descrip- tion demand immediate amputation of the thigh. Frightful injury is sometimes in- flicted upon a joint indirectly, as when a ball, passing through the extremity of a long bone, causes a fissure which extends through the synovial mem- brane, as in fig. 771. Occasionally the missile traverses a joint, channel- ling a groove into the articular car- tilage, but not inflicting any serious lesion upon the integument. Such accidents, although, perhaps, apparently insignificant, are often followed by the most vio- lent inflammation, imperilling both limb and life. Patients sometimes perish from secondary involvement of a joint, its structures taking on fatal action in consequence of a severe wound in its immediate vicinity. Lastly, an articulation may suffer terribly from gunshot injury without any external wound, as when it is struck by a partially spent ball or shell. binder such circumstances, indeed, as has been shown by Ledran, Legouest, and others, a joint may be completely dislocated, and yet the integument remain intact. ’W hen, in the more violent forms of these articular injuries, an attempt is made to save the limb, the patient often perishes within the first three or four days, from the conjoined effects of shock, hemorrhage, and traumatic fever. If he survive for any length of time, large abscesses are liable to form in and around the joint, the matter burrowing exten- Fig. 769. Ball imbedded in the Head of the Humerus. Fig. 770. Fig. 771. Bones of the Knee Fractured by an Impacted Bound Ball. Perforation of the Femur with Fissure into the Joint. CHAP. xix. GUNSHOT WOUNDS. 997 sively among the muscles, and causing detachment of the periosteum, with caries and necrosis of the bones. From all, then, that precedes, it may be assumed, as a general proposition, that, in the milder cases of these injuries, especially as they occur in the more insignificant joints, the ordinary precepts of conservative surgery should be enforced; whereas, under oppo- site circumstances, it will usually be necessary either to resect the articular extremities of the bones, or to remove the limb at a suitable distance above the seat of the injury. Excision is adapted chiefly to gunshot wounds of the joints of the superior extremity, while amputation is more frequently required in those of the inferior extremity. All large wounds of the knee-joint, or even comparatively small ones, if they involve the epiphysis of the femur or tibia, imperatively demand the latter operation; and few cases of gunshot injuries of the ankle will be likely to arise on the field of battle in which such a procedure would not be preferable to excision. 5. Wounds of Bones The effects of balls upon the osseous tissues are subject to great diversity. In the first place, the injury may be very superficial, involving merely the periosteum or this membrane and a little of the compact substance of the bone; or, secondly, the missile may simply strike the bone, causing more or less severe concussion of its substance without penetration, but yet inflicting a sufficient amount of mischief to induce violent inflammation, terminating in abscess, caries, or even necrosis; or, thirdly, the ball, as it courses along, may plough a groove into its surface, also liable to be fol- lowed by bad effects; or, fourthly, the ball may produce a partial fracture, without complete detachment of the fragment, as represented in fig. 772; or, fifthly, the vul- neratingbody may enter the bone, breaking and comminuting it, as in fig. 773, each fragment, as it is driven about among the soft parts, becoming thus an additional source of injury. The old round ball often glanced when it came in contact with a bone, but the Minie ball almost invariably per- forates it, grinding it at a fearful rate, and so producing the very worst fonn of compound fracture. The number of fragments is extremely variable ; thus, there may, on the one hand, be only two, three, or four, or, on the other, as many as a dozen or twenty, or even thirty. Their size, too, is very indefinite. Some of the fragments may be entirely detached, while others may retain their connection with the main body of the bone, either by osseous tissue or through the periosteum. A long bone, instead of being broken, may be simply perforated. Hennen relates two cases in which the shaft of the femur was thus pierced, and three cases are referred to by Esmarch in which a similar accident befell the upper third of the tibia. The lesion has also been observed in the humerus, radius, and ulna. A bone is sometimes terribly shattered by a large stone, set in motion by a round shot, or a fragment of shell. Occasionally, again, a severe fracture is produced by a ball in ricochet without any apparent injury whatever of the integument, as in a case which I saw at Washington, in a sergeant of Rickett’s Battery, who was struck in this way on the arm by a twelve-pound shot, which broke the humerus at three different points, but did not even bruise the skin. In the treatment of this class of injuries, the first object, if the limb can be saved, is to stanch hemorrhage, and to extract any loose splinters of bone that may be present. The wound should be thoroughly examined with the finger, the patient being, of course, under anaesthesia, and no efforts should be spared to place the parts in the best possible condition for early reunion. A superficial exploration is worse than useless. The work Fig. 772. Fig. 773. Partial Longitudinal Fracture of the Femur by an Impacted Conoidal Ball. Comminution o the Humerus by a Conoidal Ball. 998 DISEASES AND INJURIES OF THE EXTREMITIES. chap, xix. must be done thoroughly and promptly, otherwise the patient will he subjected to immense pain and suffering, if not to ultimate loss of limb and life. I am satisfied from what I have seen of such cases that these injunctions are frequently most shamefully neglected. In the milder forms of the injury, the treatment must be conducted according to the ordinary rules of practice; by rest, elevation, and medicated water-dressings, conjoined, if necessary, with leeches and scarification, especially if erysipelas should arise. If the bone is severely broken and comminuted, resection, or amputation, will probably be re- quired, and should be performed at once, as soon as reaction is sufficiently established. Gunshot fractures of the femur are particularly dangerous, especially when inflicted with the Minie ball, and frequently demand amputation on account of the frightful shattering of the bone, causing not only great shock, but, if the patient survive, rapid and exten- sive swelling of the soft parts, followed by copious infiltration of pus. In the Crimea, a bad compound fracture of the thigh was considered as synonymous with death ; and the surgeons of the Black Sea Fleet never attempted to save a limb after such an injury, except at the risk of the patient’s life. Stromeyer, in commenting upon the subject, de- clares that gunshot injuries of the shaft of the femur are among the most dangerous lesions of the bones, and he adds that they are particularly liable to end unfavorably when they are produced by a piece of exploded bomb or a grazing cannon ball, without division of the soft parts. Numerous instances, one of which is represented in fig. 774, occurred, during the late war, of recovery from gunshot fractures of the middle and upper third of the thigh, with a very useful, although generally a much shortened and de- formed, limb. Not less than half a dozen of such cases came under my immediate observation at the George Street Military Hospital of this city; and hundreds of similar instances can attest the skill and attention of our army surgeons elsewhere. The most simple treatment alone is usually admissible in this class of injuries. Hardly any apparatus is required, beyond a few short splints at the seat of fracture, and two long, broad ad- hesive strips to secure the limb to the foot of the bedstead. Sometimes a long bracketed splint may advantageously be ap- plied. Occasionally the limb may be suspended in a sling, or supported with a Smith’s anterior splint; but the straight posi- tion will generally be found to be most comfortable to the patient, and best adapted to a good union. The requisite de- gree of counterextension may generally be readily made by sim- ply elevating the foot of the bedstead. The wound must, in bad cases, be dressed at least twice a day, dead bone removed as soon as it is detached, and bagging of matter prevented by suit- able counteropenings and the use of the bandage. A ball impacted in the superior extremity of the femur is very liable to be followed by abscess of the joint and caries, if not also necrosis, of the bone, necessitating amputation. In the medical museum at Netley, England, is a preparation in which an old matchlock ball was lound firmly imbedded in the head of the femur three weeks after death, caused by tetanus. The missile had entered opposite the great trochanter, and passed through the biim of the acetabulum. The capsular ligament was filled with pus and splinters of bone. In the case of an officer, narrated by Larrey, a ball remained in the neck of the femur for twenty years, the man finally dying of disease of the chest. Gunshot fracture of the supei ior extremity of the bone, extending into the articulation, almost inevitably gives rise to violent inflammation and profuse suppuration, followed, if left to nature, by hectic irritation, pyemia, erysipelas, and osteophlebitis. A remarkable instance of recovery of gunshot fracture of the thigh occasionally occurs when the condition of the limb is apparently in the most desperate condition. Of this description was the case of Lieut. Adams, detailed in the chapter on gunshot wounds. "I he injury could hardly have been more frightful, and yet he got well with a very useful imb. An example like this should certainly serve to admonish the military surgeon not to sacrifice indiscriminately every limb, even when the injury is apparently of the most hopeless nature; unfortunately, however, he cannot always, on the field of battle, carry out the dictates of his judgment; everything around him is unpropitious, and lie is, there- 01 e, olten compelled to use the knife in cases which, under more auspicious circum- Fig. 774. Consolidated Gunshot Frac- ture, with shortening of four inches. CHAP. XIX. GUNSHOT WOUNDS 999 stances, as it respects locality, air, nursing, and after-treatment, lie might possibly have saved. Gunshot fractures of the patella, unless attended with great comminution of this bone, and penetration of the knee-joint, do not necessarily require amputation. The cases observed by Hennen, Stromeyer, Tripler, and other military surgeons, show that such acci- dents are often followed by excellent recoveries. Extensive laceration, on the contrary, of the ligament of the patella, with wound of the synovial membrane, will usually result badly if an attempt be made to save the limb. Gunshot fractures of both bones of the leg are also, generally speaking, bad accidents ; great swelling, followed by diffuse abscess, usually rapidly sets in, and, unless, the patient is peculiarly fortunate, he will be very apt to sink under the effects of erysipelas, pyemia, osteomyelitis, or hectic irritation, not to say anything of the danger of mortification, which is often very great, especially when the bones are comminuted, at the same time that severe injury has been sustained by the soft parts. Gunshot fracture of the fibula alone is usually much less serious than similar injury of the tibia. Gunshot fractures of the tarsal bones are generally grave accidents, liable, if an attempt be made to save the limb, to lead to very serious consequences, especially when the injury has been inflicted by a Minie ball or a piece of shell. I have seen several instances of the kind caused by the common round ball, which were promptly followed by tetanus and death, and such occurrences are by no means infrequent in military practice. Gunshot fractures of the ankle-joint nearly always demand primary amputation. This is especially true of comminuted injuries of this kind. Gunshot fractures of the arm, forearm, and hand are, compared with similar lesions of the inferior extremity, generally of a much less grave character, requiring, on the one hand, much less frequently amputation, and admitting, on the other, much oftener of re- section. A great deal, of course, will depend, in every case, upon the extent of the com- minution and the amount of injury sustained by the more important soft structures. A very terrible form of contusion is sometimes inflicted upon the upper extremity of artillerymen by the premature explosion of the gun in the act of loading; causing exces- sive commotion of the entire limb, horrible laceration of the soft parts, and most exten- sive infiltration of blood, accompanied, in many cases, by comminuted fracture, and pene- tration of the wrist and elbow-joints. The constitutional shock is usually great. If an attempt be made to save the parts, diffuse suppuration, and more or less gangrene, will be sure to follow, bringing life into imminent jeopardy. The proper remedy is amputation, performed promptly at a considerable distance above the apparent seat of the injury, otherwise mortification will be apt to seize upon the stump. Gunshot fractures of the extremities are often attended with frightful hemorrhage, in consequence of the injury sustained by the soft parts from the loose splinters which are often driven about in every direction. The blood may proceed altogether from the smaller vessels, and the amount effused may be such as to cause the most extensive infiltration of the connective tissue, both beneath the skin and among the muscles; or a large artery or vein may be opened, producing great distention of nearly the entire limb, especially if there is accidental closure of the wound. The parts will be found, immediately after the occurrence, to be cold and numb, and of a remarkably pale appearance, soon succeeded by a mottled, purplish hue, and this, in turn, if the patient survive, by a greenish or brownish color. When an attempt is made to preserve the limb, the first duty is to extract all the loose pieces of bone, and the second to place the ends of the fragments in accurate apposition, retention being afterwards effected in the usual manner. Special attention must be paid to drainage and cleanliness. Splinters, unless very small and sharp, that still retain a decided connection with the parts, whether by osseous matter or periosteum, should not be molested, as they will in all probability soon unite, and thus afford important aid in the process of repair. If they are thrown off during the suppurating stage, it will be sufficiently easy to extxact them through the sinuses in the soft structures. At all events, it will be well, in every case, not to be overofficious; for by too much cutting and pulling an enormous amount of harm may be done, not only by causing improper waste of blood, but by interrupting nutrition, and permitting too free access of air. When, in addition tosex-ious injury of the bones, there is extensive infiltration of blood, the case may generally be regarded as a bad one, likely, if an attempt be made to save the limb, to eventuate in mortification. In the slighter forms of the accident, the blood will usually rapidly disappear under the use of the roller and of spirituous lotions. 1000 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. In the treatment of gunshot wounds of the carpus and metacarpus, the greatest care should be taken to pick away every particle of loose bone, and to place such pieces as are retained in the most suitable position for accurate and speedy reunion. Unless this be done, the hand will become enormously swollen, numerous abscesses will form, and the soft parts will be so completely matted together by lymph and new osseous matter as to render them permanently stiff and useless. Similar measures should be adopted in the treatment of gunshot injuries of the tarsus and metatarsus. If amputation be advisable, it must not be performed too near the seat of the injury, as the effects of the mischief often extend much farther than the eye can discern, especi- ally when it has been inflicted by a shell or heavy ball. The proper time for performing the operation is the moment sufficient reaction has taken place. AFFECTIONS OF THE NAILS. When a nail is torn away along with its root, perfect regeneration is, of course, im- practicable; a slight attempt at reproduction may occur, but nothing more. When the matrix remains, a new nail, generally as smooth and perfect as the original one, will in due time be formed. The period required for the development of the nail of the thumb, in this condition, is, according to my observations, about four months and a half, a few weeks less being required for the nails of the fingers. Wounds of the nails, whether transverse, oblique, or longitudinal, possess the peculi- arity of being insusceptible of repair. The transverse and oblique always disappear with the natural growth and extension of the nail, and the same is true of the vertical, except when it extends through the entire matrix of the nail, when it invariably remains as a rough, irregular fissure, causing more or less permanent inconvenience. Contused and lacerated wounds of the nails are always excessively painful, and are often followed by severe inflammation and even considerable suppuration. They should be treated in the usual antiphlogistic manner, with special attention to rest and elevation of the part. If matter form, an early opening should be made for its evacuation. The blood which is so often effused under the nail in external injury generally disappears spontaneously; should it remain, and cause painful pressure, an operation may be neces- sary. . Splinters of wood, pieces of glass, and other foreign bodies are liable to be forced under the nails, causing violent pain and severe nervous symptoms, followed, if not speedily removed, by a bad form of inflammation. Extraction may generally be easily accomplished with the common dissecting forceps, but I have sometimes found it necessary to make quite an extensive incision before dislodgment could be effected. The nails are liable to be seriously affected by different mechanical occupations, as dying and tanning, becoming short, thickened, fissured, tender, and painful. In herpetic diseases they are often very short, scaly, and of a thick, rounded, button-like form. In Polish plait, the nails both of the fingers and of the toes sometimes acquire an extraordi- nary bulk, and a yellowish, livid, or black complexion. In strumous persons they are occasionally deeply grooved, enlarged, and of a firm, horny consistence; and the changes which they now and then undergo in tertiary syphilis are well known to every one. In paralysis of the limbs their growth is often temporarily arrested, especially if dependent on softening of the brain. Some of these affections admit of relief, while others are either partially or wholly in- curable. In all cases, the first object should be to get rid of the exciting cause, when the morbid action will often disappear under the most simple applications. When the disease, whatever it may be, is at all obstinate, or of long standing, the local treatment must be conjoined with internal remedies, of which the most valuable are iodide of potassium and mercury, especially when there is a strumous or syphilitic taint. The best topical means are lotions of copper, tannic acid, chloride of zinc, and bichloride of mercury. Zinc oint- ment is also of great value, and in some cases signal benefit accrues from the dilute oint- ment of nitrate of mercury. To keep the nails in a sound condition it is impossible to bestow too much attention upon them in the way of cleanliness and paring. It is the neglect of these precautions that entails so much disease upon them among the lower classes of people. CHAP. XIX. ONYXITIS. 1001 ONYXITIS. Onyxitis usually begins in a small circumscribed swelling of the ungueal matrix, attended with more or less pain and discoloration of the skin. A narrow ulcer or cleft soon appears at the root of the nail, and gives vent to a thin, ichorous fluid. The sore gradually ex- tends, until it finally involves the whole of the ungueal matrix, or even the entire nail. The surface has a foul, dirty aspect; the margin is thin and sharp; the discharge is irri- tating and offensive. The skin around the ulcer is indurated, tender, and livid ; the nail is yellowish, brownish, or black, dry, and disfigured; and the affeted member, often twice or thrice the normal size, has a peculiar bulbous appearance. In some instances the nail becomes loose, and ultimately drops off. The pain, which is generally slight, is occasionally so excessive as to deprive the patient of appetite and sleep for days and nights together. The disease is slow in its progress, and may continue for many months before it is arrested. Although not strictly of a malignant nature, its tendency is to destroy the affected nail, and to produce serious changes in the surrounding structures. Onyxitis is most common in the great toe, thumb, and index-finger. It commonly occurs before the twelfth year, chiefly in scrofulous, ill-fed subjects, or in children whose Fig. 775. Fig. 776. Onyxitis of the Index Finger. system lias been deteriorated by syphilis. The fact is there is reason to believe that it is generally, if not inva- riably, merely one of the more remote hereditary effects of this complaint. External injury, as a bruise or punc- ture, may provoke the disease, but in most instances it it arises without any assignable cause. The health often suffers in onyxitis, and the secretions are almost always considerably disordered. The annexed drawing, fig. 775, from a clinical case, conveys an excellent idea of this affection as it occurs in the great toe, and fig. 776, from Druitt, as it shows itself in the finger. The treatment of onyxitis is sufficiently well established. After the bowels have been cleared out, and the secretions restored, the system should at once be brought under the influence of mercury, carried to the extent of very slight ptyalism. The best prepara- tions are calomel and blue pill, the latter of which is usually preferable, because it is more mild and gradual in its operation. It may be administered two or three times a day, in the proportion of one or two grains at a dose, according to the age of the patient, with a small quantity of opium to prevent griping and purging. Bichloride of mercury with iodide of potassium is also an excellent remedy. As soon as the gums become tender, the medicine must either be entirely withheld, or used at longer intervals, and in smaller quantity. The effects of the mercury, however, should be steadily maintained, in a gentle form, for several successive weeks, otherwise the disease will be sure to reappear, or to resume its original character. The local treatment should be of the mildest description. The sore, washed several times a day with tepid water and soap, is kept constantly cov- ered with scraped lint, wet with a weak solution of chlorinated sodium, creasote, nitric acid, or compound tincture of myrrh and aloes, or, what is better than anything else, a solution of nitrate of lead. In some instances I have derived great advantage from the use of lime-water, containing two grains of bichloride of mercury and the same quantity of opium to the ounce. When there is much inflammation in the parts around the sore, warm water-dressing, or an emollient poultice, medicated with Goulard’s extract, will afford great relief. For a similar purpose balsam of Peru may sometimes be advantage- ously used. An ointment composed of two grains of arsenious acid and an ounce of spermaceti ointment occasionally acts almost as a specific. Now and then great benefit accrues from local mercurial fumigation. As soon as the ulcer assumes a healthy granu- Onyxitis of the Big Toe. 1002 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. lating aspect, the best application is opium cerate. The nail should be well trimmed, but evulsion is not necessary, except when the nail is devitalized or otherwise seriously diseased; nor is it proper to amputate the affected part, unless, after the cure is effected, it be found, by its bulk or unseemliness, to interfere with the convenience and comfort of the patient. SECT. I SUPERIOR EXTREMITY. 1. AFFECTIONS OF THE HAND AND FINGERS. The hand and fingers afford frequent opportunities for surgical interference, on account of deformities which not only greatly mar their beauty and symmetry, but seriously im- pede the exercise of their functions. These defects may be either congenital or acquired, being the result of various kinds of diseases and accidents, particularly paralysis and burns. The principal malformations met with here are, deficiency or redundancy of parts, a webbed condition of the fingers, and organic contraction of the muscles and palmar aponeurosis, constituting a species of distortion analogous to clubfoot. CONGENITAL IRREGULARITIES OF THE FINGERS. A deficiency in the number and size of the fingers is occasionally observed, one or two being entirely wanting, or they may be so stunted as to give the hand a very singular, unseemly appearance. In a case recently at my clinic, the fingers were all very short and stumpy, each being deficient in a phalanx. They were connected together by thick webs, smooth on the palmar surface, but rough and grooved on the dorsal, and were pro- vided each with an excellent, well-shaped nail. The thumb was small, but natural, and had no membranous attachment to the index finger. The person, a member of the medi- cal profession, enjoyed a very good use of the limb. In some cases there are only two fingers with a thumb; and I have seen one example in which there was but one. The members, under such circumstances, may be of the natural shape and size, or they may be variously changed in their appearance, being gen- erally thick and clumsy, or more or less contracted and stumpy. Occasionally they have a bulbous, knotty look, as if the umbilical cord had been twisted around them, and had thus interrupted their natural growth. The thumb, I believe, is rarely involved in these mis- haps. In one instance under my observation each hand had four fingers but no thumb. In a case communicated to me by Dr. D. M. Appel, U. S. A., there was total absence of the ring finger and of the corresponding metacarpal bone, the little finger standing off at an angle of about twenty degrees, and the middle one being flexed at the middle joint. The defect was evidently inherited, as the child’s maternal grandmother was simi- larly affected. In such a condition an operation similar to that for harelip would probably be advisable, the two sides being connected together by a series of sutures on the dorsal and palmar surfaces of the hand. A supernumerary finger is uncommon, while it is by no means rare to see an ad- ditional thumb, as in fig. 777. Such a freak is occasionally met with on both sides; and several cases have come under my ob- servation in which each hand had a super- numerary thumb, and each foot a supernu- merary toe, the individuals being, in other respects, perfectly well formed. Occasion- ally this redundancy of parts is associated with great stature, as in the case of the giant of Gath. Sometimes the occurrence is hereditary. An additional finger now and then exists in connection with the little finger. Forster has recorded a case of nine fingers in the same hand; Saviard one of ten ; Voight one of thirteen. Annandale saw a woman who had six fingers and two thumbs on each hand. These malformations are usually associated with a similar condition of the toes. Thus, a case has been communicated to me of a family of nine children, each of whom has six fingers on each hand and six toes on each foot, the father being similarly affected. An instance of double hand is occasionally witnessed. Fig. 777. Supernumerary Thumb. CHAP. XIX. WOUNDS OF THE HANDS AND FINGERS. 1003 The supernumerary member is generally a good deal smaller than the normal one, but well-shaped, and furnished with an excellent nail. Occasionally it is bulbous, knobby, curved, and very unseemly. Its attach- ment may be purely cutaneous, but in most cases it will be found to be through the medium of a separate joint, having a distinct synovial membrane. Congenital irregularities of the fin- gers and toes are occasionally associated ■with other malformations, as harelip, cleft palate, bifid spine, clubfoot, and hydrocephalus. In a case which I re- cently saw with Dr. Bournonville there was a double thumb on one side, with a stunted thumb, hand, and forearm on the other, and an imperforate anus, the rectum opening into the vagina. A deficiency of fingers is, of course, an irremediable affection. If the per- son belongs to the higher ranks of society, something may be done to supply it by the adaptation of artificial substitutes, secured to a glove, which, when worn, as it readily may be in company, shall hide the defect. Any supernumerary piece that may exist is readily taken away by a very simple opera- tion, care being taken to leave a sufficiency of integument to cover the wound, and to remove the part close to its attachment. When the finger is adherent by a narrow cutaneous pedicle, the best plan is to throw a ligature around its base and snip it off, as this will effectually prevent hemorrhage. I have seen two cases in which, a portion of the proximal phalanx being left, an unseemly projection remained, not at all creditable to the skill of the surgeon. The operation may be done within a few weeks after birth; if neglected until the person attains the age of manhood, he will be very apt to grow indif- ferent about it. A webbed condition of the fingers, fig. 778, is easily remedied by passing a bistoury vertically from below upwards, through the redundant fold, and, after having removed what is superfluous, tacking the edges of the wound together by several points of the interrupted suture, or allowing it to heal by the granulating process. The fingers during the cure are supported upon a carved splint, lint, spread with simple cerate, being inter- posed between them to prevent readhesion. Instead of the above procedure, which I prefer to any other, some surgeons adopt a method practised by Liston and others, which consists in piercing the web at its proximal extremity with a bistoury, inserting a foreign body, as a piece of India-rubber cord, into the wound, and dividing the remainder of the web as soon as the edges of the oi'ifice thus made are completely cicatrized. The chief advantage of this plan is that there is less danger of reunion between the two opposing surfaces than in the more ordinary method; its disadvantage is that it is more troublesome and tedious. Irregularities of the tendons of the hand and fingers are occasionally witnessed, and they may be of such a nature as to interfere more or less seriously with certain movements, or the performance of certain functions, as in a case recently in the practice of Professor W. A. Forbes, of this city. In this case the man, a pianist, experienced so much re- straint from the peculiar arrangement of the extensor tendons of the three ulnar fingers as to interfere materially with his occupation. The subcutaneous division of the offending cross slip resulted in immediate relief by affording the needed range of motion. WOUNDS OF THE HAND AND FINGERS. Wounds of the hand and fingers present themselves in a great variety of forms, as incised, lacerated, contused, punctured, and gunshot, and require essentially the same kind of treatment as similar lesions in other regions of the body. After the removal of foreign matter, their edges should be carefully approximated by suture and adhesive strips, when the parts should be supported upon a well-padded splint, extending from the inferior third of the forearm to the ends of the fingers, so as to place the wrist and phalangeal joints in the most easy and quiet position. If the fingers are fractured, the affected members may Fig. 778. Webbed Fingers. 1004 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. be placed in a hollow pasteboard splint. Unless the bones are comminuted and the soft structures extensively lacerated, it would be improper, as a general rule, to amputate. Most cases will do well under simple treatment. Even when a joint is pretty freely laid open, provided the articular cartilage has not sustained any serious injury, an attempt should always be made to save the parts. The same principles are strictly applicable to wounds of the carpus and metacarpus, involving the bones. Extraordinary recoveries often occur, especially in young, healthy subjects, in injuries of these parts under circum- stances apparently of the most adverse character. Wounds of the hand occasionally bleed very profusely, from involvement of the palmar arch, and, as the affected vessels are generally deep-seated, the hemorrhage is often checked with difficulty. The proper plan always is to enlarge the wound very freely, as early as possible, as a preliminary step, and to apply two ligatures, as a safeguard against the recurrent circulation. It is folly, in such a case, to tamper with the comfort and wel- fare of the patient by a resort to compression, whether direct or indirect, if the vessel is of any considerable size, as the bleeding will be sure to return whenever the mechanical support is taken off; and in this way quarts of blood may be lost before relief is finally afforded. Ligation of the radial and ulnar arteries will be equally unavailing, for blood will still be sent to the wound by the interosseous branch, and even if this also were secured, the probability is that the bleeding would still go on, especially if some time has elapsed since the occurrence of the accident, owing to the numerous and intricate anas- tomoses. We occasionally hear of cases in which the brachial artery has been tied for the arrest of hemorrhage of the palmar arch; but such a procedure is only justifiable when there is great swelling in the parts, obscuring the site of the bleeding vessels, and render- ing operative interference extremely difficult and painful. The advice of John Bell, in his Principles of Surgery, in regard to the treatment of wounded arteries in general, can- not be too strongly enforced here : “Meet the danger boldly, and don’t be afraid to look your enemy in the face.” When the hand is greatly swollen and inflamed, as it often is in these cases after the lapse of several days, an effort should be made to arrest the hemorrhage by acupressure, or percutaneous ligation, as it may be extremely difficult, if not utterly impracticable, to expose the bleeding vessel, and tie it in a satisfactory manner, owing to the softened and con- fused condition of the tissues. When these means fail, or are unavailable, the only thing to be done is to apply a thick compress directly to the wound, and another, at least three inches in length, to each artery of the wrist, the whole being confined by a roller extend- ing as high up as the elbow. The fingers should be well flexed and separately bandaged. The limb, bent at an acute angle, is secured in a sling to the chest. Mr. Edward L. Hussey, of Oxford, has reported the particulars of three cases of wounds of the palmar arch in which he successfully employed this expedient, and‘he is disposed to give it a decided preference over every other procedure in ordinary cases of hemorrhage in this situation. Sometimes a portion of a finger is torn off along with one of its tendons and, perhaps, also a portion of the fleshy belly of the corresponding muscle. If the two last bones are seriously involved, it will be best to amputate at the metacarpo-plialangeal articulation, otherwise an attempt should be made to save the finger, although it should turn out, as it will be likely to do, to be permanently stiff. The most suitable application in most cases of wounds of the hands and fingers is cold water, with the addition, if there be much contusion or laceration, of a little alcohol and laudanum. The dressings must not be disturbed too often, as such a procedure generally materially impedes the reparative process. In cleaning a fresh wound of the hand and fingers, the patient often experiences exces- sive pain from the use of cold water, especially if he is of a nervous, irritable temperament. For this reason, the fluid should always be tepid, and it may even be proper, under such circumstances, to dispense with cold water-dressing altogether for several hours after the receipt of the injury. Punctured wounds of the hands and fingers are often followed by distressing neuralgic pains and atrophy of the muscles, attended with great coldness of the surface, a sense of numbness, and stiffness of the joints. The immediate cause of these occurrences is the injury of some nerve from the prick of a needle, pin, scissors, splinter of wood, or piece of glass. The pain is frequently periodical, recurring once a day or every other day in regular paroxysms, often of the most violent character. It generally darts about in dif- ferent directions, but in many cases it is confined to the seat of the original injury, and is of a dull aching, gnawing, or boring nature, and accompanied with exquisite morbid sen- CHAP. XIX. CONTRACTION OF THE HAND AND FINGERS. 1005 sibility of the skin. Occasionally the pain extends as high up as the top of the shoulder, and the whole limb is cold, numb, and wasted. The constitution often suffers very severely, especially if the patient is of a strumous predisposition, or of a nervous, excitable .temperament, or if the health happen to be much impaired at the time of the accident. Obstinate neuralgia of the fingers sometimes occurs in sempstresses, type-setters, shoe- makers, and persons of similar occupation, from excessive fatigue incurred in the exercise of their particular vocation. The treatment of such lesions is seldom very satisfactory. The general health, if dis- ordered, must be corrected; and quinine, strychnia, and arsenic freely given when the neuralgia assumes a periodical type. The most suitable topical remedies are the hot and cold douches, leeches, veratria ointment, saturnine lotions, aconite, and chloroform lini- ments, with hypodermic injections of morphia. The parts must be kept at rest in an easy, elevated position, well protected from cold. Change of air is often very beneficial. Excision of the injured nerve is sometimes the only thing that affords permanent relief. Any vicious cicatrice should always be promptly removed. HYPERTROPHY OF THE FINGERS. Hypertrophy of the fingers, although uncommon, is now and then observed; generally as a congenital vice, but sometimes as an acquired one. It usually affects several fingers, either simultaneously or successively, the others remaining sound. All the component structures, hard as well as soft, are equally involved, and the result is that there is often great and inconvenient deformity, the parts being heavy, cumbersome, and, perhaps, nearly twice as thick and long as in the natural state. The affection, of the true nature of which we are ignorant, is occasionally hereditary, and it has also been observed in several members of the same family. The treatment consists of systematic compression and sorbefacient applications, as the tincture of iodine, and the ointment of iodide of lead. If these means fail, as they generally do, and the enlarged member is not only useless, but unseemly and inconvenient, the only resource is amputation. THUMB SUCKING. A bad habit into which infants not unfrequently fall, and which, in order to promote quiet, the nurse, and even the mother, often inconsiderately encourage, is thumb or finger sucking, more frequently the former than the latter, as it offers greater conveniences. Serious effects, both local and constitutional, are liable to be caused by this practice, especially if long continued; the former manifesting themselves chiefly in malposition of the teeth and deformity of the mouth and nose, and the latter in disturbance of the res- piration, interference with sleep, and the occurrence of nervous irritation. More or less deformity is also liable to show itself in the thumb or finger. The habit should be broken up as early as possible by fixing the elbow with a suitable strap so as to prevent the child from carrying the hand to the mouth. Any teeth that may be misplaced in this way should be gradually restored to their normal position by a systematic course of pressure applied several times a day with the mother’s finger, aided, if necessary, with gum-elastic cords for fastening the misplaced teeth to the adjacent sound ones. CONTRACTION OF THE HAND AND FINGERS. Permanent contraction of the thumb and fingers from gout, or rheumatism, burns, para- lysis, and other causes, is not uncommon, and is liable to be attended with the most dis- tressing deformity and inconvenience. Such a condition is sometimes the result of a congenital vice, as in fig. 779, from one of my clinical cases. The distortion may ex-ist in various degrees, and may be occasioned simply by a contraction of the flexor tendons, of the palmar aponeurosis, or of a diseased cicatrice, or all of these structures may be involved simultaneously. The inodular tissue left by burns and scalds has an astonishing contractile tendency, which often resists the most ingenious efforts of the surgeon to over- come it, and which, in time, is capable of producing the most horrible deformity, the fingers being bent like claws, deeply imbedded in the substance of the hand, or firmly united to one another. In paralysis, the fingers are frequently permanently flexed, in consequence of the shortened condition of the tendons of the flexor muscles, while the extensors are elongated, and completely deprived of their functions. 1006 DISEASES AND INJURIES OF THE EXTREMITIES CHAP. XIX. What is known as Dupuytren’s finger contraction depends essentially upon an abnormal condition of the palmar aponeu- rosis and of its digital processes. When this celebrated sur- geon, in 1832, published an account of this affection, he had. seen from thirty to forty cases of it, but had given a detailed history of only three or four. The subject was afterwards more fully elaborated by some of his pupils in their inaugural theses. In Great Britain attention was first prominently di- rected to it in 1877, by Mr. William Adams, in a paper read before the Medico-Chirurgical Society of London, the substance of which along with additional matter was afterwards incorpo- rated in a valuable and exhaustive memoir, issued two years later. In this country the first complete account of the affec- tion was published by Dr. W. W. Keen, in a lecture, rich in philosophical views, which he delivered before the Philadelphia County Medical Society, in January, 1882, and published in the Philadelphia Medical Times in the following March. In this address, Dr. Keen gave an analysis of 121 cases, including 23 observed by himself. Since then he has obtained the particulars of 26 other cases, making thus in all 147 cases, of which 106 were males, and 20 females, the sex in 21 not being given. Of 44 cases in which the age is recorded the contraction in 28 began after the fortieth year, in 9 between thirty and forty, and in only 7 before thirty. Hence, Dr. Keen concludes that the disorder usually arises at or after middle life. In a few instances it has been noticed as a congenital affection, and in a few also in several members of the same family. Of its hereditary nature there can be no doubt, as this fact is distinctly mentioned in nearly one-third of the recorded cases. In 72 cases in which the occupation is given, 18 occurred in labor- ing, and 54 in non-laboring persons. The hands are attacked in nearly equal proportion ; the thumb is sel- dom affected; and while any of the fingers may be in- volved, either singly or separably, the ring and little fingers are by far the most frequent sufferers. The great factors in the disorder are gout and rheu- matism ; but it is not improbable that certain occupa- tions may create a predisposition to the occurrence, espe- cially such as have a tendency to excite and keep up irritation in the soft structures of the hand. The imme- diate cause of the disorder is contraction of the palmar aponeurosis, and of its digital prolongations. This condi- tion is admirably illustrated in the annexed fig. 780, copied from the monograph of Mr. Adams, who obtained it from a specimen in the museum of St. Bartholomew’s Hos- pital. In fig. 781, from Druitt, the contraction is limited Fig. 779. Contraction of the Thumb. Fig. 780. Fig. 781. Deformity of the middle and ring fin- gers dependent upon contraction of the Palmar Fascia, which at a is stretched across the hand like the string of a how. b. Flexor Tendons lying deeply along the concavity of the curve, close to the bones, and bound down along the first phlanges of the fingers by the dense tubular sheath c, through which they pass ; d, Digital prolongations of the Palmar Fascia, ex- tending to the articulation between the first and second phalanges in each finger. Contraction of the Palmar Aponeurosis. to t he little finger. . The affected structures under the influence of long-continued inflam- ana interstitial deposits have become converted into dense, rigid cords, standing o , like so many bows, from the deeper parts, and thus exerting a powerful effect upon CHAP. XIX. CONTRACTION OF THE HAND AND FINGERS. 1007 the corresponding fingers. In many instances the contraction is so great as to flex the fingers at a right angle with the hand or even bury their tips partially in the palm. The skin is seldom involved; and the flexor tendons, formerly supposed to be chief, if not the only, cause of the contraction, generally retain their natural condition, although in some instances they are bound down by their sheaths into immovable cords, thus seriously complicating the nature of the disorder, and throwing additional obstacles in the way of a radical cure. The idea advanced by certain surgeons that the cords are due to bands wholly of new formation has not the advantage even of plausibility. The manner in which the affection usually sets in is thus graphically described by Dr. Keen. “ A man, usually of forty years of age or over, generally,without any assignable cause, will observe that his little or ring finger is slightly stiff. On making the attempt he finds that complete extension is hindered in some unknown way. If he be a man of quick observation, he may, perhaps, notice in the palm two or three little, bean-like, smooth, and slightly tender nodules in the axis of the affected finger, and that the skin is a little depressed in a crescentic pit at one or two places, usually about the head of the lowest or middle transverse palmar line. Gradually extending over several years, from four or five up to fifteen or twenty, but without any pain, the trouble increases. The little, hard nodules coalesce into what at last becomes a well-marked cord, extending to the finger, although the cord often forms without any such antecedent nodules, the skin becomes still further retracted, forming two or three very deep crescentic folds with the convexity upwards, sharply tipped by the cord, to which it is intimately adherent at its palmar edge with deep hollows on each side of it. The finger, which at first only had its extension limited, has slowly but surely flexed, until now the first two phalanges are each, it may be, bent at a right angle, so that the finger tip nearly touches the palm. Worse still, the immediate neighbors on one or on both sides have begun to flex, and are but little behind the first. Meantime, too, the other hand, at a varying interval of years, has probably suffered from the same deformity, so that at least one or, more likely both hands, are in part or wholly useless for most of the occupations of life. Kay, more, if he live to an advanced age, he may not only find the hand useless, but the finger-tips or finger-nails by further flexion may bore into the palm, producing painful ulcers, which, as in the case of a patient now under my care at eighty-five, may render life a burden.” The prognosis of this disorder is favorable in the milder cases, taken in hand early and properly managed. Even in many of the more severe forms excellent cures may be effected under judicious treatment. The tendency to recontraction is generally very marked, and no means should, therefore, be spared to counteract it. In regard to general and ordinary local treatment, in contraction of the palmar aponeu- rosis dependent upon gout or rheumatism, it is obvious that it can be of service only in the earlier stages of the disorder. When marked deformity has occurred nothing short of operative interference can do any good. The principal internal remedies are colchicum, salicylic acid, and the iodides along with bichloride of mercury, perhaps carried to gentle ptyalism. The best topical applications are tincture of iodine, leeches, and vesication with cantharidal collodion. When, by these and other means, the morbid action has been arrested, the adhesions should be broken up by forcible flexion and extension, followed by passive motion of the joints, and the maintenance of the straight position by appropriate appliances. Any occupation having a tendency to reproduce the contraction must, of course, be abandoned. The plan of treatment pursued by Dupuytren, and his pupils, was by direct incision and division of the offending bands, an operation always followed by suppuration and much suffering, seldom terminating in a complete cure. The method now pursued is the subcutaneous, suggested by Mr. Adams, and now so successfully practised by scientifio surgeons. Mr. Adams divides the resisting bands by several punctures with a very small tenotome, passed under the skin, and made to cut from above downwards, towards the dorsal surface. Sometimes as many as six or seven punctures are required ; and, to pre- vent the effusion of blood into the connective tissue, a pledget of lint should be placed over each as soon as the knife is withdrawn, and confined with a strip of adhesive plaster. The fingers should at once, if practicable, be extended to the full limit, and maintained in this position by appropriate appliances; as that, for example, represented in fig. 782, from Adams. In performing this part of the operation, which is generally so painful as to re- quire anaesthesia, care must be taken not to lacerate the skin at the seat of the puncture, as this would seriously endanger the cure by converting the subcutaneous wound into an open one. Care must also be taken not to interfere with the nerves and bloodvessels. The dressings are retained until the end of the third or fourth day, unless circumstances arise in 1008 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. the mean time to render their removal necessary. Mr. Adams suggests, what is very im- portant as tending to effect a good and rapid cure, that the extension should be continu- ously maintained, day and night, for at least three weeks, and afterwards at night only for a similar period. The hand and fingers should be well w'ashed eveiy twenty-four houis, Fig. 782. Adams’s Apparatus applied on the Dorsal Aspect of the Hand: a with two rack and pinion movements, opposite knuckles; b, and c, for making gradual extension. and the affected joints gently moved to promote restoration of function. The operation may be performed upon the palm of the hand and in immediate succession upon all the affected fingers or it may be limited to the palm and to one finger, as may be deemed most advisable. Dr. Keen, who has had great success in the treatment of this affection, has slightly modified Mr. Adams’s apparatus, as is shown in the annexed cut, fig. 783. “To prevent lateral displacement of the dorsal splint a, which is made of sheet iron, and covered with leather, I have added,” says Dr. Keen, “ a piece of covered tin, a, which hooks around the radial border of the hand, and, as it is fiexible, it admits of easy adjust- ment. The finger splint, which is movable so as to place the joint b exactly over the knuckle-joint, is likely to cause pain and ulceration by its pressure both here and at the first phalangeal articulator, espe- cially the latter. To avoid this, besides ample pad- ding, the screws at b and c are tilted upwards, a piece is cut out of d under b, and a plate, concave from side to side, projecting beyond the screw c, and saddle-shaped at this end, is placed over the first phalanx. The second and third phalanges do not require separate joints. The finger is secured to the splint by leather bandages, or glove-fingers.” The apparatus must be removed daily, and be worn continuously, like that of Mr. Adams, for several weeks. Dr. Keen has found that the good effects of the treatment are promoted by friction and by the use of ointments, hot douches, and soaking of the hand in hot or cold water; and adds that he has often used with advantage a pine wood cylinder, from one and a half to two inches in diameter, on which the patient may practise flexion, the size being diminished as the motion improves. For dividing the contracted structures, Dr. Keen uses a knife one-half of an inch in length by one-eighth of an inch in width, entered flat- wise under the cord which is then severed by a sawing motion, the heel of the instrument being buried under the skin in such a manner as not to enlarge the incision. When deformity of the hand and fingers is occasioned by permanent shortening of the muscles, or of the muscles and their tendons, however induced, tenotomy is of questionable propriety, experience showing that, although the operation may relieve the distortion, the patient never regains any material use of the affected part; on the contrary, indeed, he is generally made worse by it. Hence, the judicious surgeon should hesitate before he undertakes a procedure likely to be followed by such a result. In particular should this Fig. 783. Keen’s Modification of Adams’s Apparatus for the Rectification of Dupuytren’s Finger Con- traction ; intended for the right hand. CHAP. XIX. CONCUSSION AND CONTUSION OF THE FINGERS. 1009 be the case when all, or nearly all, the fingers are involved; for it has happened, under such circumstances, that what little use of the hand the poor patient still possessed, was entirely destroyed by the division of the tendons, their ends refusing to unite. When one finger only is concerned, and the object is to relieve an ugly and inconvenient de- formity, no objection whatever can be urged against the operation. Deformity of the hand and fingers arising from the vicious cicatrices of burns and scalds, as in fig 784, seldom admits of satisfactory relief. When the inodular tissue presents Fig. 784. Vicious Cicatrices of the Fingers. itself in the form of narrow bridles, it may be completely exsected, and the wound ap- proximated by suture; or the bands may be cut across at different points, and the gaps healed by granulation, the limb being maintained in the extended posture during the cicatrizing process, as well as for some time after, in order to prevent a recurrence of the contraction. When the cicatrice involves a large surface, nothing short of its entire re- moval, and the transplantation of a flap of healthy integument, will be likely to answer any useful purpose. The graft might be borrowed from the other arm, or from the chest, as might seem most feasible. In a case recently in the hands of Professor Agnew the integument was successfully borrowed from the abdomen. Numerous surgeons, both at home and abroad, have busied themselves in devising plans by operative and mechanical means for the cure of cicatricial contraction of the hands and fingers consequent upon scalds and burns. For some very valuable suggestions of this kind illustrated by graphic drawings, the reader is referred to a short essay from the pen of Professor Alfred C. Post, of New York, in the Transactions of the American Medical Association, for 1879. CONCUSSION AND CONTUSION OF THE FINGERS. These affections, of which I have witnessed numerous cases, are generally the result of falls, in which the finger is doubled under the hand, or struck against some hard body, as the floor or pavement. Sometimes the effects of concussion predominate, at other times those of contusion ; and there are cases in which both are conjoined with sprain, caused by the sudden and forcible extension of the ligaments of some of the articulations. How- ever this may be, the affected finger feels not only painful but benumbed and heavy; occasionally an unpleasant tingling is experienced. Considerable swelling often ensues, and for days, if not weeks and months, the patient is unable to use the affected member. In some instances the suffering is confined to one particular spot, perhaps not more than two- or three lines in diameter; at other times the chief trouble is in one of the joints, manifesting itself, in either case, simply in a little soreness or tenderness, with some degree of numbness. The affection is most liable to prove obstinate and troublesome, if, at the time of the accident, there is impairment of the general health, or a dyspeptic con- dition of the system, with disorder of the secretions. Indeed, the secondary effects are often, in this condition, much more annoying than the primary. In some instances, the whole finger, and even a portion of the hand, become permanently cold, enfeebled, and wasted. The treatment is at first strictly antiphlogistic, the principal remedies being leeches, saturnine lotions, and tincture of iodine. When the case is chronic, the hot and cold douches will be serviceable, conjoined, when the general health is deranged, with a mild alterant and tonic course, exercise in the open air, and a properly regulated diet. Vesi- cation is seldom of much benefit. When the pain or tenderness depends upon deep-seated inflammation, recourse may, with advantage, be had to subcutaneous scarification ot the periosteum. 1010 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. CLUBHAND. The hand is sometimes distorted in such a manner as to present an appearance analo- gous to clubfoot, especially the variety called varus. Hence it is generally termed club- hand, an appearance well seen in tig. 785. The affection is occa- sionally congenital, but in the great majority of cases it supervenes upon paralysis, or loss of antagonism in the two classes of muscles. The alterations are characteristic. The hand is inverted, the internal margin inclining strongly upwards, the fingers are more or less flexed, and the carpus seems to be partially dislocated from the radius and ulna, forming a marked projection at the inner border of the limb. Sometimes the hand is turned in the opposite direc- tion, in imitation, as it were, of valgus, or the everted variety of clubfoot. However this may be, the affection is not unfrequently associated with distortion of other parts of the body, and usually occurs in persons of a debilitated frame, or in such as are particu- larly prone to suffer from nervous diseases. Very recently, I saw a case in which both hands and both feet were clubbed, the patient being a child three months old. The treatment consists in the removal of the exciting cause, and the improvement of the general health. To accomplish the latter, a course of chalybeate tonics, exercise in the open air, and the daily use of the cold shower-bath will be the best means. Electric currents may occasionally be passed through the affected limb, and the surface may be frequently rubbed with some stimulating lotion. If the case be recent, and the deformity comparatively slight, forced extension, repeated several times a day, and long-continued, will sometimes effect a cure. When this fails, an attempt may be made at rectification by the employment of appropriate apparatus, similar to what is used in the milder foi'ms of clubfoot; but, under opposite circumstances, division of the affected tendons alone will enable us to relieve the distortion, although a long time will elapse before there will be much improvement of the functions of the parts. The muscles whose section will generally be necessary are the long palmar, the flexors of the radius and ulna, and the superficial flexor of the fingers, the knife being introduced with the greatest caution, lest injury be inflicted upon the arteries and nerves of the forearm. REMOVAL OF RINGS FROM THE FINGERS. Serious difficulty is sometimes encountered in removing rings from the fingers, either in consequence of tumefaction caused by their pressure, or of the increased size of the member, as when the ring, put on early in life, has not been taken off" for a long time. Most generally, however, it arises from a small ring being forced, either accidentally or designedly, upon a disproportionately large finger. If relief be not promptly afforded, severe inflammation will ensue, terminating in ulceration and, perhaps, even in gangrene. Several methods may be adopted for effecting this object. In the first place, the hand may be immersed in iced water, to cause contraction of the finger; or the finger may be tightly bandaged, and then held in iced water. If these expedients fail, a piece of pack thread, or saddler’s silk, well waxed, should be closely and firmly wrapped around the finger, beginning at the distal extremity, and extending as high up as the ring. The thread is then passed by means of a small blunt bodkin under the ring, when drawing it very tightly, the ring is gradually forced down as the ligature is untwisted. A plan sug- gested by Dr. A. C. Castle sometimes succeeds when other means fail. It simply consists in polishing the ring with a piece of muslin or buckskin, and then covering it with quick- silver, under the influence of which it is speedily corroded, and rendered so fragile as to be easily broken. Should this device also prove fruitless, the only other resource is to cut the ring in two with a file, or a delicate pair of bone-nippers. WHITLOW. This disease, technically called paronychia, and vulgarly felon, is an affection of the thumb or finger, commencing in inflammation, which soon terminates in suppuration, and sometimes even in gangrene. It is distinguished by the great severity of its pain, and exhibits itself under two varieties of form, the superficial and deep, the former being Fig. 785. Clubhand. CHAP. XIX. WHITLOW. 1011 limited to the skin and connective tissue, whereas the latter involves not only these structures, but also the tendon, periosteum, and bone. Whitlow is very rare in children, and I do not remember ever to have met with it in infants. It is most common between the ages of twenty and thirty-five, but is also suffi- ciently frequent in elderly persons, cases occasionally occurring after the eightieth year. Females are more subject to it than men, and the probability is that certain occupations predispose to its development. Thus, washerwomen, and other persons who have their hands habitually immersed in water, are particularly obnoxious to it. At times, the disease is epidemic, as happened a few years ago in various sections of the Union, when an unusual number of cases, in both sexes, and of different ages, fell under my observa- tion and treatment. An affection similar to whitlow is occasionally met with in the toes. In the superficial forms of whitlow, the inflammation is generally seated immediately around and beneath the nail, commencing either at the side of the finger, upon its dorsal surface, or at its extremity. Without much, if any, swelling, the part is of a dusky red- dish aspect, tender on pressure, and exquisitely painful, throbbing violently and inces- santly, and causing more or less constitutional disorder. In from two to three days after these phenomena present themselves, matter is observed in the finger, lying immediately beneath the epidermis, which is elevated into yellowish vesicles at the side and back of the nail; in many cases, pus is also situated below the nail, especially at its posterior ex- tremity ; and sometimes, again, it is found chiefly, if not exclusively, in the connective tissue immediately beneath the true skin. The inflammation generally extends some distance up the finger, and occasionally even over a considerable portion of the hand, which maybe a good deal swollen, stiff, and painful. Not unfrequently, a reddish line, indicating the course of an absorbent vessel, is seen running along the limb, as high up, perhaps, as the axilla. In the deep-seated variety of whitlow, the inflammation involves all, or nearly all, the structures of the finger, and is frequently followed by the destruction of one or more of the phalanges. The pain is of extraordinary severity, depriving the patient of sleep for days and nights together; throbbing, tensive, and diffused, often extending as high up as the elbow and even to the shoulder; steady and persistent, but greatly aggravated by de- pending position, and only subsiding with the evacuation of the inflammatory deposits, or the death of the part. The swelling also is great, sometimes enormous, involving both finger, hand, and wrist; the skin is red and oedematous, hav- ing a puffy, erysipelatous aspect ; and the whole limb is often stiff and useless. If the morbid action is not speedily checked, matter will form deep among the tissues, within the sheaths of the tendons, and beneath the periosteum, and, spread- ing in different directions, cause extensive havoc, burrowing along the finger and hand as far up, perhaps, as the wrist and forearm. In neglected cases, gangrene occurs, followed by sloughing of the tendons, and exfoliation of the phalanges. The external characters of whitlow are well illustrated in fig. 786, while the effects which the disease often exerts upon the bones are dis- played in fig. 787. Whitlow, in its more severe forms, is always attended with well-marked constitutional disturb- ance. The patient, tortured with pain, is feverish and unable to sleep; his appetite is lost; his, head, back, and limbs ache ; the face is flushed, and the pulse is strong, hard, and frequent. In some cases delirium is present. Paronychia is a bad form of inflammation, not unlike erysipelas or carbuncle, occurring, in a constitution more or less depraved, in consequence of a disordered state of some of the secretions, particularly those of the digestive apparatus. In the female, it is occasionally associated with irregularity of the menses, but whether as an effect or coincidence, is undetermined. Whatever the nature of the disease may be, it has an inherent tendency to suppuration, which hardly any treatment can prevent. There is no disease with which paronychia is likely to be confounded. Its peculiar situation, the severity of the pain, the dusky appearance of the skin, and the speedy occur- Fig. 786. Paronychia of the Thumb Fig. 787. Necrosis of the Bones in Whitlow. 1012 DISEASES AND INJURIES OF THE EXTREMITIES. CRAP. XIX. rence of suppuration, always readily distinguish it from other affections. Boils and car- buncles rarely, if ever, occur upon the extremity of the fingers. In the treatment of this affection very little is to be expected from the employment of abortive measures, since, as has already been stated, its tendency is always to pass into suppuration. In its milder forms, and earlier stages, the morbid action may occasion- ally be limited by a brisk cathartic, and the application of the undiluted tincture of iodine, made two or three times in the twenty-four hours, with an emollient poultice, wet with laudanum and acetate of lead, in the intervals. A strong solution of nitrate of silver, thirty to sixty grains to the ounce of water, is also a very excellent remedy. When the swelling is very considerable, leeches may sometimes be advantageously used in the vicinity of the focus of the inflammation, and, in such an event, I have also occasionally experienced great benefit from thorough vesication with cantharidal collodion. To relieve the exces- sive pain, opiates must be given in full and sustained doses, either alone or in union with antimonial and saline preparations. The above means are, however, at best, only palliative, relieving pain, and, perhaps, limiting morbid action, but not eradicating it. The great and indispensable remedy, after all, is the knife, employed early and boldly, not expectantly and timidly ; the incision being long and deep, the edge of the instrument grating upon the bone, and the tendons being carefully avoided by carrying the knife along the border of the finger. Suppuration is, if possible, anticipated, and structure thus saved. When the matter has been per- mitted to burrow’, numerous openings may be necessary, and extensive mischief may take place, before we may be able to reach the point of repair, the fingers, hand, and wrist long, if, indeed, not permanently, remaining stiff, painful, and unserviceable. Dead bone is removed as soon as it is easily separable, the periosteum being as little interfered with as possible, and amputation always avoided, experience having showrn that a new phalanx is sometimes formed, and that, even when this does not happen, the boneless finger will be both useful and sufficiently seemly. When the violence of the inflamma- tion has subsided, the parts should be kept constantly wet with some anodyne and as- tringent lotion, alcohol and laudanum, or a solution of opium and chloride of ammonium. At a still later period, they should be well douched, first w'ith warm, and then with cold water, dried, and rubbed with soap liniment or camphorated mercurial ointment, and sup- ported with a bandage, each finger being enveloped separately. These directions may seem trivial, but any one who has had whitlow in his own person, or wTho has seen much of the disease in others, will not fail to appreciate their value. In opening paronychial abscesses, the incisions, as a rule, should be carried along the border of the finger, apart from the neighboring joints and the digital artery. SYPHYLITIC AFFECTIONS OF THE FINGERS. Under the terms syphilitic dactylitis, syphilitic panaris, and gummy syphilis, have lately been described certain affections of the phalanges of the fingers, due to hereditary syphilis. An excellent account of the disease was published in 1871, by Dr. R. W. Taylor, in the American Journal of Syphilography and Dermatology. He considers the malady very uncommon, a statement with which my experience is altogether at variance. Hardly a winter has elapsed for years in which wre have not had cases of it at the Hospital Clinic, and I have also met with a considerable number of examples in private practice. The disease, according to my experience, is most common in children, from three to seven years of age, but it is occasionally met with in infancy and early youth. In seve- ral of my cases it came on soon after birth. It frequently coexists with syphilitic affec- tions in other parts of the body, as the hands and feet, the superficial bones, the subcuta- neous and intermuscular connective tissue, skin, nose, mouth, and anus. The disease generally begins in one of the phalanges of the fingers, from which it gradually extends to the other bones, as well as to the intermediate joints, the affected member being at length transformed into a large, shapeless.mass. In its character it is essentially identical with the nodes so often witnessed on the tibia and on the skull in the adult. The gummy matter, the chief morbid product, is generally deposited both in the areolar tissue of the bone and upon its outer surface underneath the periosteum. As it accumulates, it gradu- ally causes expansion and softening of the affected structures, soon followed by great swelling, and eventually by ulceration, the resulting sore being always of a foul, rebellious character, attended with more or less profuse sanguinolent and fetid discharge. The discoloration varies from light pink to deep red, and even purple. The attendant pain is usually slight, especially in the earlier stages of the disease. In some cases, however, it CHAP. XIX. is more or less severe throughout. The general health is frequently much impaired. The child is pale, feeble, and emaciated, although, now and then, he is fat and plump, with an excellent appetite, and in every respect, save the local disease, well conditioned. The diagnosis of syphilitic dactylitis is based upon the history of the case, the age of the patient, the coexistence of similar disease in other parts of the body, and the peculiarly distorted appearance of the affected parts. The most important internal remedies in the treatment of this affection are the iodides, either alone, or, what is preferable, in union with a minute quantity of bichloride of mer- cury. Chalybeate tonics are indicated in case of anemia, flatulence, and indigestion, along with nutritious food and drink. The local measures most likely to be beneficial are dilute tincture of iodine, emollient poultices, leeches, and free incisions, extending down to the bone. When the disease assumes an open form, nitrate of lead, iodoform, cata- plasms, and deodorizing applications must mainly be confided in. Amputation will be necessary when the affected member is hopelessly involved in the morbid action. ANEURISM AND NiEVUS OF THE FINGERS. The fingers are liable to varicose aneurism, consisting, as the term implies, in an en- largement of the arteries and veins, superficial as well as deep ; usually commencing before birth, and progressively augmenting until, as seen in fig. 788, it occasions great deformity and inconvenience. In some instances, the disease extends over the hand, the fore- arm, and even the arm, as high up as the axilla. The fingers are of a purple color, of a soft, spongy consistence, nodulated, and several times the natural bulk. They pulsate synchronously with the heart, and are readily diminished by pressure, but im- mediately regain their former size when the pressure is discontinued. Dissection shows the vessels to be not only enlarged, but also tortuous, thickened, and indurated, with a predominance, at one time, of the arterial, and, at another, of the venous element. The disease is rarely attended with pain. The treatment of this affection is unsatis- factory, as it has hitherto proved refractory under every variety of local measures. So long, therefore, as it causes no serious incon- venience, or evinces no disposition to increase, no attempt should be made to interfere with it. A spontaneous cure is, of course, never looked for. When the enlargement is limited to several arterial trunks, ligation may be employed, the varicose veins being afterwards treated by injections with subsulphate of iron. If the deformity is very great, nothing short of amputation will suffice. A very rare case of traumatic aneurism of the internal artery of the ring-finger has been described by Mr. Thomas Annandale, of Edinburgh, in a woman forty-one years of age, who nine weeks before had pricked the vessel with a sharp hook. The tumor, about the size of a small marble, pulsated synchronously with the heart, and a distinct thrill could be felt on touching it. The proper treatment of such a tumor is to lay it open and to tie both ends of the vessel. Naevus of the fingers is uncommon. It is easily distinguished by its peculiar florid appearance, by its history, and by its slight projection beyond the surrounding level. In a case under my care at the College Clinic, in a child three months old, in which the disease occupied the dorsal and lateral aspects of the middle finger, a satisfactory cure was effected by strangulation with three pins, introduced lengthwise, each being encircled with a stout ligature. BURSAL SWELLING OF THE FINGERS. The subcutaneous burses, naturally situated upon the dorsal aspect of the joints of the fingers, so admirably described and delineated by Schreger, are, like other serous struc- tures, liable to inflammation and its consequences. The most common causes are wounds, BURSAL SWELLING OF THE FINGERS. 1013 Fig. 788. Varicose Aneurism of the Fingers. 1014 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. bruises, and contusions, but the disease may also arise from a gouty, rheumatic, or syphi- litic state of the system. The usual symptoms are, a circumscribed swelling, pain, dis- coloration, and increased heat, with impairment of the function of the corresponding articulation, and more or less involvement of the surrounding vessels. If the morbid action is not soon arrested, suppuration follows, with marked aggravation of the local distress. From the proximity of the disease to the digital joint, the affection is very liable to be mistaken for ordinary inflammation. In the chronic form of the disease, the sac is thickened by interstitial deposits, and there is often a considerable effusion of serum ; the movements of the joint are impeded, and the finger presents an unseemly aspect. Enlargements, not unlike flattened corns or bunions, sometimes form in the situation of these pouches, and may be a source of serious incon- venience, if not actual suffering. Similar formations are liable to occur on the palmar aspect of the fingers, especially in hardworking mechanics, as carpenters, masons, stone cutters, and blacksmiths. Mr. Ilolden, of London, has described a peculiar hernia-like protrusion of the synovial membrane of the sheaths of the flexor tendons of the fingers. It occurs as a small body, from the size of a pin’s head to that of a pea, of irregular shape, firm to the touch, and accompanied by a reddish substance, of the consistence of jelly. It is liable to become painful, and to interfere with the free movements of the fingers. The treatment of these different affections must be conducted upon antiphlogistic princi- ples; by rest, leeching, iodine, and saturnine lotions. If matter form a free and early incision must be made. In chronic cases nothing generally answers so well as a series of little blisters. PHLEGMONOUS INFLAMMATION AND ABSCESS OF THE HAND. A very distressing form of inflammation, closely resembling whitlow, occasionally occurs in the hand, generally in the palm, in consequence of external violence, as a puncture or contusion. It is deep-seated, commencing either in the palmar aponeurosis, in the sub- aponeurotic connective tissue, or in the sheaths of the tendons. However this may be, all these, as well as the other structures, both hard and soft, rapidly become involved in the morbid action, which often spreads over a large extent of surface. The symptoms are those of violent inflammation ; the parts are excessively swollen, of a dark red or livid color, and the seat of exquisite pain, of a throbbing, pulsatile character. The fingers and wrist are stiff and tumid, and there is always high constitutional excitement, not unfrequently attended with intense headache and even delirium, especially when matter is about to form. The treatment, to be effective, must be prompt and energetic. Blood must be taken freely from the part by leeches, or even from the arm, if the patient be at all plethoric; the bowels must be thoroughly evacuated, and vascular excitement must be subdued with depressants. The hand, elevated, and kept at rest, is surrounded with cloths wet with a strong solution of acetate of lead and laudanum, and no time is lost in letting out pus. If this be neglected, the worst consequences are to be apprehended, as necrosis of the bones, ankylosis of the joints of the fingers, and permanent contraction of the tendons, or tendons and palmar aponeurosis. Occasionally mortification occurs. SCRIVENER’S PALSY. Under this appellation may be described a peculiar affection, long known as writer’s cramp, and consisting in a partial paralysis of certain muscles of the hand and fingers, which, in consequence, are deprived of their coordinating power. Although it is most common among persons who are constantly occupied in the use of the pen, it is not limited to them, as it also occurs among shoemakers, milkmaids, musicians, compositors, semp- stresses, and persons who wield a single handed hammer, as file forgers, and tinsmiths. It has its origin generally in fatigue arising from long-continued exertion of the muscles of the hand and fingers concerned in holding the pen, in playing upon instruments, and in performing various other delicate movements. Among the earlier symptoms of the complaint, is a sense of fatigue and numbness of the thumb and forefinger, or of actual cramp, which compels the person to throw down his pen, and to rest himself. On attempting to extend the affected structures, they are found to be stiff, crippled, and perhaps even painful. Rest affords temporary relief, and the hand, in consequence, always feels much better in the morning after a sound and refresh- CHAP. XIX. scrivener’s palsy. 1015 ing sleep. The affection is usually progressive, developing itself gradually, so that gene- rally a considerable length of time elapses before it attains its height. In its worst forms it involves not only the muscles of the fingers, but also those of the hand, and even those of the forearm, the arm, and shoulder, causing more or less lameness, pain, and numbness in the entire limb. When the affection has reached this point, the pen cannot be held beyond a few minutes at a time without severe suffering; the muscles soon become cramped and stiff, and the writer is obliged either to desist from further effort, or to wrap up his pen in his handkerchief in order to afford him a fuller grasp. Thus the case progresses, from bad to worse, until, at length, complete inability ensues. The sensation experienced in the affected parts varies much in different cases; some- times it is a numbness, sometimes a tingling, smarting or burning. Occasionally the thumb and fingers feel as if they had been sprained. Sometimes the principal distress is situated in the knuckles of the fingers, at the extremity of the metacarpal bones, in the wrist, or in the muscles of the forearm. In some cases the pain resembles that of rheum- atism, in others that of neuralgia. Sometimes it is sharp and darting, at others dull and aching. However this may be, numbness, tingling, or burning is always a prominent symptom when the affection has attained full development, the muscles are then also wasted, and the fingers soon become cold, stiff, and almost insensible under the slightest exertion. These various sensations are liable to be aggravated by disorders of the general health, mental excitement, and damp states of the atmosphere. When the person is pre- disposed to rheumatism, gout, or neui’algia, the pain is often so great as seriously to in- terrupt sleep and comfort. Cases have been met with in which writing with the sound hand caused severe pain and fatigue in the muscles of the affected one. Aching of the spine has occasionally been observed as an accompaniment of the complaint. The pathology of scrivener’s palsy is not well understood. Judging from the cases that have fallen under my own observation, and from what I have experienced, at times, in my own person, I am strongly inclined to believe that it is simply a local nervous affec- tion of the muscles of the thumb and fingers, originating in excessive fatigue, and eventu- ating finally in partial paralysis and atrophy. That the paralysis is not complete is shown by the fact that the affected parts may still be usefully employed in the ordinary concerns of life, as in eating, drinking, and various other manipulations. Solly and some others suppose that it has its origin in the cells of the gray substance of the spinal cord, and in support of this opinion it is asserted that the affection occasionally begins in the shoulder, arm, or forearm. Such instances, however, are manifestly exceptional, even if it be ad- mitted that they are, which, however, is doubtful, genuine examples of scrivener’s cramp. Some, again, as Brown-Sequard and Claude Bernard, suppose that the disease is due to reflex action, while Fritz and others consider it a reflex neurosis. However this may be, it is seldom that any case, when fully established, is ever completely cured. In the worst case that I have ever seen the affection lasted for upwards of thirty years, with no material improvement from any of the various plans of treatment, local and constitutional, that were tried for its relief. Both hands were involved, the right first, and afterwards the left, the latter nearly in the same degree as the former. The only hope of relief in scrivener’s palsy is from early and efficient treatment. Naturally the first thing that suggests itself is total rest, not for weeks, but months, if, indeed, not for several years, of the affected parts. The hand and forearm should be sup- ported in a sling, and daily douched, first with hot and then with cold water, after which they should be well rubbed with veratria ointment or some stimulating embrocation in order to give tone to the disabled muscles. Electricity, in the form of faradization, has been found useful and is worthy of trial, especially in obstinate cases. Shampooing is also serviceable. In cold weather the parts should be protected from the contact of the air. The hypodermic injection of morphia should be tried when the pain is localized at a particular spot. The general health must not be neglected. Tonics, change of air, and a residence at the seashore, are often productive of great good. Quinine, iron, and arsenic must be used when the system is broken down, or the case is complicated with neuralgia. When the disease is fully established artificial support is the only thing likely to be of any benefit. A celebrated journalist, now deceased, who often consulted me about bis case, managed to write for several years, by using a pen the handle of which was made very large by surrounding it with a silk handkerchief, and grasping it with the thumb and fingers in a state of extension. In this way he could write for several hours a day, until, at length, he became completely disabled. He finally resorted to various mechanical expedients, with, however, hardly any benefit. In a case reported by Cazenave the spasms that in- 1016 DISEASES AND INJURIES OF THE EXTREMITIES. terfered with the act of writing were controlled by compressing the muscles of the hand and forearm with a laced bracelet. Froschell refers to a case in which the man was enabled to write by placing the pen in a piece of wood pierced with holes, and grasped with the whole hand. A plan occasionally advantageously employed consists in securing the pen to the dorsal groove formed by the junction of the fore and middle fingers by means of rings, as represented in fig. 789. A somewhat similar contrivance, sketched in fig. 790, was devised by Mathieu, an eminent cutler of Paris, with this difference, that it was fastened to the thumb and forefinger. The object is to support these structures while their muscles are kept in a passive condition. Velpeau suggested the use of a large pen- cil ap. xix. Fig. 789. Fig. 790. Fig. 791. Apparatus for Scrivener’s Cramp Mathieu’s Apparatus for Writer’s Cramp. Velpeau’s Apparatus for Scrivener’s Cramp. holder, consisting of a fluted, pear-shaped ball, designed to be grasped by the entire hand. This contrivance, which was afterwards modified by Mathieu, has often been employed with great comfort, and is one of the very best of the kind ever invented. Fig. 791 affords a good idea of its general appearance with the penholder attached to the smaller end of the ball. Tenotomy holds out no prospect of relief in this disease. Dieffenbach utterly failed with it, and Stromeyer and Yon Langenbeck met with only a very transient improve- ment. Attention has lately been called to the treatment of scrivener’s palsy by Mr. Wolff, a German writing-master, by a combination of massage and gymnastic exercises, and his success has been such as to engage the favorable consideration of Charcot, Nussbaum, Billroth, Esmarch, and other eminent authorities. The method consists in making the patient move his hand and fingers in every direction from half an hour to an hour and a half three or four times a day, and in stretching the muscles more or less forcibly several hundred times in the twenty-four hours. Massage and friction are also employed, and considerable stress is laid upon percussing the affected muscles. The most essential part of the treatment, however, is the extension of the muscles. The improvement under this management is generally rapid, good cures being often effected within a few weeks. When no benefit follows after five or six sittings, the case should be abandoned as hopeless. TUMOKS OF TIIE HAND AND FINGERS. The thumb and fingers are occasionally the seat of various kinds of tumors, benign and malignant, interfering with their comfort and usefulness, and requiring removal. Both classes of affections are, however, very uncommon as primary developments. I was obliged, not long ago, to amputate the thumb of an elderly lady for a melanotic disease of twelve years’ standing, and I have removed several fingers on account of epithelioma. Among the benign tumors of the thumb and fingers, one of the most common is the chondromatous, fig. 792, begining early in life, in children of a stunted, rickety forma- tion, and soon attaining so great a bulk as to interfere materially with the usefulness of the part. The growth, which is hard, tense, and incompressible, and which takes it srise in the osseous tissues, is often multiple, several masses affecting the same finger, or even the same bone. Now and then, nearly every finger suffers. Its volume varies from a pea to that of an orange. The formation is generally unattended with pain, the only in- convenience which it occasions being caused by its weight and size. If permitted to go on unrestrained, or if imperfectly removed, it may assume malignancy, but such an event is uncommon. CHAP. XIX. The diagnosis of the chondromatous tumor is very easy, the history of the case, the absence of pain, and the peculiar form, density, and situation of the growth always sufficiently declaring its character. The proper remedy is ablation, not of the tumor, but of the linger upon which it is situated. If the mass only is excised, there will inevitably be speedy recurrence, with a tendency, in all likelihood, to malignancy from rapid cell formation, the part being softer than originally, and growing with un- usual vigor. When the tumor involves the hand, a portion of that also must be sacrificed. A fibrous tumor, hard, firm, dense, and inelastic, is occasionally met with in the hands and fingers. It ranges in size from a small pea to that of a hazelnut, is perfectly movable and free from pain, and is situated immediately beneath the skin, to which it is generally more or less closely adherent. The number of growths is sometimes consider- able, as many as twenty having been noticed in the same person. Occasionally they are perfectly symmetrical, occupying similar positions both upon the hands and lingers. The cause of these tumors is unknown. In some of the cases that have fallen under my obser- vation, they appeared to be due to a syphilitic taint of the system. The treatment of this form of tumor must depend upon circumstances. When its origin is clearly traceable to the effects of syphilis, the most suitable remedy will, of course, be one of the iodides, in union with mercury. Excision can only be proper wdien the growth acts obstructingly. Sarcoma of the fingers is a very uncommon disease which may spring from the bones as a central or peripheral tumor, or, as occasionally happens, from the sheaths of the tendons. A case of sarcomatous tumor of the thumb in a lady, forty-seven years of age, sent to me by Dr. Ward, of Bristol, recently came under my observation. The affection had made its appearance about two years previously around the nail, in the form of a little tubercle, which, as it enlarged, became the seat of heat, pain, and swelling, and ulti- mately broke out into an open sore, the seat of a constant, thin, sanious, and offensive discharge. The distal phalanx being removed, the member remained well for about six months, when the disease recurred in the articular extremity of the first phalanx, causing great expansion of the bone, and rendering further surgical interference necessary. An exostosis of the thumb and fingers is very uncommon. Not long ago I met, in a young woman of twenty-one, with a case of such a growth under the forepart of the nail of the right thumb, where it had made its appearance nearly two years previously. It was of an irregular hemispherical shape, and About the size of a marrowfat pea. The only remedy is excision. Entozoa in bone are extremely unfrequent, and, so far as I know, there is only one in- stance upon record in which these parasitic animals were developed in the hand. The case, described by Professor Jiinghen, of Berlin, occurred in a man, twenty-one years of age. The entozoa, which belonged to the cysticercic variety, occupied the first phalanx of the forefinger, the interior of which was expanded into a large cavity. A cystic tumor, filled with serous fluid, or more or less solid material, is occasionally found upon the fingers, generally just beneath the skin, and is easily disposed of with a knife. In a case recently brought to me by Dr. Phister, of this city, a tumor of this kind occupied the palm and inner border of the left hand. The patient was a man forty-one years of age. The tumor, which was of eight years’duration, was of a mutilocular char- acter, consisting of four distinct nodules, soft, fluctuating, and free from pain. The man could open and shut his fingers with the greatest facility. A colloid tumor of the fingers is sometimes met with, as in a case under my care in a man seventy-eight years of age. The tumor occupied the ulnar border of the last phalanx of the left index finger, and was filled with a white jelly-like substance, visible under the attenuated skin. A tent worn in the cyst for a few days was speedily followed by a cure. A few examples of neuroma, in the form of the subcutaneous painful tubercle of the hand, are upon record; and Dr. Robert W. Smith, of Dublin, has given two illustrations of such a growth occurring on the digital branch of the median nerve of the in- TUMORS OF THE HAND AND FINGERS 1017 Fig. 792. Chondroma of the Index Finger. 1018 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. dex finger. The diagnosis of such formations is not difficult. The painful nature and chronicity of the enlargement are always sufficiently characteristic of the disease. The only remedy is excision. The fatty tumor of the hand is extremely rare. I have myself seen only one example, in a lady, sixty-five years of age, kindly sent to my Clinic by the late Dr. James Taylor, one of my former assistants. The tumor, about the size of an egg, was situated in the palm of the hand beneath the palmar aponeurosis, a process extending forward over the corresponding aspect of the ring finger. It had existed for twenty-two years. Its nature was sufficiently evident before it was removed. In his “ Surgical Observations” the late Dr. J. Mason Warren has given the particu- lars of two cases of adipose tumors, one of which was situated on the hand, while tlie other involved the first phalanx of one of the fingers, to which it clung so closely as to induce the belief, prior to amputation, that it was malignant. It lay in immediate contact with the bone, and the pressure exerted upon it by the tendons and fascia had imparted to it this deceptive appearance. The patient was a child. In a case of fatty tumor of one of the fingers, reported by Professor Bigelow, of Boston, the part so closely simulated a burse that it was punctured. Terrible suffering and deformity of the thumb and fingers, with great impairment, if not total loss, of function, occasionally arise from gouty deposits in the phalangeal joints. The affection, of which the annexed sketch, fig. 793, from Garrod, affords a good illustra- Fig. 793. Gouty Deposits in the Joints of the Fingers and Burse of the Elbow. tion, usually coincides with similar formations in other parts of the body, especially the elbow, knees, toes, and heel, and is evidently dependent upon the retention of the lithate of sodium, the morbitic material of gout, the kidneys being unable to eliminate it with suffi- cient rapidity. The fingers, at first merely stiff and painful, present a tuberoid appear- ance, looking, as Sydenham expresses it, like a bunch of parsnips, and becoming ultimately completely immovable and useless. The substance upon which the deformity depends is originally of a soft, creamy consistence, and of a whitish, grayish, or dark color ; but, by degrees, it assumes the solidity of chalk or mortar, so that, if several pieces coexist, the diseased joints sometimes rattle like bags of marbles. As the swelling augments, the con- cretions approach the surface, causing attenuation, and finally ulceration, of the skin, with a partial discharge of the characteristic material. The treatment consists in rectifying, by appropriate diet, purgatives, colchicum, and alkalies, the peculiar state of the system upon which the formation of the lithic acid depends, and in removing, if necessary, by puncture and pressure, the inspissated matter from the affected joints. Amputation must not be thought of, unless the pain and deformity are excessive, and cannot be relieved in any other way. ANKYLOSIS. Ankylosis of the joints of the thumb and fingers is a very common occurrence, and may be the result of traumatism, syphilis, or ordinary causes, eventuating in synovitis and plastic deposits. In what is styled false ankylosis of these joints, the impediment is dependent upon inflammation of the sheaths of the tendons, or the presence of morbid CHAP. XIX. AFFECTIONS OF THE ELBOW. 1019 growths. Inflammatory affections of the wrist-joint, and fractures of the lower extremi- ties of the radius and ulna, are singularly liable to be followed by ankylosis of the articu- lations in question. The treatment must be antiphlogistic in the first instance, and sorbefacient with pas- sive motion after the acute symptoms have been subdued. The hot and cold douches, frictions with mercurial ointment, and support of each finger and the hand with the roller, daily readjusted, are especially valuable. No permanent benefit can be expected in any case without great perseverance in the treatment. Tailors, shoemakers, dressmakers, and persons who pursue similar occupations are liable to a peculiar form of deformity of the ring and little fingers of the right hand, due to the manner in which these fingers are so constantly crooked or flexed in the performance of their work. As a consequence of this position the tendons soon contract, followed by adhesions and ankylosis of the several joints of the fingers. The preventive measures consist in the proper exercise of all the fingers, and in keeping the affected ones extended upon a light, straight splint at night with passive motion of the joints. No benefit will be likely to accrue in any case when the affection is fully formed, or when it exists in an aggravated form. BURSAL ENLARGEMENT OF THE WRIST. Bursal swelling of the wrist is an occasional occurrence, often of a very serious nature, especially when it exists in a high degree, as it is then very liable to cause more or less pain, and such amount of stiffness as to interfere very greatly with the functions of the joint. Not unfrequently, indeed, the hand is rendered perfectly useless. The most com- mon cause of the affection is chronic inflammation, the result of external injury or of a gouty or rheumatic state of the system. Certain occupations predispose to its occurrence, such as those, for example, in which the wrist is subjected to frequent and severe flexion and extension, as in scrubbing, sewing, and horseshoeing. Women are, on the whole, more liable to it than men, and it is most common, according to my observation, in per- sons before the age of thirty. The disease consists essentially in an accumulation of synovial fluid, with thickening of the inclosing membrane, the effect of long-continued irritation. In very chronic cases, the sac generally contains, in greater or less numbers, small fibrous bodies, resembling, in shape and size, cucumber seeds, formed out of the enlarged and detached papillae of the synovial membrane. The tumor is easily recognized by its history, by its situation in front of the joint, and by its fluctuating nature. When unusually voluminous, it is not uncommon for it to present an irregularly constricted or hour-glass appearance. The more insignificant cases of this affection, especially in their earlier stages, gene- rally yield to sorbefacient applications, aided by the evacuation of the fluid by subcutane- ous incision, and compression with a piece of sheet lead confined with a roller. Injections of dilute tincture of iodine are sometimes curative. In cases of long standing and of unusual size, or in cases in which the cyst contains numerous fibrous concretions, the most certain remedy is free incision of the sac with the thorough division of the annular ligament; an operation originally practised by Professor Syme in 1844, and reintroduced to professional notice, in 1881, by Dr. J. E. Copeland, of Virginia. The operation, which is not devoid of danger, should be performed under antiseptic precautions ; and a compress, saturated with oil and confined with a roller, should be placed in the wound to prevent protrusion of the flexor tendons. The wound must not be allowed to close too soon, lest recurrence be favored. 2. AFFECTIONS OF THE ELBOW. The large synovial burse which is interposed between the tendon and triceps muscle and the top of the olecranon, and which in some instances is multilocular, is liable to inflammation and great distention from the accumulation of its natural secretion, forming thus a swelling, occasionally of extraordinary size, at the posterior and lateral aspect of the elbow. The parts are tender on pressure, and impart a peculiar crepitating, fluctuat- ing sensation, which readily distinguishes it from other affections in this situation. The usual cause of the disease is external violence, although it sometimes arises spontaneously. Persons, as miners, for example, who lean habitually upon the elbow, are very subject to the disease. The morbid action may become chronic, or even pass into suppuration ; and in cases of long standing the coats of the synovial bag are occasionally very much 1020 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. thickened and indurated. Now and then such a tumor contains loose fibroid bodies, resembling small melon seeds in appearance. Fig. 793 affords a good illustration of a burse filled with gouty matter. The treatment is by leeches, blisters, and sorbefacient lotions, with rest of the parts, and an occasional purgative. If the accumulation of fluid is unusually great, a free in- cision must be made, and the sac mopped with dilute tincture of iodine, or filled with lint soaked in a weak solution of Monsel’s salt. Matter should always be promptly and thor- oughly, evacuated, not by puncture but by a deep long cut. The lymphatic gland, situated immediately above the elbow, between the biceps and triceps muscles, is often enlarged in secondary syphilis, in conjunction with cervical adenitis and affections of the skin and mucous membranes, and generally speedily sub- sides under the application of a few leeches, tincture of iodine, and saturnine lotions. In tertiary syphilis the gland is occasionally affected with gummy deposits, eventuating in the establishment of an unhealthy abscess, filled with ill-elaborated pus. A free opening should be made, and the patient placed under appropriate constitutional treatment. Ankylosis of the elbow is a frequent consequence of caries, dislocations, and fractures, and may present itself in various degrees, from the slightest stiffness to complete osseous immobility. The forearm is generally bent nearly at a right angle, but occasionally it is in a straight position, thus rendering it, in great measure, if not completely, useless for the ordinary purposes of life. The treatment must depend upon the nature of the adhesions, as to whether they are fibrous or osseous. In the milder cases, the proper remedy is the laceration of the morbid connections by forcible flexion and extension with the aid of an anesthetic, regular passive motion being afterwards maintained to prevent relapse. Osseous union, if not too strong, may be broken up with the perforator, introduced subcutaneously ; or, if the operation fail, or is contraindicated, resection may be employed, a V-shaped portion of bone being cut out from the back part of the elbow, with a view of establishing a false joint. Sometimes the ankylosis depends mainly upon osseous adhesions of the olecranon, the rest of the articulation partially retaining its integrity. In two instances of this kind I succeeded in effecting excellent cures by forcibly breaking this process; an operation which is usually not difficult in recent cases, as the osseous tissues are then always more or less softened. An Adams’s saw may be used with the same object. The elbow-joint is sometimes rendered useless by the contraction of the brachial apone- urosis and of the tendon of the two-headed flexor muscle, in consequence of paralysis, rheumatism, or burns. The proper remedy consists in the division of the affected parts, the operation being performed in such a manner as not to interfere with the brachial artery, and extension being afterwards made with an angular splint united by hinges, and worked by a screw. In this manner, the limb may often be restored to usefulness in a very short time, especially when there is no serious disease of the joint. 3. AFFECTIONS OF THE SHOULDER. Wounds of the shoulder, of whatever character, must be managed upon the same general principles as similar injuries in other parts of the body. Several remarkable instances have been recorded in which the arm and scapula were suddenly torn off from the trunk, and yet the hemorrhage was so slight as not to require the ligature. The cases of Cheselden and La Motte have become classical. Frightful and extensive as were the wounds, the patients rapidly recovered without an untoward symptom. Although there is generally no copious bleeding in lacerated wounds, the possibility of such an event, upon the occurrence of reaction, should always dictate the propriety of securing the principal arteries. Dr. Stephen Rogers, of New York, in 1868', brought forward eleven examples in which the arm along with the scapula was torn away from the trunk, the first being that of Cheselden, in 1737. The bleeding in this case was so slight as not to require the liga- tion of any vessels, and the man made a prompt recovery. In Clough’s case the patient, a girl eleven years old, was well in two months. In Mussey’s patient, no ligature was employed; less than a pint of blood was lost, and the recovery was complete in eight weeks. The case of James, in 1830, was of a similar nature. Scarnell in dressing a wound of this kind thought it necessary to excise the outer third of the clavicle, and he also, as a precautionary measure, tied the principal vessels, although little bleeding had C'HAP. XIX. AFFECTIONS OF THE SHOULDER. 1021 occurred. The patient, a lad thirteen years old, was about in a fortnight. In the sixth case, reported by Braithwaite, there was hardly any hemorrhage until the main artery was disturbed with the forceps, when a violent gush of blood took place, and the ligature was at once employed. Prompt recovery occurred. In a case observed by Lizars, the outer half of the clavicle was torn away along with the arm and scapula; and, although there was no hemorrhage of any consequence, the subclavian artery was tied as a matter of safety. Dr. Cooper, of San Francisco, attended a boy seven years old, whose arm and two-thirds of the scapula had been severed by machinery, with little bleeding. The re- mainder of the bone was removed along with the outer third of the clavicle, followed by rapid recovery. In the three other cases, reported, respectively, by King, Cartwright, and Lowe, there was nothing unusual in the symptoms, and all the patients got well without any untoward occurrence. The shock in nearly all the cases here detailed was very trifling; and secondary hemor- rhage does not seem to have occurred in any, although in several none of the larger ves- sels were tied. All the patients recovered, most of them very promptly, and without any serious accident. Paralysis of the muscles of the shoulder, but more particularly of the deltoid, the re- sult generally of external injury, as a blow or fall upon the part, is sometimes met with, and often proves exceedingly obstinate, if not irremediable. Although the affection is ordinarily occasioned by direct injury, cases occur in which it is produced indirectly, through force applied to the elbow or hand. A considerable number of cases have fallen under my observation in which the attack was apparently due to the effects of cold. The immediate cause of the paralysis appears to be the contusion, compression, or lace- ration, or these different lesions combined, of the nerves of the affected muscles, and, doubtless, also of the fibres of the muscles themselves. However this may be, the mus- cles, the natural stimulus of which is thus cut off, soon fall into a state of atrophy, becom- ing thin and flabby, and partially, if not completely, powerless. By degrees, the morbid influence extends to the shoulder-joint, causing inflammation of the synovial membrane, followed by morbid adhesions between the contiguous surfaces, and eventually, in many instances, by complete ankylosis. The sensibility of the part is often, althongh not always necessarily, much impaired, and the patient usually experiences fixed or darting pains, resembling those of rheumatism. The paralysis may be limited to the deltoid, or it may affect, either simultaneously or successively, the other muscles of the shoulder, as well as some of those of the arm and forearm, followed by a cold and withered condition of the entire limb. The general health is usually more or less impaired. The prognosis is variable. In the milder cases, the parts, under judicious management, commonly recover in from three to eight weeks, whereas, in the more severe, very little benefit is to be expected from therapeutic measures of any kind. The treatment of paralysis of the muscles of the shoulder must, in the first instance, be conducted upon strictly antiphlogistic principles; by rest, leeches, and soothing applica- tions, as weak solutions of lead and opium, spirituous lotions, or arnica and laudanum, with a view of subduing the inflammation which must necessarily follow when the disease is of traumatic origin. Subsequently our main reliance must be upon hot and cold douches, frictions, stimulating liniments, passive motion of the shoulder-joint, shampooing of the muscles, and electricity. The general health must not be neglected. In most cases, the patient will be greatly benefited by a course of tonics, alterants, change of air, and sea-bathing. In obstinate cases I have sometimes derived marked relief from the repeated application of a blister. Ankylosis of the shoulder-joint may be caused by injury, or by want of use from paral- ysis of its muscles, eventuating in effusion of plastic matter. Such cases generally admit of cure, simply by breaking up the morbid adhesions under an anaesthetic, and then institu- ting a regular system of passive motion, aided by the use of the douche, sorbefacient lini- ments, and dry friction. When the ankylosis is osseous and not too extensive or old, an effort maybe made to destroy the connections with the perforator employed subcutaneously ; or, this failing, resection may be performed. Injury and rheumatism of the shoulder-joint are sometimes followed by contraction of the soft parts in its vicinity, seriously interfering with the restoration of its functions. Passive motion will do much for such cases, and the knife can only be required when there is marked shortening of the pectoral muscle, pinioning the arm to the side. In making the section of the muscle, regard must be had to the safety of the axillary vessels and nerves. In consequence of burns and scalds giving rise to vicious cicatrices, the arm is some- 1022 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. xix. times pinioned to the side of the chest, thus restricting the movements of the shoulder- joint, and rendering the limb in great degree useless. Unless the attachments are very broad and extensive, a very simple operation, consisting in the division of the fibrous or cutaneous bands, will generally suffice to afford relief, especially if care be taken during the healing process to keep the arm away from the trunk. Occasionally it will be found necessary to aid the cure by the division of some of the fibres of the pectoral muscle. A remarkable case of injury of the superior extremity caused by a burn, and followed by sloughing of the shoulder, including the whole scapula and clavicle, was communicated to me, in 18G5, by Dr. W. S. Hitch, of Delaware. The patient, a female, twenty-three years of age, in an epileptic fit, fell into the fire, where she remained until she awoke from the attack. The arm and shoulder, together with a portion of the breast, were found, soon after, to be completely charred and insensible. Mortification rapidly set in, a line of demarcation formed, and precisely four weeks from the time of the accident, the parts were detached by nature’s efforts. The granulating process proceeded kindly, and the stump finally completely cicatrized. Various kinds of tumors, benign and malignant, solid and fluid, are liable to form upon or around the shoulder, commencing either in the soft structures, in the joint, or in the bones, especially the scapula and humerus. Of the benign growths liable to appear here the most common are the fatty, fibrous, and chondromatous, all of which are capable of attaining a great bulk; they are distinguished chiefly by the tardiness of their develop- ment, and by the fact that they generally occasion no other inconvenience than what results from their weight and size. Erectile tumors are always easily recognized by their history, color, and consistence. They are situated either in the skin, or skin and connective tissue, and are, for the most part, of a purely venous structure, although sometimes they are decidedly aneurismal. The annexed sketch, fig. 794, represents an enor- mous chondroma of the left shoulder of an elderly woman, measuring twenty-seven inches in length, and estimated to weigh upwards of fifty pounds. The drawing wras kindly sent to me by Dr. R. H. Brown, of the army. The growth had begun six years previously in consequence, apparently, of a severe blow. In a case of chondroma under my observation in 1864, in a man twenty-six years old, the mass occu- pied the right shoulder, and involved the whole scapula and nearly the upper half of the humerus, along with the outer extremity of the clavicle. It was of very irregular shape, and almost of bony hardness, measuring forty-five inches in circum- ference at its base, and weighing, as wms ascertained after death, thirty-one pounds. It had been first noticed about six years previously, as a small growth upon the back of the scapula. The general health had remained excellent until within a short time before death. The tumor, the size of which had more than doubled itself during the last twelve months, might, doubtless, have been removed before it had acquired its great bulk. Dr. J. B. S. Jack- son, who made the examination after death, states that it wras easily separated from the walls of the chest, and that the subclavian vessels and nerves ran along its surface, but were not imbedded in it. A very curious tumor sometimes forms upon the shoulder in consequence of a hyper- trophied condition of the skin and subcutaneous connective tissue, strongly resembling elephantiasis of the scrotum and other parts of the body. A remarkable case of this kind has been reported by Nelaton in a man twenty-eight years of age. It had taken its rise sixteen years previously by a narrow pedicle in the neck on a line with the fifth cervical vertebra, and at the time of its removal formed an immense fold covering in the posterior part of the trunk, along with the right shoulder and arm, as far down as the sacrum. Its weight was twenty-five pounds. Large veins traversed it in every direction, and all the smaller vessels were excessively increased in size. The tumor, which had much increased in bulk within the last eighteen months, was transfixed with numerous stout ligatures, tied so firmly as effectually to strangulate the whole mass. The growth was then cut off, Fig. 794. Chondroma of the Shoulder and Arm. CHAP. XIX. AFFECTIONS OF THE AXILLA. 1023 the pedicle alone being left to slough. Violent erysipelas arose soon after the operation, followed by death on the fifth day. Of malignant tumors almost the only one liable to occur here is the encephaloid or round-celled sarcoma, which may take its rise either in the connective tissue, or, as is more commonly the case, in the scapula, humerus, or clavicle. It is characterized by the rapidity of its growth, its soft, semielastic consistence, its deceptive sense of fluctuation, and its great bulk. Enlargement of the subcutaneous veins is generally a prominent phenomenon. In regard to the treatment of these tumors no definite rules can be laid down. When situated superficially, they should be extirpated in the usual manner; if, on the contrary, they involve the osseous structure, excision or amputation, performed as early as possible, will be required. The subject of sub clavicular friction, dependent upon the adventitious development of a mucous burse beneath the scapula, is worthy of brief notice, attention having been par- ticularly called to it by Gaujot, Boinet, Demarquay, Galvagni, and Terrillon. The most common seat of the crepitation is near the inferior angle of the bone, but it has also been observed higher up; its occurrence would seem to be promoted by atrophy of the sub- scapular, great serrated, and intercostal muscles, thus favoring the contact of the scapula with the ribs. An exostosis of the scapula or of the ribs may also occasion the affection, and partial ankylosis of the shoulder-joint may act as a predisposing cause by inducing wasting of the muscles and increased movements of the scapula. The crepitation is generally very rough, unlike that produced by a deposit of plasma. Relief must be sought in the removal of the exciting cause. 4. affections of tiie axilla. The axilla is liable to wounds, inflammation, abscess, tuberculosis of the lymphatic glands, cystic tumors, and malignant disease, especially sarcoma and scirrhus. Aneu- rism may also occur here, but as this disease is described elsewhere, it is not necessary to repeat what was then said. Wounds in this situation derive their chief importance from their involvement of the ax- illary vessels and nerves. They may be of various kinds, as incised, lacerated, punctured, or gunshot, and must be treated upon the same general principles as similar injuries in other regions. Bleeding from the axillary artery must be checked with the ligature, applied both to the cardiac and distal side of the vessel, thoroughly exposed for the purpose, the wound serving as a guide to the knife. A good deal of embarrassment frequently attends the operation on account of the infiltrated and discolored condition of the connective tissue, which, from its great laxity, admits of the ready diffusion of the blood. The subclavian artery should never be tied for such an accident. It is not often that the division of the axillary artery is followed by gangrene of the hand, but such an occurrence will be very likely to ensue when the lesion coexists with a wound of the axillary vein, or of some of the principal nerves of the limb. In the latter event, indeed, mortification may arise without any injury whatever of the vessels. Wounds of the axilla, from their peculiar valve-like shape, and the movements of the shoulder, are occasionally followed by emphysema, even when there is no injury of the lung. As such a phenomenon might cause great alarm in the mind of an ignorant surgeon, it deserves to be remembered as one of the possible contingencies of a traumatic lesion in this situation. The cicatrization of wounds of the axilla will be materially expedited, if, after their edges have been properly drawn together, the arm be carefully fastened to the side, so as to favor drainage and insure perfect quietude to the parts. Inflammation, of a common, phlegmonous, or erysipelatous character, not unfrequently makes its appearance in the axilla, and is liable to cause great suffering, besides occa- sionally terminating in extensive abscesses. Terrible attacks of inflammation of the lymphatic glands, attended with fatal results, sometimes follow the absorption of poison, such, for example, as that received in opening or dissecting dead bodies. The virus appears to be arrested in these structures, which, in consequence, soon become swollen, tender, and exquisitely painful, the tumefaction generally rapidly spreading over the whole limb, and occasionally even over the corresponding side of the trunk. Acute abscesses of the axilla are sufficiently common. The matter may be confined entirely to the connective tissue, or it may at the same time be disseminated through the lymphatic glands. When the suppuration is at all profuse, the fluid may burrow freely 1024 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. among the surrounding parts, passing, perhaps, forwards beneatli the pectoral muscles, backwards under the scapula, up into the neck, or even into the anterior mediastinum, although such an event must necessarily be very uncommon, and should always be guarded against by a timely outlet for the pent-up fluid. In performing the operation, the sur- geon must not lose sight of the close proximity of the axillary vessels, otherwise he might produce a frightful, if not fatal, hemorrhage. The most prudent plan will be, unless the matter is very superficial, first to incise the skin, and then to divide the tissues, layer after layer, with the knife, guided upon the grooved director. Chronic abscesses of the axilla are by no means uncommon, especially in young, stru- mous subjects, the matter, which is often very abundant, evidently forming in connection with diseased lymphatic glands. The progress of the swelling is generally very slow, and the phenomena of ordinary inflammation are frequently entirely absent, although occa- sionally the skin over the affected glands is abnormally hot, red, tender, and painful. The pus is always characteristic. The treatment must be by free incision, followed by sorbefacient applications, and by a course of alteratives, or alteratives and tonics. Tuberculosis of the lymphatic glands of the axilla is sometimes met with, generally as a chronic enlargement, these bodies being aggregated together in such a manner as to form a hard, circumscribed, nodulated mass, easily distinguishable by its history, its con- sistence, the absence of pain, and its gradual tendency to suppuration. It is most com- monly found in young subjects, in association with tuberculosis of other parts of the body, particularly of the lymphatic glands of the neck and supraclavicular region. The disease is tardy in its progress, but the resulting tumor may, in time, acquire a very large bulk. The general health, at first unimpaired, ultimately suffers, and the patient may finally fall into a state of marasmus, although, in most cases, he will be likely to make a good re- covery. The most common cause of the disease is cold acting upon a debilitated consti- tution. Occasionally it is dependent upon caries of the ribs or disorder of the mammary gland. The treatment is conducted upon general antistrumous principles, iodine and bichloride of mercury constituting the more important internal remedies ; leeches, blisters, and sorbe- facients the most reliable topical ones. If matter form, it should be promptly evacuated, the disorganized glands being destroyed with escharotics, or removed with the knife and scissors. A cystic tumor occasionally occurs in the axilla ; generally as a congenital affection, of a rounded, semiglobular form, soft, fluctuating, free from pain, and filled with a watery, coagulable fluid. A typical case of this kind, in a stout and otherwise healthy child, six months of age, was sent to the College Clinic by Dr. Conry, of Manayunk. The sac, which contained about four ounces of limpid serum, was laid freely open, and its inner surface thoroughly mopped with a weak solution of iodine. The operation was followed by a speedy cure. A remarkable case of fatty tumor of the axilla, weighing twenty-one pounds, in a man fifty-seven years of age, has been reported by Dr. A. H. Scott, of Dover, Arkansas. It reached three inches below the anterior superior spinous process of the ilium, was of a pyriform shape, and measured forty-five inches in circumference at its base, Removal was readily effected by enucleation. Sarcomatous tumors are liable to a rise in the axilla. They commence either in the lymphatic glands or in the connective tissue as a small nodulated growth, which often, in the course of a few months, acquires an immense bulk. The mass feels hard, or hard at one place and soft at another, and, although movable at first, soon becomes firmly fixed in its position, filling up completely the hollow between the arm and the chest. The sub- cutaneous veins gradually increase in size, and the morbid mass at length breaks and gives way, forming a fungous, bleeding ulcer, the seat of a more or less copious, fetid discharge. The general health, in the mean time, is greatly impaired, the corresponding limb is stiff and oedematous, and the system is racked with pain. Death usually occurs in from twelve to eighteen months. Mr. Butcher, of Dublin, has described two cases of enormous sarcomatous tumors of the axilla, in both of which the pleural cavity on the affected side contained at least a gallon of watery fluid. Carcinoma of the axilla is always the result of secondary involvement in connection with carcinoma of the breast. The tumor, which sometimes acquires a large bulk, is the seat of sharp, lancinating pain, which, together with its history, form, and consistence, and the absence of enlargement of the subcutaneous veins, serves to distinguish it from sarcoma. The only remedy for these diseases is extirpation. The operation, however, besides affording the merest temporary relief, is one of great delicacy, from the fact that the CHAP. XIX. BANDAGES FOR THE SUPERIOR EXTREMITY. 1025 axillary vessels and nerves are often involved in the morbid mass. In performing opera- tions upon the axillary region, special care must be taken not to wound the axillary vein, inasmuch as such an accident might be followed by fatal consequences from the introduction of air, as happened to Dupuytren, Wattmann, John C. Warren, Clemont, and others. Great uncertainty often prevails regarding the diagnosis of the affections in this situa- tion. Thus, for example, surgeons have occasionally mistaken an aneurism of the axillary artery for an abscess. Ferrand, Desault, Dupuytren, and Syme, each committed an error of this kind, followed in all, except the latter, by death. On the other hand, a solid tumor may be confounded with an aneurism. Pelletan and Nicoll each ligated the sub- clavian artery in a case of sarcoma under the supposition that the malady was aneurism. Both patients perished. Such blunders—for this is the mildest term that can be applied to them—should serve to put surgeons upon their guard in reference to the diagnosis of diseases of the axillary region. 5. BANDAGES FOR THE SUPERIOR EXTREMITY. Bandaging of the fingers is a very nice operation, particularly called for in inflamma- tion after fractures of the radius and ulna, and in cases of burns and scalds, with a view to the prevention of adhesions. The roller should be from three-quarters of an inch to an inch in width, and should be carried up, by circular and reversed turns, as far as the root Fig. 795. Fig. 796. of each member, when the extremity should be stretched across the back of the hand, which, when all the fingers are enveloped, should be surrounded with a broad bandage, extending from the knuckles a short distance beyond the wrist, as exhibited in fig. 795. For retaining dressings upon the hand, the bandage represented in fig. 796 is usually employed. It consists of a roller, an inch in width, and several yards in length, carried, first, around the wrist, and afterwards across the carpus, in front and behind, in such a manner as to embrace the root of each finger. The most suitable bandage for the forearm and arm is the ordinary roller, fig. 797. The application, commenced at the fingers, is gradually continued up the limb as far as the elbow, and thence as high up as the axilla, where the end is fastened with a pin. Some- times, as when it is desired to secure the arm to the side, the bandage may Bandages for the Hand and Fingers. Fig. 797. Roller for the Superior Extremity. 1026 DISEASES AND INJURIES OF THE EXTREMITIES. chap, xix be carried horizontally around the trunk. The hollow of the hand may, if necessary be filled up with cotton, lint, or old muslin. Great care must be taken in carrying tin bandage around the elbow, otherwise it will be apt to lose its hold or to produce undu< compression. The usual length of the roller for the upper extremity is from six to eigh yards, its width being about two inches and a quarter. In fractures and other injuries likely to be followed by severe swelling of the hand, the thumb and fingers should be pu up in separate bandages. For confining dressings in the treatment of wounds, abscesses, and other affections o the axilla, the most simple and efficient contrivance that can be used is a large hand kerchief, folded cornerwise, the centre being placed under the arm, and the ends, crossei Fig. 798. Fig. 799 Bandage for the Axilla. over the shoulder, carried around the chest, and tied under the opposite axilla, as illustrated in tig. 798. The spica bandage for the shoulder and the upper part of the arm, represented in fig. 799, consists of a roller from eight to ten yards in length by two inches and a half in width, with compresses for the axilla of the affected side. Leaving about two feet and a half of the end of the bandage pendent at the posterior part of the arm, the application is commenced by several spiral and reversed turns around the limb, passing from its outer towards its inn< surface. The bandage is then carried up over the outer aspect of the shoulder, oblique' across the anterior part of the chest, to the axilla of the sound side, and thence across tl back to the affected shoulder. In this manner one turn after another is made, eat succeeding one partially overlapping the preceding, until the roller is consumed, wht the initial extremity at the back part of the limb is brought around under the axilla, at thence over the front of the shoulder and around the back of the neck to the sound sid where it is secured by a pin. SECT. II INFERIOR EXTREMITY. 1. AFFECTIONS OF THE FOOT AND TOES. The foot and toes, like the hand and fingers, are liable to various affections, either co genital or acquired. Among the former are supernumerary, webbed, and hypertrophh toes, flatfoot, and clubfoot; among the latter, corns, bunions, podelkoma, pododynia, ai certain diseases of the toes. CONGENITAL AND OTHER DEFORMITIES OF THE TOES. Congenital absence of the toes is a very rare occurrence; supernumerary toes, on t contrary, are not very uncommon, the additional member being usually connected wi the large toe, which it closely resembles in shape, although it does not equal it in bul The anomaly sometimes exists on both feet, and cases are met with where it is associat with an additional thumb. The supernumerary member is not only unseemly, but, increasing the width of the foot, may seriously interfere with the patient’s comfort a: Spica for the Shoulder and the Upper Part the Arm. CHAP. XIX. CONGENITAL AND OTHER DEFORMITIES OF TOES. 1027 convenience. Hence it should always be removed soon after birth. The operation is very simple, the only care required being to take away the whole of the anomalous toe, and to leave a sufficient amount of integument to afford a good covering for the exposed surface. The connection is sometimes simply by a cutaneous pedicle instead of by a dis- tinct articulation. In a case recently under my charge the child had six toes on each foot, a deformed ear, and a cleft in the palate. The additional member is sometimes wholly composed of soft material. A webbed condition of the toes is uncommon, and rarely affects more than two or three of these pieces. I have seen only two cases in which all the toes were thus united. The remedy is the same as for webbed fingers. One or more of the toes have occasionally an unseemly direction as a congenital defect, being widely separated from each other. In such cases I have derived benefit from mak- ing the children wear a gum-elastic band, arranged so as to encircle all the toes, and press the recusant one in its proper place. Hypertrophy of the toes is still more uncommon than hypertrophy of the fingers. It is usually congenital, and the affected parts may acquire a very large bulk, thus greatly interfering with the comfort and convenience of the foot. The proper remedy is removal of the offending structures, as it would be worse than useless to waste time upon com- pression and other sorbefacient means. The hypertrophy may be limited to the toes, or, instead of this, it may involve also the foot, leg, and thigh, as in a remarkable case at the Philadelphia Hospital, in a little girl two years and a half old. The enlargement was, as usual, congenital, and extended over the entire left extremity, with the exception of the heel and the fourth and fifth toes, which were little, if at all affected. The circumference of the limb was nearly twice that of the sound one. The length of the foot and great toe was six inches and a half; the thigh and leg were notably elongated; and the soft parts were of a dense, fibroid con- sistence. The chief mass of the limb seemed to consist of adipose matter strongly inter- mixed with fibrous tissue. The microscope revealed the existence of numerous fat cells. The child had for some time past labored under tubercular disease of the lungs and a scaly, syphilitic eruption of the skin. Deformity of the toes occasionally arises from the effects of rheumatism, from paralysis, or from the wearing of a tight shoe, causing them to project in an unseemly and incon- venient manner, either above or below the natural level, as in fig. 800, or producing an incurvated, claw-like appearance. The immediate cause of the distortion is a contracton of the tendons of the flexor muscles, which should accordingly be divided, as they pass beneath the first phalanx, by subcutaneous section, the faulty toes being afterwards treated Fig. 800 Fig. 801. Deformity of the Second Toe. Deformity of the Great Toe from Inflammation of the Metatarso-phalangeal Joint. in the extended posture by splint and bandage, until they are completely straight. When the great toe is mainly involved, as generally happens when the affection is induced by paralysis, or by inflammation of the metatarso-phalangeal joint, as in fig. 801, it may be necessary to divide the long flexor in the sole of the foot; but in doing this proper care must be taken to keep the knife close to the affected tendon, made previously as tense as possible, otherwise the internal plantar artery might sutler. 1028 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. WOUNDS OP THE FEET AND TOES. Wounds of these parts require the same treatment as similar lesions in other regions. The hemorrhage which complicates them is often profuse, and not always easily arrested, especially when it proceeds from the plantar arteries, owing to the great depth at which they are situated, and the confused condition of the tissues, if some time has elapsed since the occurrence of the injury. Acupressure with long needles, deeply inserted, frequently answers better here than the ligature. When the bleeding cannot be controlled in this way the proper plan is to enlarge the wound, and to tie the vessel at both ends. For further remarks upon this subject, the reader is referred to the chapter on the arteries in the first volume. Punctured, contused, and lacerated wounds of the feet are extremely liable to be fol- lowed by erysipelas, abscesses, and even tetanus, especially in persons of a nervous, irrit- able temperament, and they should, therefore, always be watched with the greatest care until the danger is fairly passed. Free incisions are often required to relieve pain and tension, as well as to evacute the pent-up fluids ; and anodynes, in large and sustained doses, can seldom be dispensed with, if the suffering be at all severe. Among the best local applications are strong solutions of acetate of lead and opium. Leeches, blisters, and iodine are also valuable agents. Foreign bodies, as needles, tacks, splinters of wood, chicken bones, and pieces of glass, are very liable to lodge in the sole of the foot, where, if they are not speedily removed, their presence may occasion the most disastrous consequences, as tetanus, erysipelas, and abscesses. Hence no time should be lost in getting rid of them, and for this purpose large incisions are often required, the knife being guided by the puncture left by the foreign substance, or by the sensation which the substance imparts to the finger. The toes and feet are sometimes badly contused; and cases occur in which the injury is attended with more or less extravasation of blood, followed by severe pain and tender- ness in the parts. The most suitable applications ai'e lotions of lead, arnica, and laud- anum. If the blood is slow in disappearing, or if it be productive of severe distress, by the pressure which it exerts upon the surrounding structures, it should be evacuated through a suitable puncture. The toes often suffer severely by being struck forcibly against a hard, projecting body, as a stone, step, or piece of timber. The concussion thus occasioned not only causes violent pain, but is very liable to be followed by stiffness of the joints, the effects of which may not pass off for many months, if ever. Such cases should always engage the serious consideration of the practitioner. INFLAMMATION. Inflammation of the foot and toes, especially of the former, is extremely prone to assume an erysipelatous character, particularly when caused by punctured, contused, or lacerated wounds. The disease often spreads to a great depth, causing severe swelling, with in- tense pain and excessive constitutional disturbance. If matter form, it will be very liable to burrow, owing to the resistance offered by the plantar aponeurosis, thus seriously com- plicating the case, and augmenting the suffering. When the pus is pent up for any length of time, there will be danger of involvement of the bones, leading to caries and necrosis, especially in subjects of a strumous habit of body. The toes sometimes suffer from a form of inflammation, closely resembling paronychia ; deep-seated, extremely painful, and of a spreading tendency, with an erysipelatous condition of the skin. The great points in the treatment of inflammation of these structures, apart from the ordinary measures, are to relieve tension and to afford early vent to effused fluids, parti- culiarly to pus, that no undue ravages may be committed by burrowing. These indic- tions are fulfilled by free and timely incisions, care being taken that no injury be inflicted upon the plantar arteries. Leeches are generally of immense service in these inflam- mations, and the same is true of lotions of lead and opium, especially in the earlier stages of the disease. BUNIONS. A bunion is a corn on a large scale, caused in a similar manner, having a similar struc- ture, and requiring a similar treatment. It consists in a thickening, and induration of the common integument over the first metatarso-phalangeal joint, accompanied by malpo- sition of the great toe, which is usually forced inwards, either against, over, or under the CHAP. XIX. BUNIONS. 1029 adjoining one, thus occasioning a sharp, angular projection on the outside of the articula- tion. These appearances are well shown in fig. 802, from a female patient. The whole difficulty is originally dependent upon the wearing of a short, narrow-soled, high-heeled boot, by which the whole weight of the body is thrown upon the anterior part of the foot in progression. A similar tumor sometimes forms over the first joint of the little toe. Hereditary malformation, preternatural laxity of the ligaments, and a gouty or rheumatic state of the system, may be men- tioned as so many predisposing causes of the complaint. The cuticle, when the disease is somewhat advanced, is thick, scaly, or lamellated, hard, brawny, and, at times, studded with superficial corns; the subjacent burse, which is often of large size, and occasionally com- municates with the articular capsule, contains a consider- able quantity of synovia ; and the corresponding joint of the toe is always chronically inflamed and hypertrophied, if not partially ankylosed. Exercise is painful, and never fails to aggravate the disorder, not unfrequently occasioning erysipelas of the foot, and abscess in the sac of the bunion. In the worst forms of the disease, a painful intractable ulcer sometimes forms, and thus greatly increases the local distress. Mr. Oliver Chalk has recorded a remarkable case of bunion in which the ulcer, after having continued for a long time, finally degenerated into epithelial carcinoma. The treatment is palliative and radical. The first thing is to procure a proper shoe, in order to diffuse the pressure over the foot, instead of concentrating it upon the toes. Pain, tenderness, and inflammation are best relieved by rest and elevation, along with leeching, blistering, and cold water, medicated with laudanum and acetate of lead. If matter form, an early and free incision is made down to the bones. The malposition of the toe may generally be easily rectified, in the slighter cases by strapping it, from time to time, to the anterior extremity of a trough of sole leather, care- fully moulded to the inner margin of the foot, and laced to the instep and heel by appropriate bands. By this arrangement the metatarsus is made to serve as a fulcrum, keeping in check the action of the adhesive plaster by which the toe is gradually re- duced to its natural situation. When the deformity is more con- siderable, the apparatus of Mr. Bigg, represented in fig. 803, may be advantageously employed. It consists simply of a deli- cate lever of steel, with an oval ring in the centre, and attached by a laced band to the instep. At the anterior and posterior margins of the ring is an ordinary hinge-joint, allowing the articulation to move freely in the natural plane, but calculated to oppose any lateral tendency. The toe is secured to the ex- tremity of the apparatus by a piece of webbing. The patient will generally be able to wear a shoe without any difficulty. A radical cure may be effected by excision of the sac, but, unless the part and system have been well prepared, the opera- tion may prove dangerous from its liability to be followed by erysipelas. A much safer plan is to divide the sac subcutane- ously with a delicate tenotome, cutting it up into numerous frag- ments, and then pencilling the surface of the swelling several times a day with tincture of iodine. I have practised this method in numerous cases with highly gratifying results. Amputation through the meta- tarsal bone may become necessary when the parts are hopelessly crippled, and the seat of constant suffering. When the above remedies fail in effecting rectification, the only thing to be done is to excise the articular extremities of the affected bones, so as to restore the toes to their natural position, suitable dressings being employed until the object is attained, and care taken to keep the resulting inflammation within proper limits during the after-tieatment. The subcutaneous burses, naturally existing upon the dorsal surface of the joints of the toes, are liable to suffer from inflammation, occasioned by external injury, by the pressure of a tight shoe, or by a rheumatic, gouty, or syphilitic state of the system. The swelling is circumscribed, discolored, hot, tender, and painful. Suppuration may take place, and Fig. 802. Bunion. Fig. 803. Apparatus for the Treatment of Bunion. 1030 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. then the entire toe may become seriously involved in the morbid action, especially if it assumes an erysipelatous character. The treatment is by rest, leeches, saturnine lotions and tincture of iodine, with free incisions if matter form. INVERSION OF TIIE NAIL OF THE GREAT TOE. The big toe is subject to the inversion of its nail, consisting, as the name implies, in an ingrowing of its edges into the common integument. The affection is productive of severe suffering, and is, therefore, as well as on account of the frequency of its occurrence, de- serving of particular attention. It is not peculiar to the big toe nail, although it is most common here, and it is here, also, that it has been best studied. It is mosf frequent in young adults, and occasionally exists in several members of the same family Several cases have come under my observation in very young children, under circumstances which induced me to believe that it might have been hereditary. Thus, I know two instances where a mother and two of her children are afflicted with this disease. In a case recently at the College Hospital the inversion was congenital. T-he affection consists essentially in a vicious formation of the nail, in consequence of which its edges become incurvated, and pushed down into the skin at the margin of the toe, which overlaps them. I his often happens with the hardest as well as with the softest nail. The incurvation generally exists on both sides, although rarely in an equal degree, and we sometimes meet with cases where both the big toes are involved. When the affection is fully developed, the edge of the nail dips into the flesh almost vertically leaving a well-marked gutter upon the removal of the offending part. Long, however,’ before it has attained this height, it becomes a source of severe suffering, on account of the pressure which it exerts upon the soft structures at the side of the toe, which at first inflame and swell, and afterwards ulcerate, the sore discharging a foul, fetid fluid, and being usually covered with tender, fungous granulations. In some cases, the inflamma- tion involves nearly the whole toe, which is then proportionately painful, and thus greatly augments the distress; so that, at length, the patient is in constant misery, and hardly able to wear a shoe or take any exercise. The habitual use of a tight, narrow shoe, caus- ing severe lateral pressure, no doubt often contributes to the production of this affection, but most commonly it arises from the vicious manner in which the nail is cut down at the edges, thereby allowing the thickened and indurated integu- ment to rise above the level of the nail, which always grows more slowly than the other structures, in which, consequently, it is ultimately buried. Once formed, it is extremely difficult to get rid of. Great convexity of the nail no doubt acts as a powerful predisponent. A arious methods of treatment have been suggested for the cure of this affection, most of which can hardly be regarded even as palliatives. Paring the inverted portion of the nail occasionally with a sharp knife, and removing the callous skin by its side, will always afford marked relief, and may, if steadily persisted in, sometimes eradicate the evil, but, in "gen- eral, it will soon return, and ultimately call for a more decisive procedure. Scraping the back of the nail, so much lauded by some surgeons, is commonly useless, as it is hardly productive even of transient comfort. Dr. Robert Campbell, of Georgia, i ecommends systematic compression with a small compress and lollei, but the operation, without being by any means free from pain, is troublesome and tedious, from six to eight weeks being required to effect a cure, and even then it is seldom, if e\ei, permanent. W hen the affection is fully formed, and the patient s time is valuable, the best plan is at once to excise the offending portion of the nail, an anaesthetic being given to prevent suffering, which will otherwise be With . . , a stout’ narrow, and very sharp scalpel, the nail is divided irougi its whole length, as seen in fig. 804, down almost to the bone, on a line with ie incurvated edge, which is then rapidly detached, root and all being embraced in the dissection. A ery little bleeding ordinarily attends the operation, which is over in a few seconc s. aim water-dressing, with acetate of lead and opium, is applied, and the foot kept at rest untl1 the wound is measurably healed. I generally excise both margins at Fig. 804. Excision of Inverted Toe-nail. CHAP. XIX. NEURALGIA OF THE FOOT. the same time. By this procedure, a large portion of the nail is left for the protection of the toe, and a radical cure is effected. I have repeatedly accomplished the same object simply by the removal of the indurated skin and connective substance at the margin of the toe, without interfering at all with the affected nail. The incision is directed in such a manner as to leave a sloping surface, which, after the cicatrization is completed, bears pressure well, and is an effectual guarantee against future trouble. Everything else is merely palliative, the patient being at last obliged, perhaps after long suffering, to submit to the knife. The barbarous practice, formerly so fashionable, of removing the entire nail for the relief of this affection cannot be too strongly condemned, as, aside from its cruelty, it often utterly fails, from the distorted condition of the newr nail. EXOSTOSIS OF THE GREAT TOE. The last phalanx of the great toe, as seen in fig. 805, is sometimes the seat of an exos- tosis, so large as to cause serious inconvenience and pain in walking. It may appear at various points of the bone, but generally it is seated at its inner margin, partly under the nail, which, in time, it lifts up and par- tially destroys by ulceration. Its form is spherical or pyramidal, and in size it varies from that of a millet seed to that of a hazel- nut, its structure and consistence resembling those of the natural osseous tissue. Arising generally without any assignable cause, its origin is usually ascribed to a blow, or to the pressure of a tight shoe; it is most common in young adults, is slow in its progress, is attended with more or less fetid discharge, and is amenable to excision with a stout knife, aided, if necessary, by the saw and gouge. Amputation of the phalanx is not to be thought of unless the whole bone, nail, and soft parts are in- volved in destructive ulceration. A marked tendency to recurrence occasionally exists, requiring further interference. For this reason the excision should always be performed with the greatest possible care. An exostosis sometimes forms on the small toes. NEURALGIA OF THE FOOT. Neuralgia of the foot is usually associated with neuralgia in other parts of the body, dependent upon similar causes, and demanding similar treatment. There is one form of the affection, however, which is so peculiar in its character as to require special consid- eration ; and as it was first accurately described by Dr. Thomas G. Morton, of this city, it is eminently proper that it should hereafter be known by his name. In a paper in the American Journal of the Medical Sciences for January, 1876, I)r. Morton called the attention of the profession to what he denominates “ A Peculiar and Painful Affection of the Fourth Metatarso-Phalangeal Articulation,” illustrated by an account of sixteen cases, of which thirteen occurred in females, mostly of a nervous temperament. The neuralgia in ten of the cases was caused by direct injury to the fourth toe, and in three others by the pressure of the shoe. In none of the cases was there any evidence of inflammation, or of disease of the affected articulation. The pain, which wras always more or less intense, w'as, generally, greatly aggravated by exercise, by the pressure of the shoe, and by disorder of the health, the suffering often lasting for hours, and extending up the leg sometimes even as high as the hip. Dr. Morton is inclined to ascribe this affection to the contusion experienced by the fourth metatarso-phalangeal joint and by the digital branches of the external plantar nerve by the pressure exerted upon them by the adjoin- ing toes, especially the small one, which, by its great mobility, frequently impinges inju- riously upon the fourth, as when the person habitually wears a tight shoe. The most reliable remedies in the treatment of this disorder are leeches, tincture of iodine, and anodyne and saturnine lotions, perfect rest with elevation of the foot, and the use of a broad-soled somewhat square-toed shoe, laced in front. A shoe made of buckskin often affords great comfort. Any derangement of the general health that may exist must of course be promptly corrected. When the case is rebellious, the only thing to be done is to excise the tender joint along with the neighboring nerves, or even to amputate the toe and a portion of the corresponding metatarsal bone, as in one of Dr. Morton’s patients. In the case of a young man under my charge, in 1881, I succeeded in relieving the ex- quisite tenderness of the big toe and the inside of the foot by the excision of the internal plantar nerve. Fig. 805. Exostosis of the Distal Phalanx of the Great Toe. 1032 DISEASES AND INJURIES OF TIDE EXTREMITIES. CHAP. XIX. CLUBFOOT. Clubfoot consists in a, peculiar distortion of the foot, attended with a deviation from its natural direction, and also, generally, with a diminution of its proper length. Presenting itself in various degrees, the deformity to which it gives rise is sometimes so great as to occasion the most disagreeable disfigurement and the most painful inconvenience, render- ing the individual an object of constant attention and remark, as well as sadly interfering with progression. The affection is for the most part congenital. It may, however, be developed after birth, and even at an advanced period of life, from the foot being accidentally placed in a constrained position, and so retained until the soft structures, particularly the muscles and ligaments, are moulded into a new shape, or thoroughly fixed in their new relations. Various mechanical causes may give rise to it, as splints and bandages, by which the parts to which they are applied are injuriously compressed, or forced out of their normal position. Similar effects are produced by convulsions, dentition, nervous irritation, con- tusions, sprains, fractures, partial luxations, and preternatural laxity of the ligaments. Sometimes the defect is occasioned by the presence of a corn, an ulcer, or some other disease which induces the person to walk on one side of the foot, the tip, or the heel, to ward off pressure from the tender parts. A vicious habit is thus established, which, if continued for any length of time, as it frequently is, inevitably leads to irregular action of the muscles, and to distortion of the bones into which they are inserted. Etiology The etiology of congenital clubfoot has never been satisfactorily explained. The hypothesis of arrested development, so warmly advocated by some modern patholo- gists, is altogether untenable, being essentially contrary to the facts of the case in every particular. The imperfect growth, if any such really exist, is not congenital, as this doc- trine teaches, but acquired, being the result of causes which are brought to bear upon the child during its intrauterine life, leading to shortening and contraction of certain mus- cles, and not to the want of development properly so called. It must be acknowledged, however, that instances occasionally do occur, although rarely, which strongly favor the doctrine under consideration. Thus, I have, in my own practice, seen two infants, born at the full term, but who died immediately after birth, who had each well-marked hare- lip, cleft palate, and clubfoot, the result evidently, so far at least as we can judge of such an occurrence, of an arrest of development. Dr. F. H. Getchel, of this city, met with an instance in which this affection was associated with bifid spine, exstrophy of the ab- dominal viscera, and absence of the anus and genital organs. Another hypothesis of the formation of clubfoot that has met writh considerable noto- riety, is that the distortion is caused by the pressure of the uterus upon the feet of the infant during gestation, in consequence of a deficiency of the amniotic fluid. But the question may be asked, if such an effect may be exerted by this organ upon the feet, why should it not be also exerted upon the hands, head, nose, chin, legs, and knees ? Such a coincidence, supposing the doctrine to be true, ought to be of constant occurrence, and yet it is so rare that it is probably not noticed once in a hundred cases of the affection. Besides, it remains to be proved that women who bear clubfooted children have always a deficiency of amniotic liquor. The most plausible view, perhaps, is that the distortion is produced by a defect of ner- vous influence, leading to a permanent contraction of certain muscles, with a correspond- ing retraction and incurvation of the bones into which these muscles are inserted. This hypothesis derives corroboration from what occurs in strabismus, in which the straight muscles of the eye frequently almost in a instant, simply from irritation, or an attack of convulsions, lose their parallelism, without the ability afterwards to regain it except by an operation. Here the contraction of the muscles must be the direct result of a lesion of innervation, or of perverted nervous action ; for the effect is generally too rapid to justify the conclusion that it can possibly be due to inflammation, which has sometimes been invoked as its exciting cause. How a lesion of the nerves is produced in the foetus in the womb is of course inexplicable ; but that it does occur, in various forms and degrees, is a clearly established fact. It is worthy of remark, in connection with this hypothesis, and as strikingly confirmatory of it, that congenital clubfoot has been repeatedly met with in the embryo as early as the third and fourth months. Moreover, it is not unfrequently associated with imperfect development of the cerebro-spinal axis, or of certain classes of nerves, and with an atrophied and contracted state of the muscles in different portions of the body, especially of the back, shoulder, and hand. T he congenital variety of clubfoot often affects both feet, but rarely in an equal degree. CHAP. XIX. CLUBFOOT. 1033 The relative proportion, however, of double to single clubfoot has not been determined; and it is not unlikely that it varies materially in the practice of different surgeons. In my own hands the number of cases of single clubfoot has considerably exceeded, perhaps in the proportion of three to two, the number of double cases. In 1G7 cases, reported by Dr. Detmold, of New York, the distortion occupied both feet in ”93. At the Royal Orthopaedic Hospital, London, the two forms are said to occur almost with equal frequency. Thus, of 688 cases, 363 were double, and 326 were single. When the distortion is single, it involves the right foot a little oftener than the left. Both sexes are liable to clubfoot, but males suffer more frequently than females, probably, if I may judge from personal observation, in the proportion nearly of two to one. Some very remarkable cases have been recorded of the occurrence of this distortion in different members of the same family. In one instance, observed by Held, all the children, six in number, were the subjects of congenital clubfoot; and its history would seem to show that the affection was hereditary, inasmuch as one of the parents was laboring under a similar infirmity. Varieties of Form Clubfoot presents itself under several varieties of form, of which there are four principal ones, differing from each other not only in regard to the character of the distortion and the accompanying phenomena, but likewise in relation to the fre- quency of their occurrence, and the nature of their treatment. These may be respectively denominated the inverted, everted, phalangeal, and calcaneal varieties, each name having reference to the manner in which the limb touches the ground in standing or progression. Thus, in the inverted clubfoot the inner margin of the foot is inclined upwards, while in the everted it is turned downwards ; in the phalangeal variety the heel is elevated, and in the calcaneal it is depressed, the toes, in the former case, being, of course, turned down, and up in the latter. Besides these varieties there are several subdivisions, depending upon a combination of two of the principal forms, as, for instance, the inverted and pha- langeal, which are extremely common, and the inverted and calcaneal, which are more rare. Of 1218 cases of congenital and noncongenital clubfoot, recorded by Lonsdale, varus existed in 583, equino-varus in 112, equinus in 226, valgus in 151, calcaneal in 50, equino-valgus in 40, and different compound forms in 56. The most common form of clubfoot by far is the inverted, usually denominated varus, figs. 806 and 807, in which the patient walks upon the outer ankle, the great toe being directed inwards and upwards. The muscles of the calf and the abductors of the foot are contracted, and hence there is not only elevation of the heel, but a peculiar inward twist of the foot analogous to supination of the hand. This alteration occasions the most Fig. 806. Fig. 807. Varus serious impediment to progression, and when it reaches its highest point imparts a most disagreeable aspect to the affected limb. In the more severe grades of the disorder, the sole of the foot is literally scooped out, as it were, as well as deeply furrowed ; the instep, on the contrary, is unusually convex and prominent ; the small toes generally present in a vertical position, while the big one, separated from the rest, looks upwards and inwards; the outer margin of the foot, which, in conjunction with the corresponding malleolus, chiefly sustains the weight of the body, is almost semicircular in its shape, rough, and 1034 callous; and the tendo Achillis, forced obliquely towards the inner side of the leg, forms a tense, rigid cord beneath the skin. When both feet are affected with varus, their points may form an acute angle with the leg; or they may approach so nearly as to touch, and even overlap each other. In the majority of cases the thigh and leg retain their natural conformation, being merely somewhat atrophied; occasionally, however, the knees project slightly inwards or outwards, in con- sequence of the contraction of the hamstring muscles. The second variety of this deformity, an- ciently called valgus, fig. 808, may be regarded as the opposite of varus, the patient treading on the internal margin of the foot, while the external is entirely removed from the ground. The sole is directed outwards and slightly back- wards, the toes are more or less elevated, and the outer ankle is in a state of semiflexion. The heel is drawn upwards and somewhat out- wards, the internal malleolus is uncommonly prominent, the instep is flatter than natural, and the muscles of the calf, together with the abductors of the foot, are permanently con- tracted. When the disorder has attained its highest point, the patient has an unsteady, vacillating gait, from the difficulty which he experiences in preserving his centre of gravity. Valgus is comparatively rare; like the first variety of the distortion, it may affect one or both limbs. It is seldom congenital, but is almost always produced by some local injury, as a sprain, blow, or contusion. The most simple form of the affection constitutes what is called flatfoot. The phalangeal variety of clubfoot, figs. 809 and 810, the pes equinus of the older writers, is caused by a shortening of the gastrocnemial and soleal muscles, aided, in some cases, by the flexor of the toes. It is nearly always, in its uncomplicated forms, a non- congenital affection. In this variety of the deformity the individual walks upon the ball of the foot, the toes, or the metatarso-plialangeal articulations, without the heel or any other part of the sole DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. Fig. 808. Valgus. Fig. 809. Fig. 810. Equinus. touching the ground. The distance to which the heel is raised ranges, in different cases, fiom six lines to tour or five inches, according to the extent of the contraction upon CHAP. XIX. CLUBFOOT. 1035 which the distortion depends. Considerable diversity is observed in regard to the manner in which the person treads on the ground; most commonly the ball ot‘ the little toe bears tbe brunt of the pressure, but in some instances the weight is thrown upon the great toe, or it is diffused over the whole of the forepart of the plantar surface. In the worst grades, the heel is so much elevated that the foot forms nearly a straight line with the leg, the toes are much deformed, and perhaps re- tracted, if not doubled under, the instep is unnatu- rally convex, from the projection of the astragalus, the plantar aponeurosis is greatly contracted, and the skin above the heel is thrown into large, dense wrinkles. Phalangeal clubfoot, without some com- plication with the other forms of the affection, is exceedingly rare. In the fourth variety, the calcaneal, fig. 811, the limb rests upon the heel, the toes being drawn upwards towards the anterior surface of the leg, with which they sometimes form an acute angle. The immediate cause of the deformity is a contrac- tion of the anterior tibial muscle and of the ex- tensor of the great toe, assisted occasionally by that of the common extensor of the foot. The tendons of these muscles form an evident pro- tuberance under the skin, where they present the appearance of tense, rigid cords, which powerfully resist the flexion of the limb. The inner margin of the foot, as seen in the cut, is sensibly elevated above the outer, and there is always considerable atrophy of the leg. The distortion, which is almost constantly congenital, is exceedingly rare. I have seen only a few cases of the noncongenital variety. The most remarkable one was that of a young female, who, in consequence of an ulcer on one of the toes, had got in the habit of walking on the heel, until at length the parts became rigidly fixed in their abnormal position. Occasionally the foot inclines slightly outwards, owing to the inordinate contraction of the common extensor muscle. The changes which the bones, ligaments, and muscles undergo, vary, not only in the different species of clubfoot, but in the different stages of the same case. The greatest alteration appears to exist on the part of the tarsal bones, which, although they are rarely completely dislocated, are generally somewhat separated from each other, twisted around their axes, variously distorted, atrophied, or marked by irregular spicules or exostoses. The calcanelirn, cuboid, scaphoid, and astragalus always suffer more than the other bones; which, however, as well as those of the metatarsus and of the toes, usually participate, more or less, in the deformity. The ligaments, in recent cases of clubfoot, are not materially changed, but in those of long standing, or in the higher grades of the affection, they are invariably stretched in the direction of extension, and relaxed in that of flexion. In some instances the original structures are partially replaced by bands of new formation, of a dense, fibrous character, the volume and resistance of which vary according to the duration of the disease, and the pressure of the parts which they serve to connect. The muscles also are not much altered in the first instance, except that they deviate from their natural direction, and that, like the ligaments, they are elongated, on the one hand, and shortened, on the other. In ancient cases the whole limb is always considerably wasted, and many of the muscles are remarkably thin and pale, or even transformed into soft, fatty bundles. The connective substance is condensed and diminished in quantity; the fat is absorbed ; and even the vessels and nerves supplying the affected parts are re- duced in volume. The skin of the foot, which receives the principal brunt of the pressure in standing and walking, is generally very much thickened and indurated, and large synovial burses are often formed beneath it, which are apt to inflame, and thus add to the suffering of the patient. There is always, even in the most recent cases, a marked dimi- nution of temperature with more or less atrophy of the atfected limb. Clubfoot, both congenital and acquired, is liable to be complicated with various affec- tions, interfering, more or less, not only with the comfort of the patient but the permanent restoration of the limb. Among the more common of these defects are corns and bunions, cutaneous cicatrices from burns, scalds, or ulcers, ankylosis of some of the joints, and Fig. 811. Calcaneus. 1036 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. deviation, absence, or increase of the number of toes. Fortunately nearly all of these complaints admit of relief by treatment. Treatment—The treatment of clubfoot should always receive early and efficient atten- tion, for the longer it is deferred the more difficult it will be, other things being equal, to effect a cure. This is equally true of the congenital as of the accidental form of the affection. The bones in early life, and in recent cases of deformity, are much more easily restored to their normal position than in youth and adolescence; and the muscles also regain much sooner, as well as more completely, their native power. In the worst grades of the lesion, it is generally extremely difficult, if not impossible, when treatment has been neglected until after the age of puberty, to make a satisfactory cure without the division of a considerable number of tendons, and the necessity of compelling the patient to wear, for a long time, various kinds of apparatus; or, what is worse, removing some of the tarsal bones. The precise period at which the treatment should be commenced has been variously defined by different authorities. Provided the infant is healthy, my custom has long been to begin it as early as the end of the second month, and, unless the case is very bad, I have rarely found it necessary, at this early period, to do more than confine the limb in a well-adjusted splint, worn steadily day and night, and assisted by stretching of the shortened muscles and tendons. This duty may always be very properly entrusted to the mother or nurse, who, with the child lying across her lap, steadies the limb by grasping the leg just above the ankle with one hand while with the other she moves the foot more or less forcibly in a direction contrary to that of the displacement. This operation, to be effec- tive, should be repeated at least twice a day, the limb being well washed and rubbed at each dressing, in order to invigorate and develop the muscles, which, as previously stated, are always greatly atrophied. Some surgeons, among others, Dr. Thomas G. Morton, assert that, by steady perseverance in these efforts, a permanent cure is occasionally possible. That this is true I have no doubt, but the cure must always be tedious, and, in the end, often unsatisfactory. Hence I never hesitate to use the knife, even in the more simple forms of clubfoot, knowing from long experience how simple the operation is, how free it is from danger, and how seldom it is followed, when properly performed, by any mishap. It will, I am sure, accomplish in a few months, under proper supervision, what manual treatment cannot accomplish, as a rule, under several years. When the distortion is at all considerable, I invariably employ tenotomy as a preliminary measure, and this may always be done with the most perfect safety, within the first few weeks after birth. Of course, no operation should be undertaken during severe teething, or other serious trouble incident to infancy and childhood. Different kinds of apparatus are in vogue for the cure of clubfoot, and it is, therefore, not always easy for the practitioner to determine which is the best, or which should be employed to the exclusion of others. Every orthopaedic surgeon, almost, has some peculiar notions upon the subject, which induce him to adopt such measures as whim, fancy, or experience may dictate. This very circumstance, however, goes to show' that the same end may be attained by different means. Whatever plan be adopted, the great caution to be observed, on the part of the surgeon, is that the extension be made in a slow and gradual manner, that the skin be protected from friction and unequal pressure, that the dressing be worn day and night, and, finally, that the limb be frequently washed, and immediately afterwards rubbed with some mild sorbefacient lotion. The object of these instructions is self-evident, and must be constantly borne in mind in our curative proce- dures. During the first few days, the apparatus should be applied rather loosely, until the limb has become accustomed to its presence, w'hen it must be gradually tightened. If the skin becomes chafed, hot, and tender, measures must immediately be adopted to moderate or shift the pressure, or the apparatus must be left off altogether for a few days. In young children, the skin is so delicate that, unless the greatest caution is used, the foot may be seriously injured before any one is aware of it. By inattention to this rule, I have seen deep ulcers produced, which greatly interfered with the subsequent management of the case. The foot at each dressing should be strongly extended and everted, for the twofold object of elongating the tendo Achillis and the tendon of the anterior tibial muscle. Too much stress cannot be laid upon these efforts. The whole of the after-treatment must be conducted under the supervision of the surgeon, who should give the case his daily attention during the first three or four weeks, or until the new material has become thoroughly organized. The time required for restoring the limb to its normal position must necessarily vary in different cases, and must depend upon so many circumstances as to render it impossible CHAP. XIX. CLUBFOOT. 1037 to lay down any specific rule. From six to twelve months, however, may be regarded as a fair average, although occasionally a much longer period will elapse, even under the most unremitting attention. The division of the faulty tendons always, as previously stated, materially expedites the cure. Mr. Richard Barwell, of London, considers tenotomy as a remedy for clubfoot entirely unnecessary; or, at all events, that the tendo Achillis is the only muscle that ever requires division. The means upon which he mainly relies for rectifying the faulty position of the foot are, adhesive strips, longitudinal and circular; a piece of turned iron about an inch in width, as long as the child’s leg, and provided at its upper extremity with a wire loop; a few India-rubber cords of various lengths by three lines in diameter; and some eyelets, with pincers for fixing them. The object of the whole proceeding is to aid the atfected muscles in regaining their action upon the foot, by compelling them to adapt themselves to the normal posture. Mr. Barwell’s plan of treatment is warmly advocated by Dr. Sayre and several other eminent surgeons. As an exclusive practice, it cannot, I think, be too pointedly con- demned. While in some instances it answers the purpose ad- mirably, it is certain that in the great majority tenotomy consti- tutes a most important preliminary step to a rapid and successful cure. My reasons for this statement are twofold. In the first place, tenotomy, when carefully performed, is, as stated before, a perfectly harmless operation; and, in the second, the treatment pursued by Barwell, Sayre, and others requires an amount of skill and attention which few practitioners can command. Dr. Little, of London, long ago recommended the application of the plaster of Paris bandage; and Professor P. C. Conner, of Cincinnati, has recently recalled the attention of the profession to the value of this mode of treatment. He enjoins great caution in the use of the bandage, which should be retained, on an average, for about six weeks, when it should be replaced by a new one. The treatment may be commenced within a few weeks after birth, and may be preceded or not, by the division of the tendo Achillis. The only objection to this treatment is the long retention of the dressing, which thus seriously interferes with the employment of massage, so important a means of developing the wasted limb. A great variety of clubfoot apparatus has been constructed during the last thirty-five years, all based upon the original well- known shoe of Scarpa. The adjoining sketch, fig. 812, affords a good idea of what such a contrivance ought to be, and, under the superintendence of any accomplished cutler, it may readily be made with the aid simply of a plaster cast, which may now be sent by express to any part of the country. The essential elements of the apparatus are a shoe and two side- pieces, extending as high up as the lower third of the thigh, the whole being so arranged by means of screws as to permit the angle of flexion to be regulated at pleasure. The shoe, composed of soft leather, well padded, and laced in front, has a steel sole, consisting of two pieces, moved by a concealed screw, the spring of which projects at the side. In this way the foot may readily be turned to one side or the other, according to the. exigen- cies of the case, while it is depressed or elevated by an oblique screw at the ankle, con- necting the shoe with the leg-piece of the apparatus, and worked by a key, as seen in the accompanying drawing. The lateral steel rods are so constructed that they may be lengthened or shortened at will, and are fastened by means of well-padded straps, each inclosing a semicircular piece of steel behind, in order to afford proper support to the limb in that situation. They are united, opposite the knee, by a hinge-joint, to permit the full play of that articulation. There is an apparatus, differing from the preceding chiefly in having only one side- piece, and in being worked by an endless screw, situated opposite the ankle. Its great value consists in the facility which it affords for depressing the displaced margin of the foot. In the calcaneal form of the affection, attended with great depression of the heel and inordinate contraction of the plantar arch, the most suitable apparatus, after the division of the faulty tendons, is the one depicted in fig. 813. Its construction and mode of action Fig. 812. Clubfoot Apparatus. 1038 DISEASES AND INJURIES OF THE EXTREMITIES CHAP. XIX. will be understood at a glance, without the aid of any description. By means of the spring or elastic cord attached to the back part of the apparatus the heel is gradually forced up, and the foot pro- portionately lowered, until the defect is permanently remedied. The division of the faulty tendons requires more care and atten- tion than is usually imagined. Every tyro in surgery thinks he can easily effect it ; but this is a great mistake. To do it well re- quires skill, judgment, and a perfect knowledge of the anatomy of the foot and leg. It is this presumptuous interference that has brought so much obloquy upon the operation. Very little, if any, preliminary treatment is generally necessary. If the child, how- ever, is several years old, and has been accustomed to much ex- ercise, it will be well to keep him at rest for a few days before the operation, to wash the foot repeatedly with cold water, and to enjoin a light diet. I he operation may then be commenced, an anaesthetic being given or not, according to circumstances, and every faulty tendon and fibrous band being divided at one sitting. The posi- tion of the patient must necessarily vary according to the exigen- cies of the case. I he number and nature of the tendons requiring division vary with the extent and character of the distortion. Thus, in simple equinusor phalangeal clubfoot, the tendo Achillis alone being con- cerned in producing the affection, the operation must accordingly be restricted to that cord, and the effect is generally such that, if the patient is able to walk, no apparatus will afterwards be needed to bring down the heel. Pure uncomplicated varus requires the division of the tendon of the anterior tibial muscle, or of this muscle and of the long flexor of the toes. In the more simple forms of valgus, the tendons of the peroneal muscles are mainly concerned; while in calcaneal clubfoot the distortion depends upon the contraction of the anterior tibial and common extensor muscles of the toes. In equino-varus, and in the worst forms of clubfoot generally, more or less extensive division of the*plantar aponeurosis is required. Age is no bar to tenotomy. I have repeatedly performed the operation within the first two months afterbirth, and I should not object to it, if the child were perfectly well, and the distortion very great, within the first fortnight, although, as a general rule, it is best to wait a longer time. Mr. Stromeyer Little, of London, has operated with excellent suc- cess within twenty-four hours after birth. L oung adults are often immensely benefited, and sometimes entirely relieved, by the operation; and cases have been reported of ex- cellent results in persons of forty and even fifty years of age. The tenotome which I am in the habit of using is represented in fig. 814 ; it is nearly six inches in length, of which one inch and three-quarters are occupied by the blade. The cutting portion of the blade is spear shaped, very sharp, thin, and a little more than five-eighths of an inch in length by two- thirds of a line in width at its widest part. 1 lie instrument, of course, makes a mere puncture in the skin. Some operators use • , , two tenotomes ; a sharp one for incising the integument, and a blunt one for severing the deep structures ; and I have myself not thVotlim’1 11S nie^ although it is questionable whether it is any safer than In dividing the tendo Achillis, the patient is placed upon his abdomen, and the limb, extended upon the table, is firmly held by an assistant. The operator, sitting in a c uur, grasps the foot with his left hand, and, bending it over the edge of the table, brings town the heel as far as possible. The necessary tension being thus given to the tendon, ie m e is entered flatwise between it and the deep-seated structures, about three-quarters o an inch above the calcaneum, and pushed on until it reaches the opposite side, care eing taken that the point does not pierce the skin. The instrument is now turned in such a manner as to bring the edge of the blade against the anterior surface of the cord, which is then completely severed by pressing the handle steadily and firmly backwards, with a kind of sawing motion. The division of the parts is generally indicated by a distinct snap, and by the immediate cessation of resistance. The operation is attended with iardly any pain, and with the loss only of a few drops of blood, although occasionally it Fig. 813. Apparatus for Calcaneal Clubfoot. Fig. 814. Tenotome. CHAP. XIX. CLUBFOOT. 1039 amounts to several draclnns, owing to the division of a small vein or two. The only actual danger is the wounding of the posterior tibial artery, but this may easily be avoided simply by keeping the knife in close contact with the anterior surface of the ten- don, and cutting from before backwards. The puncture may be made on the inner or outer side of the limb, as may be most convenient. The knife must not be entered too low down, otherwise it may penetrate the synovial burse interposed between the upper part of the tuberosity of the calcaneum and the tendo Achillis. The late Professor Joseph Pancoast, instead of severing the tendo Achillis, preferred, in most cases attended with retraction of the heel, the division of the inferior portion of the soleal muscle, on the ground, not only that the procedure is free from danger, but that it admits of the more rapid rectification of the deformity. The operation, which he per- formed a number of times, is, however, applicable, only where there is marked tension of the soleal with relaxation of the gastrocnemial muscle ; and its execution requires so much skill and such accurate knowledge of the anatomy of the parts that none but the most adroit and experienced operator should attempt it. Several cases have been reported in which fatal hemorrhage occurred from injury inflicted upon the posterior tibial artery. Violent erysipelas has also been known to follow upon it. The tendon of the posterior tibial muscle is cut most conveniently about an inch and a quarter above the inner ankle, the patient lying on his side, with the inner surface of the leg looking upwards. The operation is conducted upon the same principles as in divid- ing the tendo Achillis, and the only precaution necessary is to avoid the posterior tibial artery and nerve, which might be endangered by carrying the knife too deeply. The ten- don of the long flexor muscle may be severed at the same point. In the slighter cases of distortion, the tendon of the posterior tibial muscle may be cut below the ankle, in its passage to the scaphoid bone, but in the more aggravated forms such a procedure is im- practicable on account of the concealed situation of the cord. The tendon of the flexor muscle of the great toe may be divided in the sole of the foot, where, when it interferes with the rectification of the limb, it forms a tense, prominent cord. The most favorable situation for dividing the tendon of the anterior tibial muscle is in front of the ankle-joint, where it may usually be readily felt as a tense cord lying some- what nearer to the internal malleolus than in the natural state. The patient rests'on his. back during the operation, and care is taken not to wound the anterior tibial artery. The tendons of the peroneal muscles are most easily divided a short distance above the outer ankle, as they run over the fibula. The operation will be facilitated if, as the knife is carried outwards towards the surface, the foot is rotated downwards and inwards, the cords being thus rendered more tense. In dividing the plantar aponeurosis the knife is inserted flatwise beneath the skin, and made to cut from before backwards, the patient lying upon his back, and the foot being put on the stretch. As the aponeurosis is extremely dense and firm, its division generally requires a very sharp, well-tempered knife, worked with a kind of sawing motion, the finger resting the while on the skin immediately over it, to prevent it from cutting through. It is seldom necessary to divide more than two bands, one in the posterior part of the sole, and the other at the inner margin of the foot, corresponding with the meta- tarsal bone of the great toe. As soon as all the faulty structures have been thoroughly divided the foot is forcibly flexed and extended, in order to break up any morbid adhesions that may exist, and sepa- rate as widely as possible the ends of the tendons, as much force being used for this pur- pose as may seem to be compatible with the safety of the limb. The advantage gained in this way is generally very great, and it is remarkable how tolerant the parts are of manipulation. The little puncture made in the operation is covered with a strip of adhe- sive plaster, and usually closes in a very short time. The limb, bandaged from the toes up, is immediately placed in an appropriate apparatus, either with or without a stocking. In the former case it will be well to cut off the part of the stocking corresponding with the toes in order that, if undue swelling arise, the fact may at once become apparent. This plan has been constantly pursued by me for many years, and I have never had any cause to regret it; on the contrary, I believe it to be decidedly preferable to waiting three or four days as usually recommended ; for at the end of this time the parts are often so tender as to be quite intolerant of pressure and extension. It is only in cases of an extraordi- nary character that this rule should be deviated from. There need be no apprehension of a want of reunion of the ends of the divided tendon when this course is adopted. I have myself never met with such an occurrence, nor heard of one that was entitled to credence. The apparatus must, of course, be applied rather loosely at first, and be grad- 1040 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. ually tightened as the limb becomes more tolerant of its presence. It should be taken off regularly every day, in order that the limb may be freely washed and rubbed with some mild sorbefacient lotion, as well as subjected to passive motion ; a circumstance of great importance in respect to the welfare of the ankle-joint, and the restoration of the muscles of the limb. For the first five or six days after the operation, the limb is kept at rest in an elevated position ; after that time the patient may be carried about or walk with the aid of a crutch or stick, as may be found most convenient. The apparatus must be worn day and night, for a period varying from three to twelve months, according to the severity of the case. When the patient is old enough to walk, and the deformity has been entirely overcome, it will be advisable to substitute for the ordinary apparatus, but only during the day, a less complicated shoe, as the one represented in fig. 815, which, by confining the foot in the normal position, without the necessity of adjustment, permits the ordinary movements of locomotion. It should be worn until further support can be dis- pensed with. It there be more than usual paralysis of the extensors, or if the contraction of the tendo Achillis have not been entirely overcome, the addition of an elastic band, as in fig. 81G, will greatly expedite the cure. Dr. T. G. Morton has improved this shoe by inserting a hinge in the outer steel bar, and a double antero-posterior hinge in the inner Fig. 815. Fig. 816. Fig. 817. Shoes for the After-treatment of Clubfoot, Morton’s Shoe. steel bar, fig. 817, through which the weight of the body imparts an outward movement to the foot, thereby overcoming the tendency to recurrence of the deformity. If the treatment is properly conducted, the patient and surgeon carefully cooperating, there will seldom be any necessity for a redivision of the tendons, a circumstance always to be greatly deprecated. During the after-treatment, much benefit may be expected from the cold douche, fric- tion with stimulating lotions, particularly such as contain veratria and ammonia, massage, passive motion, electricity, and faradization, perseveringly continued until the weakened and degenerated muscles regain their normal character. The limb should be kept warm with worsted stockings ; and the general health, if deranged, should receive due attention. An excellent walking shoe, represented in fig. 818, has been invented by Kolbe, and is much employed in this city. In simple equinus, occurring in children and young persons, I have never found it necessary to apply any apparatus, the heel rapidly coming down under exercise, which the patient may safely begin within a few days after the operation. The interval between the ends of the divided tendons is gradually filled up with plastic matter, while the blood poured out in the opei'ation is rapidly removed by the absorbents. As in other subcutaneous procedures, the plasma soon becomes organized, and is finally converted into a firm, dense substance, analogous to the original structure, which it is destined to replace. Observation shows that it is already quite firm and unyielding by the end of the first fortnight; a circumstance which proves how important it is to give due heed to the management of the extending apparatus. I he operation for clubfoot is occasionally attended with the puncture of some of the arteries, especially the anterior and posterior tibial. In such an event, the proper plan is CHAP XIX. CLUBFOOT. 1041 to divide the wounded vessels, and to use graduated compression, or, this failing, acupressure nmy be tried. Ligation is seldom necessary. A false aneurism sometimes forms, especially when, after injury of an artery, no proper treatment has been employed, the blood then diffusing itself in every direction. The tumor, which is seldom circumscribed, is soft, elastic, and pulsates more or less distinctly as in similar affections elsewhere. The only resource is ligation of the vessel at both ends, although a case has been recorded by Mr. William Adams, of London, of a speedy cure with an injection of ten drops of the concentrated solution of the subsulphate of iron, the femoral artery being compressed for five minutes before and after the operation. The cutaneous puncture made in this operation is occasionally converted into an open wound, thereby inviting suppuration and even ulceration. Such an accident is most liable to happen during the division of the tendo Achillis, when adhesions have formed with the skin after a previous opera- tion. It may, also, as in several instances in my own hands, depend upon the presence of vicious cicatrices, the result of burns, scalds, or ulcers. The foot is at once extended and the wound closed with lint and adhesive plaster, confined with a com- press and roller, the dressing remaining undis- turbed for several days. Suppurative inflammation of the sheaths of the divided tendons and of the surrounding connective tissue is an occasional consequence of this operation, but it must be very uncommon, as I have never seen an example of it. It is most liable to follow the division of the deeper tendons, and must be managed upon general antiphlogistic principles. Finally, whatever mode of treatment may be adopted, it is of paramount importance that it should be carried out under the personal superintendence of the surgeon ; to delegate this office to the parent or nurse or to the patient himself, is only a waste of time, and what no sensible practitioner should ever do. I never, in fact, like to intrust the management of a case of clubfoot even to an intelligent physician, for there are so many points that demand attention that, un- less the greatest possible care is exercised, something will be sure to go wrong, and mar the beauty of the cure. The adjoining sketch, fig. 810, illustrates the effects of the division of the tendo Achillis and plantar aponeurosis, in a case of equino- varus, attended with bad deformity. The .cure was perfect. In the rigid clubfoot of subjects who have either never undergone treatment, or in whom the deformity has recurred as a result of neg- lect, the ordinary management is powerless to overcome the changed relations of the tar- sal articulations and the adapted shortening of the ligaments and other soft structures of the foot. These deformities may, however, be improved and even cured after preliminary softening of the tissues with poultices applied for ten or twelve days, by gradually forcing the bones into a normal position with the foot-stretcher of Kolbe, represented in figs. 820 and 821. Division of the plantar fascia and of some of the tendons may become necessary during the progress of the treatment. Tarsectomy In equino-varus of adults, after the failure of other methods of treatment, Fig. 818. KolbtS’s Walking Shoe for the Treatment of Talipes. Fig. 819. Effects of the Operation for Clubfoot. 1042 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. excision of one or more of the bones of the tarsus may be resorted to; but it is doubtful whether the results of the operation are in any way better than those of Chopart’s ampu- tation. The cuboid bone alone may be removed, as was originally done by Mr. Solly, in 1857, or a wedge-shaped portion of the tarsal arch may be excised, as first practised by Weber, in 1866. Of 9 examples of the former operation, 1 died, after consecutive ampu- tation, and 8 recovered, but the result was good only in four, while of 47 cases of the Fig. 820. Fig. 821. Kolb6’s Clubfoot Stretcher. latter procedure, analyzed by Dr. S. W. Gross, 3 died, and progression was satisfactory in nearly three-fourths. For congenital equinus the astragalus has been removed six times by Ried, Lund, Verbelzi, and Erskine Mason, the operation of the latter including the external malleolus. Of these 7 cases, two were successful, in four the result was doubtful, and the patient of Mason died after amputation for secondary hemorrhage from the posterior tibial artery. The ankle-joint has been successfully excised in six cases of accidental equinus, the operators having been Ried, Volkmann, Von Lesser, and Verneuil. The operation for clubfoot, as stated in a previous chapter, was first satisfactorily per- formed in 1831, by Dr. Stromeyer, of Hanover. Tho tendo Achillis, however, was di- vided as early as 1784, by Lorenz, a surgeon at Frankfort, at the suggestion of Dr. Thilenius. The case was one of equino-varus, in a young lady who had suffered from birth. The operation was performed, not subcutaneously, but by direct incision. The heel descended two inches; and, although the cure was tedious, the patient finally ob- tained a good use of the limb. A similar operation was performed not long afterwards bv Sartorius; be made his incisions still larger than Lorenz, and it is, therefore, not sur- prising that he should have signally failed. Michaelis, at a somewhat later period, modified the procedure by dividing the shortened tendon partially, and immediately bringing down the foot by mechanical appliances. His first operation was performed in 1809. In 1816, Delpech, of Montpelier, whose name is indelibly associated with this department of surgery, conceived the idea of performing the operation subcutaneously, and he accordingly carried it into effect in a case of varus conjoined with retraction of the heel. What is remarkable, however, and what greatly marred the success of the result, was that he should have made, as a preliminary step, an incision an inch in length through the skin and deep-seated structures on each side of the tendo Achillis, evidently with a view of facilitating the division of the cord from behind forward. After much trouble and not a little sutfering the patient ultimately made a tolerably good recovery, but Delpech was so much discouraged that he never ventured to repeat the operation. Such was the state of tenotomy when Stromeyer, fifteen years later, entered the field, and, perceiving the errors of his predecessors, laid down the proper principles which should guide the surgeon in the execution of his task. FLATFOOT. This deformity, which is most common in young adolescents, occurs in both sexes and in all classes, usually from some inherent congenital defect in the structures of the foot, aggravated by overwork, by the use of imperfectly constructed shoes, or by vicious ever- sion of the foot, in attempts at polite walking. It is often associated with disorder of the general health, and is most frequently met with in persons of a strumous predisposition, with a tendency to rachitis. Although it sometimes begins very early in life, it seldom becomes a source of deformity until after the age of fourteen. Both feet commonly suffer simultaneously, but not in the same degree. The affection, as seen in the annexed sketch, fig. 822, essentially consists in a loss of the arch of the foot, so that, when the individual stands up, the sole rests flat upon the ground, instead of upon the heel and the ball of the toes. The external malleolus is uncommonly prominent, the foot inclines outwards, as in the milder forms of valgus, and the ankle is remark- ably large and full. In the worst forms of the affection, there is partial displacement of the sca- phoid, astragalus, and internal cuneiform bones, the convexity of the dorsum is lost, the toes are everted, and the foot is considerably elongated. The ankle-joint, at all times weak, eventually loses its mobility, and the patient is permanently crippled and deformed, progression being difficult, awkward, and painful. The internal lateral liga- ment is attenuated and relaxed, while the peroneal, tibial, and extensor muscles are shortened, and not unfrequently affected with the fatty degeneration. The treatment, in the earlier stages of the complaint, consists in the use of the cold douche, followed by friction with some stimulating liniment, and aided by mechanical sup- port of the ankle, as a shoe or boot with side-pieces and a screw for inverting the foot. The sole should be considerably thicker on the inner than on the outer side. The gen- eral health is amended, if necessary, by tonics and change of air. Absolute rest of the limb is sometimes of the first importance, in order to afford the weakened structures an opportunity of becoming invigorated, exercise being taken, in the mean time, in a carriage or swing. In the more serious forms of flattening, attended with great eversion and more or less elevation of the toes, recourse must be had to tenotomy, with the subsequent employment of a rectifying.apparatus. The treatment, in fact, must be very similar to that of valgus. The muscles, whose tendons may require division, are the peroneal, the anterior tibial, and the long extensors of the toes. PERFORATING ULCER. Under this appellation, Delsol and others have described a disease which, usually begin- ning as a callosity on the sole of the foot, at the root of one of the metacarpal bones, gradually terminates in an undermined, ill-looking ulcer, with a dark, foul bottom, and a peculiarly offensive, sero-purulent discharge. It is surrounded by a wall of thickened epidermis, and its edges are so steep as to give it the appearance as if it had been made with a punch. As it progresses, it erodes the ligaments and periosteum, and finally pene- trates the contiguous joint, followed by softening and caries of the bones. If not checked, the inflammation spreads among the adjoining structures, causing extensive purulent infil- tration, and such a degree of disorganization as to necessitate amputation. The character of this complaint is obscure. While some suppose it to be due to a syphilitic taint, others imagine it to be of the same nature as senile gangrene, especially as it is most commonly met with in elderly subjects, in connection with calcification of the arteries, while others, again, ascribe it to degenerative lesions of the nerves of the part. The first appearance is usually a thickening of the epidermis, like that of a corn, but more extensive and painless. The disease may last for weeks and months, and is then nearly always attended with severe local and constitutional disturbance. CHAP. XIX. FLATFOOT—PERFORATING ULCER. 1043 Fig. 822. Flatfoot. 1044 The treatment consists in thorough division of the parts, and in the application of iodine followed by lotions of acetate of lead and opium. Leeches will be beneficial when there is much swelling, conjoined with discoloration and pain. Purulent infiltration must be relieved with the knife. Amputation will be required when there is extensive disorgani- zation of the joint, bones, and tendons. The exhibition of some of the iodides and of mercury is indicated when the complaint is obviously of a syphilitic origin. PODELCOMA. A peculiar ulcerous affection of the foot, known under the name of podelcoma, is occa- sionally met with. Its precise nature is not well understood, some regarding it as of a scrofulous, others as of a syphilitic, character. It occurs in both sexes and in different classes of individuals, and is most frequent in persons of middle life, of a broken con- stitution. Commencing usually about the toes, the disease is characterized by the occurrence of numerous small sores, separated by thickened and indurated skin, their edges being steep and abrupt, and their surface incrusted with aplastic lymph. Their shape is generally oval or circular; sometimes, although rarely, several run together, or are connected merely by narrow, undermined bridges of integument. The discharge is foul, fetid, sanious, and irritating. The pain is usually very severe, and there is always sei’ious constitutional involvement, the patient being thin, wan, weak, and fretful. In cases of long standing, the disease is not limited to the soft parts, but affects the other structures also. The nails ulcerate and drop off; the phalanges of the toes are rendered carious; and the calcaneum and metatarsal bones ultimately experience a similar fate. The frightful changes which this disease is capable of producing in the foot are well illustrated in the annexed cut, fig. 823. The natives of India are subject to a form of podel- coma, due, as has been shown by Carter, Berkeley, and others, to the presence of a mucedinous fungus, which works its way into the bones of the tarsus, metatarsus, and lower ends of the tibia and fibula, causing much pain, swelling, and deformity, tunnel- ling through the tissues of the entire foot by numerous apertures and fistulous routes, attended with much fetid, irritating, and unhealthy discharge, and even- tually, unless amputation be performed, producing death by exhaustion. The affection is popularly known in India as the Medura foot. In the treatment of this disease, great advantage may be derived from a regular and persistent course of iodide of potassium along with iodide of iron and bichloride of mer- cury. Quinine and brandy will be required if much debility exist. The best topical remedies are emollient cataplasms or warm water-dressing, with the free use of the chlor- ides, to allay fetor and promote cicatrization. The nitric acid lotion will also prove useful; and many cases will do well under the application of calomel, or calomel and tannic acid, with dry lint. In the worst forms nothing short of amputation will answer the purpose. PODODYNIA. This disease, which was originally described by me in 1864, is so common among tailors, especially cutters, that I was at one time almost inclined to call it after their name. More enlarged experience, however, has shown me that all classes of persons are liable to it, and that it is not peculiar to any occupation or mode of life, or to persons who are obliged to use their feet a great deal. Both sexes are liable to it, but the subjects are, for the most part, young men. In 1877, I had at one time three young ladies affected with it under my care. I have never met with it in early or advanced life. The soreness in pododynia is generally most severe in the sole of the foot, over the calcaneum and the ball of the great toe, or in the line of the metatarso-phalangeal joints, parts which are particu- larly subject to pressure during the erect posture. The hollow of the foot, however, occa- sionally participates in the suffering. The pain and tenderness are deep seated, and are always aggravated by the pressure of the finger, and by walking and standing, which the patient is often obliged to forego in consequence. Instead of pain there is often a dis- DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. Fig. 823. Podelcoma: n, the Toes much altered ; b, the Outer Side of the Foot, in some Parts, showing Cicatrices ; c, the Line of Amputa- tion, at the Ankle ; d, the Astragalus. The Swelling is often much greater than here represented. CHAP. XIX. AFFECTIONS OF THE LEG. 1045 agreeable, tinkling sensation in the parts. Little swelling attends the disease, and there is seldom any marked discoloration of the skin, except in the more severe forms of the affection, when the surface occasionally exhibits a mottled or purplish appearance, evi- dently dependent upon a congested condition of the capillary vessels. A sense of cold- ness often pervades the entire foot; and in some cases the disease extends a considerable distance up the leg. Both feet often suffer simultaneously. The general health is seldom materially, if, indeed, at all, affected. What the pathology of pododynia is I have not been able to determine, as no oppor- tunity has been afforded in dissecting the parts. The probability is that it is a form of inflammation, chiefly of the periosteum, or of the periosteum and plantar aponeurosis, attended with a disordered condition of the vasomotor nerves and an inordinate determi- nation of blood. In the cases which have fallen under my observation, it has not been in my power to trace any connection between this disease and gout or between it and rheu- matism. The treatment which I have found most efficacious in pododynia has been a succession of blisters, with rest and elevation of the foot, and some attention to the diet and bowels. Slapping the affected parts with the end of a fringed towel has also been of marked benefit, especially when there was serious disorder of the vasomotor nerves. Medicated lotions, tincture of iodine, and leeching have exerted no special influence upon the progress of the disease. In a few cases I have tried, but without any material benefit, subcutaneous scarification of the affected parts. In one instance, a cure was effected by the division of the plantar aponeurosis, which was abnormally shortened. Colchicum has been of no service in my hands. When, as occasionally happens, the pain is decidedly periodical, quinine should be freely used, either alone or with other antineuralgic remedies. TUMORS. Various kinds of morbid growths, benign and malignant, are liable to occur in the foot, both upon its dorsal and plantar surfaces. Of the former, the most common are the fibrous and fatty ; of the latter, the epitheliomatous and sarcomatous. The fibrous tumor is most frequent on the posterior part of the sole of the foot, where it often sadly interferes with progression ; it is generally situated immediately beneath the skin, imparts a firm, slightly elastic sensation to the finger, is of a rounded, elongated shape, tardy in its growth, more or less vascular, and liable to return after extirpation. The history of the case, and a careful examination of the tumor, will usually reveal its true character. The fatty tumor of the foot is uncommon ; it is free from pain, of slow progress, lobu- lated, and of a doughy, inelastic consistence. The skin is usually sound. I have heard of a tumor of this kind in the foot, of the size of a large fist, for which the leg was ampu- tated. A similar case has been reported by Mr. Gay, of London. In this case the tumor was congenital, and occupied the sole of the foot, which was amputated under the belief that the growth was of a recurrent, if not of a decidedly malignant, nature. A rare case of hygromatous tumor of the foot, in a girl fifteen years of age, has been related by Dr. J. F. Heyfelder, of St. Petersburg. It had made its appearance six years previously without any assignable cause, fluctuated distinctly under pressure, was free from pain, but interfered with the wearing of the boot, and extended along the outer side of the foot from the tendo Achillis to the third, fourth, and fifth toes. The introduction of a trocar gave vent to a thick, turbid fluid, the flow of which was impeded by numerous small granular bodies. A cure was effected by the injection of a mixture of iodine, iodide of potassium, and water. Malignant tumors of the foot pursue the same course as similar growths in other parts of the body. The most common form is epithelioma. Sarcoma is an occasional occur- rence. Their diagnosis is generally easily determined by their history. The only remedy is early and thorough excision. When extensive involvement exists nothing short of amputation of the leg will avail. 2. AFFECTIONS OF THE LEG. BOWED LEG. This affection, familiarly known as the bowed, curved, or bandied leg, consists in an excurvation of the tibia and fibula, attended with a peculiarly arched appearance of the limb, as exhibited in fig. 824, and a singularly awkward gait of the individual. It occurs 1046 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. in various degrees, from the slightest deviation from the normal standard to the most unseemly deformity. The tibia generally suffers more than the fibula, although the latter is seldom entirely free from the defect. The curve is usually lateral, the bone being con- cave internally, and more or less convex externally. In the worst forms of the affection there is also an anterior curvature, or the curvature may exist exclusively in front. Both limbs are commonly affected, although not always in an equal degree. The deformity is sometimes associated with malfor- mation of the thigh-bones, spinal curvature, and a stunted condition of the whole body, especially when it is the result of rachitis. It is also not uncommon to meet with serious malformation of the knees, ankles, and feet, the latter of which are often greatly turned out. The immediate cause of bowed leg is softening of the osseous tissue, from defect of earthy matter. This may depend either upon rachitis or upon some other vice of the constitution, the precise na- ture of which cannot always be determined. The exciting circum- stances are two, contraction of the muscles pulling the affected bones out of shape, and the weight of the body compelling them to bend under the superimposed pressure. In rachitis the curvature is frequently attended with actual shortening; the latter defect, how- ever, often exists without the former, the pieces in which it is most marked being perfectly straight. The treatment must be early and decided. If it be postponed until the completion of the ossific process, it will be in vain to hope for relief. The general health, if at fault, must be amended by appropriate remedies; walking and standing must be interdicted; and the limbs must be supported by suitable apparatus, applied in such a manner as to make efficient counterpressure opposite the seat of the excurvation. The more simple forms of the lateral variety will generally yield to a light, well-padded wooden splint, fig. 825, stretched along the inside of the leg and inserted by a tubular socket into the heel of a laced boot. It should Fig. 824. Bowed Leg, in a High Degree. Fig. 825. Fig. 826. Fig. 827. Bigg’s Apparatus for Lateral Curva- IvolbS’s Apparatus for Bowed Apparatus for Anterior Curvature of the ture of the Leg. Leg. Leg. extend from tlie malleolus to the upper part of the condyle of the femur, and be fastened by means of strong webbing long enough to pass twice around the limb and splint, and secured with straps and buckles. The object of this arrangement is to exert the greatest amount of pressure upon the line of curvature. In the more severe grades of the affection, nothing will be found to be more efficient than the apparatus delineated in the annexed cut, fig. 82G. V A RIX. 1047 CHAP. XIX. For the relief of the anterior curvature, the best apparatus with which I am acquainted is that of Mr. H. II. Bigg, of London, represented in fig. 827. It simply consists of two stout uprights inserted into the side of a boot, fastened above to a metal band fitted to the posterior surface of the leg, and secured by means of straps around the head of the tibia. The requisite degree of pressure is made with two leather bands attached to the vertical pieces, and laced in front. In the antero-lateral or double curvature, the apparatus must be so constructed as to bear simultaneously against the front and side of the limb. Wh atever contrivance be used, care must be taken to watch its effects, otherwise it may, by its pressure, cause severe pain and even ulceration. It should, if possible, be worn day and night. The limbs should be well washed once in the four-and-twenty hours, and bathed with a strong solution of alum. When the deformity has been neglected, and cannot be overcome by appropriate appa- ratus, and the person is badly crippled, or unable to walk, the only resource is osteotomy. The division of the tibia may be effected subcutaneously with the chisel, saw, trephine, or the dentist’s drill, the point of greatest convexity of the bone being selected for the purpose, and care taken not to interfere with any important bloodvessel. The fibula may be divided in a similar manner, or broken by forcible flexion. The limb is at once placed in a suitable apparatus, or, what is generally preferable, plaster dressing. Proper vigil- ance is exercised during the after-treatment. The statistics of this operation, published within the last ten years, are of an eminently gratifying nature. Occasionally serious symptoms follow ; and instances have been recorded in which death ensued from erysip- elas, pyemia, or diffuse abscess. Tenotomy is of no use in these malformations. In the few cases in which it has been practised, it did not seem to have been even of any material temporary benefit. VAR1X. Yarix of the lower extremity is a very common disease in both sexes, and often entails much suffering. In general it involves both the leg and foot, while not unfrequently it extends even into the thigh, being particularly conspicuous along the course of the saphenous vein and its branches. An excellent illustra- tion of this affection will be found in fig. 363, Yol. I., in the chapter on the injuries and diseases of the veins, to which the reader is referred for a full account of it. The treatment is palliative and radical. In the milder cases, very little is generally required beyond attention to cleanliness of the parts, the avoidance of all constriction of the limb, and the administration, now and then, of a purgative, especially in pregnant females. If the patient is very plethoric, much benefit will arise from an occasional bleeding. The limb should be frequently washed or douched with cold water, or sponged with some alcoholic lotion, and kept as much as pos- sible at rest in an elevated posture. With the aid of these measures, the use of an elastic stocking, fig. 828, or a well-applied solid rubber bandage, the milder cases will commonly be sufficiently manageable. The solid rubber bandage is particularly valuable in cases of varicose veins attended with ulceration, or great induration of the skin and connective tissue. The mode of using it is fully detailed in the section on chronic ulcers of the lower ex- tremities. For the radical cure, various remedies have been suggested, the safest, as well as the most effectual, of which are the caustic issue, constriction with the twisted suture, sub- cutaneous ligation, and injections of subsulphate of iron. Excision and direct exposure of the diseased vessels are too dangerous to be practised, being extremely liable to be fol- lowed by phlebitis, erysipelas, and pyemia. My conviction is, that no surgeon should ever expose a patient to such risks. The treatment by the caustic issue has been eminently successful in my hands, and I, therefore, give it a decided preference. It consists in making a number of eschars with equal parts of caustic potassa and quicklime, converted into a consistent paste with alcohol. Of this, a portion of the size and shape of a three-cent, piece, only much thicker, is placed directly upon the enlarged and tortuous vessel, at intervals of three, four, or five inches, and allowed to remain for fifteen minutes, at the end of which the skin and connective tissue will be found to be thoroughly destroyed. The paste is now removed, and the Fig. 828. Gum-elastic Stocking. 1048 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. parts, carefully washed with vinegar, to neutralize any of the alkali that may still adhere to the surface, are covered with an emollient poultice, for the purpose of promoting, first, the separation of the eschars, and, secondly, the development of granulations. The cure is usually somewhat tedious on account of the length of time required to heal the issues, but it possesses the great advantage of being entirely free from danger, and always per- fectly successful. Constriction of the diseased vessels may be performed by passing underneath them, at different points, long, ordinary suture pins, and drawing tightly around each of them a stout, well-waxed thread, so as to arrest at once the circulation both within the veins and also in their tunics, as delineated in fig. 829. Some surgeons interpose a piece of wax bougie between the skin and ligature, as in fig. 830, but I do not believe that this adds anything either to the comfort of the patient or to the success of the operation. Great care Fig. 829. Fig. 830. Obliteration of Varicose Veins by Ligation. Twisted Suture. must be taken that the pins are carried fairly behind the vein, for, if they transfix it, very serious phlebitis may arise, whereas, if the procedure be properly executed, it will gen- erally prove harmless, although, as already observed, less so than the operation by caustic. The pins should not be removed until considerable ulceration has taken place, which will rarely be before the end of the sixth or eighth day. Mr. Henry Lee, of London, has modified this operation by dividing the vein sub- cutaneously between the pins as soon as the blood in it is coagulated. It is difficult to perceive the advantages of such a procedure, as a mere incision carried across such a vessel could not prevent the speedy reunion of its extremities, evidently the object of the operation. Subcutaneous ligation by means of a metallic wire, fig. 831, as originally practised in this city by Dr. II. J. Levis, is a very safe expedient, preferable to the operation by con- striction with the pin and thread. The operation is performed with a straight needle, from two and a half to three inches in length, with a sharp, angular point which perforates without cutting. The in- strument is carried across the tissues with the same precautions as in the ordinary method, and in such a manner as to bring out at the same orifices both ends of the thread, which are then firmly twisted together, and cut off about half an inch from the surface. Spon- taneous removal of the sutures will generally occur in from two to three weeks, especially if they are occasionally tightened. Dr. Bozeman effects subcutaneous ligation of the enlarged vessels with the aid of his button suture. The blood after this operation is occasionally completely devital- ized, the more especially when portions of the enlarged vein are transformed, as it were, into so many distinct sacs, some of them, perhaps, capable of containing from half an ounce to an ounce of fluid. When the blood, after having been solid, undergoes liquefaction, as indicated by fluctuation, it is an evidence that it is necrosed, and ought to be evacuated, as its absorp- tion will then be impossible. A cure of this disease has occasionally been performed by the injection of the enlarged vein with a solution of subsulphate of iron, as suggested by the late Dr. Isaacs, of New York. The most suitable instrument for the purpose is the one depicted in fig. 333, in the chapter on aneurism ; the vessel is firmly compressed as a preliminary step, by means of the finger, or a pad and roller, and a few drops, generally not more than three or four, of the officinal solution, diluted with twenty or twenty-five parts of water, are slowly Fig. 831. Subcutaneous Ligation of a Varicose Vein with Silver Wire. LACERATION OF THE TENDO ACHILLIS. 1049 chap. xix. thrown into its cavity, the contents of which are immediately coagulated. The great objection to this mode of treatment is that, while it is not always successful, in consequence of the gradual absorption of the clots, it is occasionally followed by serious accidents, as violent erysipelas and even pyemia. These remarks apply still more forcibly to the per- chloride of iron, originally employed, I believe, by Pravaz. Of 103 cases treated with this article, collected from various sources in 1862, by Dr. Sentex, of Bordeaux, 79 were cured, 19 were improved, 16 were failures, and 1 perished. Whatever mode of treatment be adopted, the case should receive every possible atten- tion until all danger from erysipelas, phlebitis, and pyemia is passed. The great object should be to restrain the inflammation that must necessarily supervene upon the operation within proper limits, for, if it be allowed to diffuse itself, the danger will be increase and hundred fold. The limb, invested with a roller, is placed in an easy, elevated position, and is kept constantly wet with water-dressing, simple or medicated, the diet and bowels being at the same time thoroughly regulated. Premature exercise must be avoided, and the leg must for a long time be supported with a bandage or laced stocking. Although surgeons are in the habit of speaking of the radical cure of varicose veins it, is questionable whether such a result is ever permanently obtained in any case, however complete the obliteration may be at the time. Gradually the collateral veins augment in size, and eventually, in many cases, become as troublesome as those originally affected. When a varicose vein of the leg gives way by ulceration, serious, if not fatal, hemor- rhage may be the result, the blood, perhaps, gushing out in a frightful torrent. The proper treatment is to clap the finger on the sore, remove the garter, elevate the heel, and place the patient on his hack. Equable pressure with a compress and roller will also promptly arrest the bleeding. ANEURISMAL VARIX. This rare form of disease is occasionally observed in the leg, or leg and foot. The most remarkable example of this kind I have ever seen, in any part of the body, came under my observation in 1858, in a woman, forty-three years of age, an in-patient of the College Clinic. The varicose enlargement extended from the base of the toes as high up as the knee, affecting both the superficial and deep vessels. Pulsation was perceptible both by sight and touch, and a well-marked aneurismal thrill, most distinct over the posterior tibial region, was readily detected by auscultation. The internal saphenous vein was enormously distended in various parts of its course, being in some places nearly an inch in diameter, and the circumference of the limb was much greater than that of the sound one. The foot had a soft, spongy feel, and a deep, excavated ulcer, of the size of a ten-cent piece, with a foul bottom and everted edges, existed upon its dorsal surface. The toes were distorted and enlarged, and near the instep there was a congenital naevus. As the limb had been for years the constant seat of severe pain, and as the poor woman had long ceased to be able to walk without crutches, I amputated the leg a short distance below the knee. A large number of arteries and also the internal saphenous vein required ligation, the latter vessel being greatly enlarged, patulous, and unable to retract. The case went on tolerably well for eighteen days, when erysipelas and pyemia ensued, followed by an enormous abscess, extending from the stump to the crest of the ilium. The woman expired, completely exhausted, at the end of the fourth week. A full report of this interesting case, with an account of the dissection of the body and limb, from the pen of Dr. S. W. Gross, may be found in the Transactions of the Pathological Society of Philadelphia for 1861. LACERATION OF THE TENDO ACIIILLIS. This accident is always the result of the sudden and violent contraction of the gastroc- nemial muscles, consequent upon inordinate exertion. It is most common in dancers and acrobats, beyond the middle age, and is probably generally connected with fatty degeneration of the substance of the tendon. The seat of rupture varies ; but in most cases it is rather low down towards the heel-bone. The occurrence of the injury is commonly denoted by a loud snap, and by a sensation as if something had suddenly given way, the patient at the same time falling down, or finding it difficult to maintain himself on his limbs. The pain is very severe, and, on examining the parts, a distinct gap is discovered at the site of the laceration, similar to that which occurs in the opera- tion for clubfoot. In the treatment of this accident, the indication is to maintain perfect apposition of the ends of the ruptured tendon until complete consolidation is effected. Unless this be promptly met, a certain degree of lameness will almost be inevitable. The apparatus that is usually em- ployed for this purpose is that devised by Monro, and sketched in fig. 832. It consists simply of a slipper and a thigh-strap, connected by a cord, the object being thorough flexion of the limb, and consequent relaxation of the gastrocnemial muscles. If the strap have a ten- dency to slip, it must be secured to the pelvis. The indi- cation may also be fulfilled by applying a splint along the front of the leg and foot, as in fracture of the heel-bone, the leg having previously been bandaged from the knee downwards so as to control the action of the flexor mus- cles, and the limb being afterwards placed in an easy, relaxed position, over a large pillow. The best dressing of all, however, is the immovable, which, if properly ap- plied, need not be renewed. A cure usually follows in from five to six weeks, but the patient must be very care- ful for some time after, otherwise the connecting bond will either give way, or become injuriously elongated. When, from neglect of proper treatment, or despite the best directed efforts, the ends of the tendons refuse to unite, the only remedy is to expose them by a free incision, and, after having cut off the offending structures, to connect the raw surfaces, rendered per- fectly square, with metallic sutures. A number of cases are recorded in which the procedure was followed by complete success. DISLOCATION OF THE TENDON OF THE PERONEAL MUSCLE. The tendon of the long peroneal muscle is occasionally displaced by external violence, resulting in a rupture of its sheath. The accident is very uncommon. In the case of a youth, recorded by Mr. T. B. Curling, of London, the dislocation was caused by the foot slipping on a stone and turning outwards. The tendon presented itself as a projecting cord at the outer and anterior part of the ankle; and, although it was easily pushed back with instantaneous relief, yet there was a constant tendency to recurrence. Permanent retention was effected by the application of a piece of cork to the margin of the fibula, confined by a suitable bandage. The leg, after such an accident, should be placed in a semiflexed position, and kept perfectly quiet until the injured structures are thoroughly reunited. RUPTURE OF THE MUSCLES OF THE LEG. Rupture of the muscles of the leg is an occasional occurrence, especially of the plantar and gastrocnemial. The accident may be caused by external violence, or by inordinate contraction of the muscular fibres at a moment when the leg is placed in a constrained or twisted position, as when the foot is implanted in a hole in the floor or ground, thus throw- ing the whole weight of the body upon the limb. Stepping out of the bed, or out of a carriage, may produce a similar effect. Fatty degeneration of the muscular tissues would act as a predisposing cause. The person at the moment of the accident is generally conscious of something having suddenly given way; he may even have heard a kind of report, noise or snap, especially if the muscles are perfectly sound, and put violently on the stretch. If, on the contrary, the muscles have undergone softening from fatty degeneration, no such occurrence will be likely to be noticed, and the true nature of the complaint may, perhaps, not even be suspected, or detectable on the most careful inspection. Generally, however, the surgeon will be able to discover a marked hollow or depression at the seat of the rupture, with an unusual prominence in its immediate vicinity, produced by the retraction of the divided ends of the muscle. The patient on attempting to walk experiences more or less impediment, to which, in a short time, there will be superadded more or less swelling and tenderness, if not actual pain. 1050 DISEASES AND INJURIES OF THE EXTREMITIES CHAP. X IX. Fig. 832. Monro’s Apparatus for Maintaining Flexion in Ruptured Tendo Achillis. CHAP. XIX. A good cure is seldom to be expected after such an accident, especially when its true nature has been overlooked, as reunion of the divided ends will then be very difficult, if not impossible. In such an event, the connecting bond will be of a fibrous nature, not muscular. The proper treatment of such an accident consists in keeping the affected limb thoroughly at rest, in an easy, relaxed position, which is best secured by the immovable dressing, or Martin’s elastic bandage, with gentle pressure applied directly over the place of rupture. Exposing the parts, and uniting the ruptured ends with the catgut suture, might be tried in old, or neglected cases, but even here the experiment is of doubtful propriety. Union in ordinary cases, of recent standing, may be expected in from three to five weeks. When the dressings are removed restoration of function will be promoted by sorbefacient lotions, unguents, and massage, aided by the use of the roller. FIRRO-CELLULAR ENLARGEMENT. This affection was originally described in 1861, by Mr. Furneaux Jordan, of Birming- ham, England. It presents itself in two varieties of form, which may occur either sepa- rately or conjointly. In the first, the enlargement completely encircles the leg immediately above the ankle-joint like a belt or collar, from two to three inches in height and from one and a half to two inches in thickness. The second form is more common; it consists in a slightly irregular, rounded or hemispherical projection, situated just below and behind the external malleolus. The enlargement, in whatever form appearing, is free from pain, tenderness, doughiness, pitting, and discoloration ; is of gradual development; is most common in young persons, especially females, and is usually connected with valvular disease of the heart. The precise nature of the complaint is not determined. It certainly bears some analogy to elephantiasis, but differs from it in being softer and less diffused, and in not seriously involving the skin. The probability is that it has its origin in local inflammation, terminating in an effusion of plasma, and the organization and ultimate con- version of this substance into fibrous tissue. The treatment is by sorbefacients, as iodine and compression with the bandage. In the earlier stages, benefit will be derived from leeching and acetate of lead. The general health must be rectified. 3. AFFECTIONS OF THE KNEE. ANKYLOSIS. Ankylosis of the knee-joint is of frequent occurrence, and may depend, first, upon contraction of the hamstring muscles ; secondly, upon disease of the ligaments and bones of the joint; and, thirdly, upon adhesions of the articulating surfaces, the union being either of a fibrous or osseous character. However induced, the limb will be sadly in the way of usefulness when the leg is straight, or flexed at a right angle with the thigh. When the ankylosis is caused by permanent contrac- tion of the hamstring muscles, a cure may generally be readily effected by the division of their tendons, passive motion of the joint being afterwards regularly maintained to prevent relapse. The operation is sufficiently simple, but requires some care to avoid the nerves and vessels in the neighborhood of the affected structures. Forcible ex- tension with the hand should be practised immediately after the section has been completed, and the subsequent treat- ment should be conducted by means of a hollow splint, composed of sheet iron, well padded to ward off pressure, worked by a screw, and applied to the posterior surface of the joint. The treatment must necessarily be tedious, demanding both patience and skill, but by proper perse- verance a good cure may be effected. The best apparatus for keeping up the requisite extension is that sketched in fig. 833, which may be readily manufactured by any respectable cutler. AFFECTIONS OF THE KNEE. 1051 Fig. 833. Extension Apparatus. 1052 When the ligaments and hones are at fault, as when there has been serious disease, resection may be required. Fibrous ankylosis, even when of long standing, may usually be effectually overcome by forced flexion under an anaesthetic, the procedure being generally well borne both by the part and system, the slight pain and inflammation consequent upon it commonly disappearing in a few days. When the connection is osseous, either Barton’s operation may he performed, or, what is preferable, the adhesions may be broken up subcutaneously by means of perforators, Adams’s saw, or other instruments, as de- scribed in the first volume, in the chapter on ankylosis. I have now performed this operation successfully in six cases, the first being that of a young man, who was under my charge at the College Clinic in 18G1, and who, notwithstanding the apparent severity of the manipulations, recovered without the occurrence of a solitary untoward symptom. The ankylosis, caused by a wTound, had existed for nine years, and the natural structures of the articulation had been completely annihilated. The leg was flexed nearly at a right angle with the thigh. I believe that such an operation will always be perfectly safe when a joint is thoroughly deprived of cartilage and synovial membrane, and care is taken not to inflict serious injury upon the soft parts. When the knee is retrocurved, or turned backwards, a very uncommon occurrence, the treatment must be conducted upon the same general principles as in the more ordinary forms of the accident. If the subcutaneous method should fail, or be inapplicable, relief should be attempted by Barton’s operation, although certainly a much more dangerous procedure. KNOCKKNEE. Knockknee is an affection in which, as the name implies, the knee is turned inwards in such a manner as to touch its fellow of the opposite side, the leg being at the same time inclined outwards. When both knees are involved, and the deformity exists in a high degree, the lower extremities, when the individual stands up, represent pretty accu- rately the outline of the letter inverted, the upper part corresponding to the thighs, and the lower to the legs, as seen in the accompanying cut, fig. 834. The feet are widely separated from each other, and are often so much everted as to compel the person to support the weight of his body principally upon the inner margin of the limb. The deformity thus occasioned is not only very unseemly, but, what is worse, produces a limping, awkward gait, which greatly interferes with progres- sion. Knockknee is always a noncongenital affection, although it is occasionally noticed at so early a period of life as to have led to the opinion, at one time suffi- ciently common, but now obsolete, that it is now and then an intrauterine lesion. It occurs chiefly in weakly, delicate subjects, from the age of two years to that of eighteen or twenty. Children of a scrofulous habit and rachitic predisposition are particularly obnoxious to it. So far as my experience enables me to judge, I am in- clined to believe that the affection is considerably more frequent in males than in females, although some allow- ance must certainly be made for the fact that the dif- ference in the clothing of the two sexes renders the former, when laboring under knockknee, a subject of much greater attraction than the latter, many of whom, simply in consequence of the difference in the dress, entirely escape detection, both in the house and in the street. The worst cases of this affection that have ever come under my observation occurred in negroes. The immediate cause of this affection is an inequality in the plane of the condyles of the femur or of the articular surfaces of the tibia, which is due, first, and most frequently, to internal curvature of the lower third of the femur, generally combined with lengthen- ing of the internal condyle; secondly, to diminished development or atrophy of the ex- ternal condyle, and of the corresponding articular surface of the tibia; thirdly, to hyper- trophy of the internal condyle; and, lastly, to enlargement of the inner tuberosity of the tibia. The influence of a relaxed and yielding state of the internal lateral ligament, and of contraction of the biceps muscle in the production of the distortion, does not meet with DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX, Fig. 834. Knockknee. CHAP. XIX. KNOCKKNEE. 1053 general acceptance, the majority of surgeons agreeing with Dr. Little, of London, that these lesions are consequences, and not causes, of the deformity. Treatment Knockknee, in its more simple forms, and when the bones are still soft, is relieved by mechanical appliances, such as a long, hollow, and well-padded splint, applied along the outer surface of the thigh and leg, and secured by straps of elastic webbing. Or, instead of such a contrivance, the surgeon may employ the more elegant and efficient apparatus, sketched in fig. 835. The mechanical support should be assisted by a course of tonics, the shower-bath, and the cold douche, followed by stimulat- ing lotions to the affected limb. In short, no pains should be spared to invigorate the general health, and to impart tone to the nervous system, which are so frequently at fault und*r such circumstances. The apparatus must be worn for a long time, inasmuch as the ten- dency to relapse is, in almost every case of the kind, remarkably great. When the affection is obstinate, or exists in an unusual degree, the two-headed flexor muscle may act as an obstacle to restoration, when the best plan is at once to divide its tendon ; a procedure which is not only very simple, but extremely valuable in furthering the cure. In performing the operation, the patient is placed upon his abdomen, when, the limb being slightly flexed, a delicate tenotome is entered flatwise at the outer margin of the tendon, from an inch to an inch and a half above the knee, and passed on until it reaches the opposite side, when, the cutting edge being directed forwards, the division is easily effected in the usual manner. No vessel is in danger of being injured, but the peroneal nerve is occasionally cut, followed by slight paralysis, which, however, seldom lasts beyond a few months. Should the femoral aponeurosis be involved in the contraction, any hard and resisting bands that may present themselves may now be severed by a cautious use of the knife. The little punctures made in the operation being covered with bits of adhesive plaster, the limb is wrapped in a bandage, from the toes up, and placed in an easy posture over a pillow; or, what I prefer, the extending apparatus may be applied at once, as the resulting inflammation is generally so slight as not to re- quire any special attention. When the bones have been thoroughly solidified or sclerosed, other measures are de- manded, of which the most important are forcible straightening of the limb and osteotomy. 1. Forcible Straightening Sudden reduction of the distortion by violent force, known as the method of Delore, consists in bending the limb into a straight position and retaining it in an immovable bandage. The great objection to the procedure is the danger of sepa- rating the femur and tibia at their epiphyseal lines, crushing the articular extremities of these bones, stripping off the periosteum, and lacerating the external lateral ligament, through which undue inflammation is liable to be excited and the development of the epiphyses interfered with. For these reasons the procedure should be discarded. 2. Osteotomy Subcutaneous division of the bones involved in the deformity includes section of the femur, section of the tibia, and separation of the internal condyle and its displacement upwards. a. Supracondyloid Osteotomy.—In the supracondyloid division of the shaft of the femur, an operation which originated with Mr. Macewen, of Glasgow, the limb being extended, an incision is made down to the bone, the inner two-thirds divided with a chisel or an Adams’s saw, and the outer third fractured by bringing the limb into a straight position, when it is managed as an ordinary fracture. The procedure has yielded most excellent results. Macewen had, up to April, 1881, operated upon 522 limbs affected with this malformation, without a single death justly ascribable to osteotomy, and in only six cases was there any suppuration in the wounds. All the patients were more or less benefited, some greatly, both in appearance and the power of progression. In many instances they were able to pursue occupations from which they were previously debarred. )3. Osteotomy of the Tibia.—Division of the tibia below its tubercle, an operation de- vised by Meyer, of Wurzburg, is performed with a mallet and chisel, the fibula being also cut if the deformity is not relieved. Schede and Koenig prefer removing a Y-shaped portion of the bone ; or it may be partially divided and the remainder fractured. Barwell, who thinks that the deformity is due to changes both in the femur and the tibia, divides the former bone and three weeks later cuts the latter. There are no statistics Fig. 835. Apparatus for Knock- knee. 1054 DISEASES AND INJURIES OF THE EXTREMITIES. bearing upon the fatality of these different procedures, but there is every reason for believing that they are not hazardous. y. lntraarticular Osteotomy Subcutaneous division of the internal condyle, and the forcible straightening of the limb, thereby restoring the articular surface formed by the femur to its original level, was first performed by Dr. Ogston, of Aberdeen, in May, 1876. Since then the value of the procedure has been tested in numerous instances, so that it may be regarded as being fully established in the confidence of the profession. It is, however, contraindicated when the deformity depends upon changes in the head of the tibia, and I am of the opinion that it is not nearly so safe as the operation of Macewen, as several cases of suppuration of the joint and at least two deaths have resulted from it. The difficult steps of the operation, which should be performed under antiseptic pre- cautions, are sufficiently simple. A stout tenotome is inserted into the tissues of the thigh about three inches above the tip of the internal condyle, along the inner side of the limb and pushed on until its point can be felt in the hollow between the condyles. An Adams’s saw is then passed along the track made by the knife, the flat surface of the latter being used as a guide. The knife being withdrawn the bone is divided by short strokes of the instru- ment from before backwards, in the direction of the dotted line, fig. 836, from Bryant. When the bone is nearly cut through, the saw is removed, and the separation completed by forcibly bending the tibia inwards. The operation is finished by push- ing the severed condyle to a level with the external one, as shown in the left limb, in fig. 836, closing the small wound, and confining the limb in a suitable apparatus. Passive motion is instituted in from two to three weeks. The only special care required in performing this operation is the avoidance of the popliteal vessels. Instead of using a saw, Mr. Reeves, of London, divides the condyle with a chisel in the same line as in Ogston’s operation, his aim being to cut down nearly to the articular cartilage with- out penetrating the joint. It is not, however, an extraarticular procedure, as the joint is broken into when the limb is straight- ’ ened. It is a less hazardous operation than the preceding one, no bad accidents having followed its performance in sixty-four examples collected by Dr. Poore, of New York. Finally, of the operations performed on the condyle, that of Mr. Chiene,of Edinburgh, should be mentioned, as the joint is not entered, and as it has heretofore afforded good results. The tubercle into which the tendon of the great adductor muscle is inserted having been exposed by an incision from two to three inches long, the periosteum is divided and turned aside, and a wedge-shaped piece of bone, the apex of which is directed toward the intercondyloid notch, cut with chisel and mallet out of the internal condyle, above the tubercle and above the epiphysial line. The tibia is then pushed inwards, a procedure through which the sides of the gap are brought into apposition, when the limb is dressed in the usual way. An affection the reverse of the preceding sometimes occurs, either in association with it or by itself. In the latter case, one knee is inverted, the other everted. The causes and the treatment are the same in both disorders. LACERATION OF THE LIGAMENT OF THE PATELLA. This accident may be produced by the same causes as fracture of the patella, that is, by the violent contraction of the extensor muscle at a moment when the leg is forcibly flexed upon the thigh, and the thigh upon the pelvis, thus throwing the ligament into a state of excessive tension. The rupture, whether occurring above or below the patella, is a very serious injury, liable to be followed by permanent lameness. When the liga- ment is torn away from the tibia complete reunion is not to be expected under any cir- cumstances. Of 24 cases of rupture of the ligament above the patella, analyzed by Binet, in 14 it occurred during an effort to prevent a fall. In 3 instances it was caused by a fall, the leg being in a state of extreme flexion. It has also been observed to be due to voluntary muscular contraction, once by Petit during an effort to jump a ditch, and once by Sedillot in rapid running. Of 23 instances of rupture of the ligament below the patella, related by Binet, 8 were due to a false step, or during an effort to prevent a CHAP. XIX. Fig. 836. Ogston’s operation ; Right limb showing line of section of the inner condyle of the femur ; Left, inner condyle brought to required position. CHAP. XIX. housemaid’s knee. 1055 fall, 6 were produced by a fall, the leg being in the flexed position, and in 1 it was caused by rapid running. The rupture of the ligament above the patella takes place commonly in the immediate vicinity of the bone. Of 18 cases in which Binet gives the prime seat of the rupture, in 11 it was on a level with the patella, in 2 two-fifths of an inch above it, and in 5 from an inch and a half to two inches and a half above the bone. Below the patella, laceration occurs near its upper or lower insertions, and it may even carry with it some bony frag- ments from the tuberosity of the tibia. The accident is most frequent in males. Middle-aged and elderly subjects are most liable to it when the ligament is involved above the patella, while rupture below the pa- tella is almost peculiar to young persons. The most reliable phenomena are an unnatural vacuity at the seat of the rupture, and an unusual prominence immediately above or below, inability to extend the leg, more or less pain, speedily followed by swelling, and a distinct noise heard at the moment of the accident, although the latter is by no means constant. The fact that the patella retains its integrity materially aids the diagnosis. The great point in the treatment is to keep the limb in an extended position upon an in- clined plane, in a state of perfect immobility until there is complete reunion, which will seldom be under eight to twelve w’eeks. As a preliminary measure, the leg and thigh should be bandaged in opposite directions, the former from below upwards and the latter from above downwards, so as to control more effectually the action of the extensor muscle, the chief agent of the displacement. No compress is required at the seat of the injury, and • care must be taken that the pressure of the bandage does not cause atrophy of the limb. 'When the patient is restive the immovable dressing should be employed. Passive motion should be cautiously instituted at the end of two months, to prevent ankylosis. In a case of ununited ligament of the patella, reported, in 1870, by Mr. John J. Hill, of New South Wales, a cure was effected by cutting down upon and paring the ends of the divided ligament, which were then kept in accurate contact by means of a long posterior splint and two leather collars, passed the one above and the other below the patella, and connected together by side straps. housemaid’s knee. An enlargement of the burse over the patella occasionally takes place, constituting an inconvenient and unsightly tumor, interfering with comfort and progression. It is most common in servant girls and persons who habitually exert much pressure upon this part, and is popularly known as the housemaid’s knee. The immediate cause of the affection is inflammation, usually chronic, but now and then acute. The swelling is soft and fluctuating, hemis- pherical in shape, and unaccompanied by discoloration of the skin and enlargement of the subcutaneous veins. Some degree of soreness is usually present, but seldom any decided pain. The appearances of the parts are well shown in fig. 837, from one of my clinical cases. Inflammation of the sac occasionally arises from overexertion in walking, from frequent pressure, or from external injury, as a blow or contusion, and, if not properly treated, is liable to terminate in suppura- tion, attended with excessive pain, erysipelas of the skin, and more or less constitutional disturbance. Gan- grene from excessive inflammatory excitement is an occasional occurrence ; and now and then severe dis- ease is developed during the progress of secondary or tertiary syphilis, especially the latter, either directly in the sac itself, or by extension from the surrounding tissues. The treatment of this disease, as it ordinarily pre- sents itself to the surgeon, consists in evacuating the contents of the sac, and injecting it immediately after with a small quantity of equal parts of tincture of iodine and alcohol, the fluid being well pressed about, and permitted to remain until it is productive of some pain. Dr. Levis has effected good cures with injections of carbolic acid. Occasionally a small seton answers an excellent purpose, but it must never be retained beyond a few days. Fig. 837. Housemaid’s Knee. 1056 DISEASES AND INJURIES OF THE EXTREMITIES. Excision I have always regarded as a dangerous procedure, and must, therefore, not- withstanding what lias been said in its favor, advise against it. Exceptional cases may certainly arise, as when the disease resists the ordinary methods of treatment, or when, as occasionally happens, it is converted into a solid or semisolid mass, in which it would be folly to temporize with injections or the use of the seton. Mr. W. Mitchell Banks, of Liverpool, who is strongly in favor of excision even in ordinary cases, performs the ope- ration with two lateral incisions, one on each side of the patella between it and the con- dyle of the femur, thus securing a freer drainage than when the cyst is opened in the usual situation, and guarding at the same time against the occurrence of a median cica- trice, which, as in persons who are compelled to kneel a great deal, might become a source of serious inconvenience. The treatment after any operation, however slight, upon bursal cysts of the patella, should consist of perfect rest of the affected joint, secured, if need be, by a suitable splint, and in the employment of the ordinary antiphlogistic measures, thorough drainage being an indispensable condition. When a burse of this kind becomes inflamed, the limb should at once be placed in an easy, elevated position, and the knee, thoroughly leeched, should be wrapped up in cloths wrung out of a strong solution of acetate of lead and opium. If matter form, an early and free incision will be required. VENOUS TUMOR. A venous tumor sometimes occurs in front of the femoro-tibial articulation, closely re- sembling, at first sight, the housemaid’s knee. In a case under my charge not long ago, in a man twenty-five years of age, the tumor, situated directly over the patella, and about the size of an ordinary orange, was of a soft, spongy consistence, of a bluish color, free from pain, and partially etfaceable under pressure. It was evidently congenital, as it was noticed soon after birth, and was composed of a mass of hypertrophied and varicose veins, a number of which were visible in the skin. There was some enlargement of the neighboring veins, but in other respects the limb was perfectly sound. The proper remedy for such an affection is subcutaneous ligation. 4. AFFECTIONS OF THE HAM. A large synovial burse sometimes forms in the popliteal region, in connection with one of the tendons of the hamstring muscles, giving rise to a swelling which eventually seri- ously impedes the movements of the knee-joint. The tumor is characterized by the tardiness of its progress, by a sensation of fluctuation, or peculiar puffiness, and by absence of pain and discoloration of the skin. If any doubt exists as to its real nature, recourse is had to the exploring-needle. The treatment usually recommended is that by seton, by injection with iodine, or by free incision, with the insertion of a tent. Such measures, apparently simple as they are, should be employed with the greatest possible caution, as the sac occasionally, if, indeed, not generally, opens into the knee-joint; a circumstance which can seldom be foreseen. Repeated vesication affords temporary relief, but does not cure. I have known mere tapping of the cyst to be followed by violent inflammation and the death of the patient. No judicious surgeon excises such a tumor. In most of the cases in which the operation was practised, fatal erysipelas ensued, or amputation of the thigh became necessary. No interference with such a tumor, however simple, should ever be thought of without a careful preparation of the system and the most earnest sub- sequent supervision. A bloody tumor occasionally arises in the ham, generally as a result of external vio- lence, as a blow or fall, eventuating in a rupture of some of the smaller vessels in the connective tissue. It is tardy in its growth, semielastic, and productive, especially when large, of pain and stiffness of the joint. It is distinguishable from aneurism by the absence of pulsation and thrill, and by the history of the case. A section of the tumor reveals the existence of organized coagula, differing in consistence and color, some being hard and pale, others soft, almost semifluid and dark. The inclosing cyst is composed of condensed connective tissue. The proper remedy is excision. A very curious instance, altogether unique in character, of arterio-venous cyst, was reported, in 1866, by Mr. C. II. Moore, of London. Formed by an expansion of the popliteal nerve, it was shaped like a double cone, and was so large as to fill the whole of the ham, its consistence being partly solid and partly fluid. An artery and a vein poured CHAP. XIX. CHAP. XIX . AFFECTIONS OF THE THIGH. 1057 their contents into its interior, and, upon being laid open, it was found to be occupied by serum, dark clots, and loose fibrin, intermixed with clusters of white corpuscles. The diagnosis could not be determined without an exploratory incision. For a more elaborate account of this interesting case the reader is referred to the chapter on the affections of the nerves. Solid tumors of various kinds, as the fibrous, fatty, and sarcomatous, are also liable to occur here, without, however, exhibiting any peculiarities requiring special notice. Their progress and consistence generally afford sufficient evidence of their true character. The sarcomatous growth, especially when of rapid formation, is very liable to be mistaken for aneurism, particularly when it receives the pulsation of the popliteal artery. A number of cases have been reported, in which, in consequence of such error, the femoral artery was ligated. Abscess of the ham is occasionally met with ; generally as a result of injury, or of the extension of disease from the knee. The matter is commonly very deep-seated, and, there- fore, slow in reaching the surface; the symptoms, both local and general, are unusually severe, and the fluctuation, especially in the earlier stages of the affection, is always very indistinct. The limb soon becomes stiff, the swelling is extensive, and the existence of pus is eventually indicated by an oedematous and erysipelatous state of the skin. The absence of pulsation will usually distinguish it from popliteal aneurism. Still, the surgeon must be upon his guard, not neglecting, in case of doubt, the use of the exploring needle. The proper treatment is a free and early puncture. General Diagnosis Too much caution cannot be exercised in regard to the diagnosis of tumors in the popliteal region. Aneurism is of frequent occurrence here, and it should be recollected that many of its morbid growths, especially if they contain fluid, are ex- tremely liable to pulsate, .simply from their proximity to the popliteal artery. On the other hand, an aneurism, even when of large size, may exist, and yet, owing to the solidi- fication of its contents, possess none of the ordinary signs of that disease. Numerous cases have been recorded in which an aneurism of the ham was opened under the belief that it was an abscess; where the popliteal artery was tied under the supposition that the affection was an aneurism, when it was merely an ordinary tumor; or, finally, where the thigh was amputated, the operator imagining that he had to deal with a sarcomatous growth, when the dissection showed that it was nothing but a consolidated and partially cured aneurism. Desault, Pelletan, and Dupuytren were each so unfortunate as to open a popliteal aneurism, under the conviction that it was an abscess, and two instances of a similar kind have occurred in this city. The only way to avoid such errors is to proceed with the greatest possible caution ; examining the parts again and again, until we are perfectly satisfied concerning the true nature of the disease. As a general rule, the leg should be rigidly extended, when, if the case be one of abscess or cystic tumor, the swelling will usually be rendered more promi- nent, at the same time that it will be completely divested of pulsation, whereas, if it be aneurismal, the pulsation will be little, if at all, affected. In ordinary growths, there is always an absence of thrill and bellows sound; in aneurism, on the contrary, these symp- toms are generally more or less conspicuous. In all cases of doubt, recourse should be had to the exploring needle. 5. AFFECTIONS OF THE THIGH. The thigh is sometimes drawn remarkably inwards, in a very awkward and constrained position, by the permanent contraction of the short adductor and 'pectineal muscles. A number of cases of this kind have fallen under my observation, chiefly in young boys from five to eight years of age, without my having been able to trace the affection to any assignable cause, none of the subjects having suffered from rheumatism. The contraction sometimes exists simultaneously on both sides, and, under such circumstances, the person usually walks with great difficulty, the gait being very unseemly and crippled, the limbs •during progression tending to cross each other. The remedy consists in dividing the faulty muscles freely by subcutaneous section, the tenotome being kept as closely as possible to the affected structures. The thighs should be forcibly abducted immediately after the operation, and in three or four days the patient may be permitted to run about. The cure will be expedited by exercise on the hobby-horse, and by whatever has a ten- dency to keep the limbs apart. Mechanical appliances are sometimes necessary aids. The thigh is occasionally rigidly flexed upon the pelvis by the contraction of the straight muscle, or of this muscle and the femoral. Such an occurrence may be the 1058 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. result of rheumatism, of accident, or of disease of the hip-joint, and is often readily relieved by very simple measures, as sorbefacient and anodyne liniments, the hot and cold douches, shampooing, and gradual extension of the limb. When the contraction, however, is of long standing, the only reliable remedy is the subcutaneous division of the affected muscles, an operation which is generally sufficiently simple, as it does not involve any large vessels. The thigh, in consequence of injury or disease, sometimes stands off in a very con- strained and unseemly manner from its fellow, owing chiefly, if not solely, to the inordinate contraction of the tensor muscle, which forms a hard, firm cord at the upper and outer part of the limb. The femoral aponeurosis often participates in the lesion, and, in that event, requires to be divided along with the tensor muscle. In hip-joint disease, whether the result of rheumatism, accident, or tuberculosis, the attempts at rectifying the deformity of the thigh are frequently very seriously counteracted by the contraction of the adductor and flexor muscles, the division of which is absolutely necessary, as a preliminary measure, to success. Among the more serious effects growing out of this faulty condition of the muscles of the thigh is permanent ankylosis of the hip-joint, the danger of which is generally in proportion to the duration of the contraction, and the consequent inactivity of the limb. It is, therefore, an object of great importance that early and efficient measures should be adopted for the relief of the parts, belore the articulation has been deprived of its normal structure. There is an affection of the muscles of the thigh, and, occasionally, also of those of the leg, in which, when a group of muscles act voluntarily, the antagonists are placed in a state of spasm, thereby counteracting each other, and causing more or less lameness. The disorder is sometimes congenital. There is marked increase of tendon reflex, but no paralysis, and hence the probability is that it does not depend upon organic disease of the spinal cord. What its precise pathology is remains undetermined. It is an interesting fact that the spasm always relaxes during sleep. Dr. Little, of London, seems to have been the first to call attention to this affection, but the knowledge of it was forgotten until it was revived, a short time ago, by Erb, Seeligmiiller, and Rupprecht, to the latter of whom we are indebted for our most recent information. It is impossible to confound this disorder with paralysis. Tenotomy is the only effectual remedy, aided by massage, and, if, necessary, by mechanical appliances. Abscesses of the thigh, often of enormous bulk, are liable to occur; they may be phleg- monous or strumous, superficial or deep, and are generally attended with great pain, swelling, and constitutional disturbance. The strumous form of the disease is most common in young subjects, from the third to the tenth year. When the matter is deep seated, it is always slow in reaching the surface, its approach being generally denoted by an oedematous condition of the skin with a slight erysipelatous blush. A chronic abscess of the thigh, firmly bound down by aponeuroses and muscles, and attended with imperfect fluctuation, might be mistaken for a sarcomatous tumor. The treatment should be by free and early evacuation of the pent-up fluid, with thorough approximation of the sides of the abscess by compress and bandage, to favor obliteration of its cavity. Caries, or caries and necrosis, of the great trochanter is most common in young strumous children, and is liable to be mistaken for coxalgia. The prominent symptoms are, pain and swelling at the outer and upper part of the thigh, more or less lameness, elevation of the buttock, and constitutional disturbance. An abscess gradually forms, and, if the matter is not speedily evacuated, it may burrow extensively among the sur- rounding structures, causing necrosis of the trochanter, and partial destruction of the capsular ligament of the joint. The diagnosis is readily determined by a thorough exami- nation. The diseased bone is removed with the pliers, gouge, and chisel. Necrosis of the inferior and posterior paid of the femur occasionally occurs, and is always to be dreaded on account of its proximity to the femoral artery. Long and deep sinuses are liable to form during the progress of the disease, keeping up more or less dis- charge and swelling, with a tendency to ankylosis of the knee. The bone is generally affected superficially, the morbid action being confined to its outer compact structure. Sometimes the necrosed part consists of the merest shell of the shaft of the femur, hardly an inch in length by a few lines in width. The only remedy for this disease is the extraction of the dead bone, an operation which should always be performed with the utmost care, on account of the great danger of injur- ing the femoral artery with the forceps, or even with the sequester itself, especially when its extremities are very sharp or spiculated. Sometimes copious, if not fatal, secondary CHAP. XIX. AFFECTIONS OF THE THIGH. 1059 hemorrhage arises, not, apparently, from any direct lesion of the vessel, but from an extension of the inflammation consequent upon the rude attempts at extraction. A case in which a sharp sequester pierced the popliteal artery, causing fatal hemorrhage, has been reported by Dr. Hunt, of this city. The extirpation of tumors of the thigh is often attended with severe hemorrhage, espe- cially when they are deep seated, and of large bulk, when they are not unfrequently accompanied with great enlargement of the femoral vessels. The danger will be particu- larly great when the main vessels of the limb are involved, or when they are thoroughly incorporated in the morbid structure. Under such cii'cumstances, the knife, however carefully used, can hardly fail to do mischief; the artery or vein, if not both, will either be pierced, or, if they escape the point of the instrument, they may give way secondarily, in consequence of ulceration of their coats, softened during the previous disease. Hemor- rhage from the femoral vein may usually be promptly checked by compression ; if this fail, the vessel may be tied below the seat of the opening, or, what will be better, because more safe, a ligature may be thrown around the femoral artery. If the vein be ligated, and the blood be sent with its accustomed force and freedom along the artery, congestive inflammation will be speedily set up in the distal parts of the limb, and the patient may thus fall a prey to gangrene. An affection of the hip, apparently of the nature of neuralgia, is occasionally met with, and is generally of so obscure a character as to lead to serious errors of diagnosis. 1 allude to the severe pain, frequently amounting to intense agony, which occurs in the hip, or hip and groin, as a consequence of endometritis. If a probe be passed into the uterus, the pain darts with the rapidity of lightning into these parts, and is followed by a sense of prostration almost equal to that produced by a severe shock of the nervous system. The disease is most common in women of a nervous, irritable temperament, and always promptly disappears on the removal of the exciting cause. Interstitial Absorption of the Neck of the Thigh-bone This affection, first noticed as a distinct lesion by Mr. Benjamin Bell, of Edinburgh, in 1824, consists, as the name implies, in the gradual removal of the neck of the thigh-bone by a process of absorption, accompanied by a remarkable change in its natural conformation. It is most common in elderly subjects, but it may occur at any period of life, even as early as the third year, as in an instance 'recorded by Dr. Knox. The most frequent cause is external injury, as a blow or fall upon the great trochanter, eventuating in severe contusion of the osseous tissue. Violent concussion, either from direct injury, or from a fall upon the knee, may be mentioned as another exciting cause of the complaint. Sudden suppression of the cutaneous perspiration, gout, and rheumatism act in a similar manner. The disease, however induced, is always insidious in its approaches, so much so, indeed, as to render it impossible to recognize its true character, in its earlier stages. Among the more prominent symptoms at this period are dull, aching pains and a sense or weari- ness in the region of the hip-joint, with more or less soreness and tenderness on pressure; the movements of the limb, especially abduction and flexion, are constrained and diffi- cult ; the body is inclined forward; the thigh is bent upon the pelvis ; and the patient is unable to stand erect or bear his weight upon the affected limb without suffering. Sometimes the pains are of a sharp, neuralgic, gouty, or rheumatic character, darting down the thigh, and extending into the sacrolumbar region. In most cases, however, the pains are fixed, and particularly severe, especially at night, after exercise, and in cloudy, damp states of the atmosphere, in the region of the great trochanter. As the lesion progresses, the affected limb becomes soft and flabby, from muscular atrophy, and more or less shortened from the absorption of the neck of the thigh-bone and the altera- tion in its direction. These changes sometimes begin at an early period of the disease; at other times, and more generally, they are very gradual in their occurrence, several months elapsing before they are distinctly noticeable. The amount of shortening, when the complaint is fully developed, varies, on an average, according to the stature of the in- dividual, from one to two inches, and there is, consequently, always permanent lameness, compelling the use of a stick, if not of a crutch. The great trochanter is inordinately pro- minent, and stands off at an unnatural angle from the body. The appearances of the neck of the bone are well shown in the annexed sketch, fig. 838, from a preparation in my private collection. The periosteum over the great trochanter and lower portion of the neck of the bone is usually much thickened ; the synovial membrarte of the hip-joint is variously altered ; the substance of the bone is frequently very porous; irregular nodules, or osseous deposits, often exist upon the margins of the acetabulum; and, in the more severe cases, the cervix is so com- 1060 DISEASES AND INJURIES OF THE EXTREMITIES. pletely absorbed that the head of the bone is brought into close contact with the great trochanter, being lodged, as it were, in a hollow of that tuberosity. The articular cartilage, and even the head of the bone itself, are often seriously involved, presenting a rough, knobby, and flat- tened appearance. The areolar texture is commonly rarefied. The affection, evidently, originally consists in inflammation of the osseous tissue, followed by loss of nutritive power, softening, atrophy, and change of form. The diagnosis of interstitial absorption of the neck of the thigh-bone cannot be determined in the earlier stages of the disease. It is only after the limb has become shortened, and the trochanter unnaturally prominent, that the true character of the lesion can be detected. The affections with which it is most liable to be confounded are, fracture of the neck of the thigh-bone, ilio-femoral dislocations, and scrofulous disease of the hip-joint. From the first it may generally be readily distinguished by the absence of crepitation and shortening; from the second, by the fixed position of the limb; and from the last, by the history of the case. In fracture, except in the im- pacted variety, the shortening is usually immediate, and is always eflaceable by extension and counterextension. Crepitation is also generally present. In dislocation the head of the bone can usually be felt in its abnormal posi- tion ; the thigh is measurably immovable, more or less rotated, and, for the most part, shortened on the occur- rence of the accident. Hip-joint disease comes on gradu- ally, and is commonly an affection of early childhood. Unless the disease is taken in hand in its earlier stages, little is to be expected from treatment. Hence, in neglected cases, or where the diagnosis is not properly determined, permanent lameness from loss of function of the hip-joint is almost inevi- table. The great remedies, for the first few months, are absolute rest in the recum- bent posture, astringent and anodyne applications, leeches, iodine, and blisters. Passive motion of the hip-joint must be instituted as soon as the violence of the inflammation has abated, and the suffering structures must be well douched twice a day with hot and cold water, followed by the use of stimulating and sorbefacient embrocations. A deep issue made with the hot iron is sometimes beneficial, and I have known frequent vesication with cantharidal collodion to be of great service. 6. AFFECTIONS OF THE NATES. Wounds of the nates require no special notice, as their treatment is generally very simple. Unless they are very deep, or complicated with lesion of the gluteal or ischiatic artery, fracture of the innominate bones, or injury of the pelvic viscera, they usually heal very kindly under simple dressing, conjoined with rest and recumbency. In the event of serious hemorrhage, the bleeding vessels must at once be searched for, and effectually ligated at both extremities, access being, if necessary, facilitated by freely enlarging the original opening. Abscesses, phlegmonous and chronic, occasionally form here, and, wlien deep-seated, may not only cause excessive suffering, but great embarrassment in regard to their diag- nosis. In general, however, the history of the case, a careful examination of the parts, and the use of the exploring needle, will dispel all doubt upon the subject, and lead to the adoption of the proper treatment. If the abscess be not soon opened, its contents may burrow extensively among the neighboring structures. La Motte relates an instance in which the pus of an abscess of the buttock travelled down the limb as far as the ankle, and cases have occurred where it found an outlet through the rectum. Aneurism of the gluteal and ischiatic arteries is extremely uncommon, and is always, or nearly always, the consequence of external injury, as a punctured, gunshot, or incised wound. The prominent symptoms are abnormal pulsation, and a peculiar whizzing, blowing, or bellows sound, easily detected by the ear. The remedy consists in exposing the sac,.and ligating the artery above and below. The operation, the method of perform- CHAP. xix. Fig. 838. Interstitial Absorption of the Neck of Thigh-bone. CHAP. XIX. AFFECTIONS OF THE NATES. 1061 ing which is described in the chapter on aneurism, is generally a very bloody one, and demands great skill for its successful execution. Of the various tumors that are liable to occur in this region the most common are the sar- comatous, chondromatous, fibrous, fatty, and cystic, the latter of which is sometimes con- genital. In their progress, these morbid growths may all extend into the pelvic cavity, or, originating there, they may gradually pass out at the sacrosciatic notch, and thus place themselves under cover of the gluteal muscles. Their diagnosis is generally attended with great embarrassment, and hence, if the surgeon is not fully upon his guard, very serious errors may be committed. A unique example of congenital fatty tumor of the buttock, connected with the spinal membranes, through a cleft in the sacral vertebra}, has been reported by Mr. Athol John- son, in the eighth volume of the Transactions of the Pathological Society of London. An operation was performed, and the child, who had previously suffered from convulsions from the pressure of the morbid growth on the spinal cord, was restored to perfect health. The congenital cystic tumor is liable to form here, and often acquires such a size as to interfere materially with the delivery of the child. Its shape is usually somewhat globu- lar or ovoidal, its attachment being effected by a pretty broad base, extending deeply among the muscles but not into the pelvic cavity. It is soft and elastic, and fluctuates distinctly under pressure. Its contents are serous, turbid, brownish, or sanguinolent, and readily coagulable by heat, alcohol, and acids. The skin is not materially discolored, although, in general, it is a few shades darker than that in its neighborhood. The inner surface of the tumor is usually smooth and polished, and pervaded by minute, tortuous vessels with tender, friable walls. In some cases the tumor is unilocular, in others, multilocular; and instances occur in which a considerable amount of solid matter enters into its composition. A good idea of the situation and shape of the cystic tumor of the gluteal region may be formed by a reference to fig. 839, from a drawing of a specimen formerly in the possession of Dr. Keller, who has given a full account of it in the Transactions of the Pathological Society of Philadelphia. The tumor, attached to the nates, immediately behind the anus, was nearly of the size of a man’s head, and, on being punctured, on the eighth day after the child’s birth, it was found to contain upwards of a quart of brownish fluid. Death occurred a few hours after the operation from hemor- rhage into the sac, the parietes of which were very dense, vascular, and studded internally with small, transparent cysts, filled with serum. There was no communication between the sac and the spinal canal, or the sac and pelvic viscera. In another case, of a similar character, Dr. Keller was obliged to puncture the tumor before delivery could be effected, the quantity of fluid drawn off being about a gallon. It was also of a brownish color. The child died six hours after its birth from capillary hemorrhage into the sac, the inner sur- face of which was covered, in parts of its extent, by a soft tissue, exhibiting, under the microscope, a rich network of vessels, very similar to the villi of the intestine. The sac had its root between the anus and the extremity of the coccyx, somewhat to the right of the middle line, without any com- munication with the vertebral canal. A tumor, evidently the result of monstrosity by inclusion, or of the presence of a blighted ovum, is occasionally found in this region, closely adherent to the sacrum or to this bone and the coccyx. It consists, for the most part, of a mass of fat, either alone or mixed with rudimentary bones, teeth, and even hair. Sometimes it contains a portion of intestine; and, in an instance observed by Dr. Richardson, a growth of this kind had an appendix attached to it, bearing a very perfect resemblance to a finger, surmounted by a well-developed nail. Dr. Spencer, of Watertown, New York, has communicated to me the particulars of a case in which the tumor was connected with the spinal cord. When the growth is merely a blighted ovum, life may be prolonged for many years. An opinion was lately advanced that the congenital cysts in this situation have their origin frequently, if not generally, in what Luschka has described under the name of the coccygeal gland, a little reddish-gray body, with a lobulated surface, from the size of a lentil to a small pea. It lies in a hollow on the top of the coccyx, between the tendons Fig. 839. Congenital Cyst of the Nates. 1062 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. attached to that part, and has been shown by Julius Arnold to consist of clumps of small, tortuous, and dilated arteries with thickened muscular and endothelial coats. The view in question is far-fetched, and cannot be adopted without further light. When a child with a cystic tumor is born alive, the best plan would be to wait a few weeks, and then draw off a part of its contents, the operation being repeated every six or eight days in the hope of its being followed by gradual shrinking and the ultimate obliteration of its cavity. In the event of failure, the injection of iodine might be tried, or, instead of this, the sac might be detached with the knife, particularly if it have a narrow pedicle. When the tumor is solid, and does not include a portion of bowel, ex- cision or removal with the ecraseur will be the proper procedure. If) a case of this kind, in a child nearly nine months old, which I saw along with Dr. Eshleman, and Dr. T. G. Morton, the tumor, partly soft and partly solid, occupied the sacrococcygeal region, and measured twenty-four inches in circumference by nineteen inches around its base, its size at birth equalling that of a large orange. The mass, after removal by Dr. Morton, weighed upwards of two pounds, and was found to be composed of a number of cysts, filled with serous fluid, and interspersed with granular, adipose, and fibrous matter. One of the larger cysts was occupied by a well-formed superior extremity, furnished with a thumb and fingers, and surrounded by a large quantity of waxy, sebace- ous-looking matter. The tumor had very extensive connections, and during the dissec- tion it became necessary to expose the wall of the rectum. The rectococcygeal portion, through which it had received its nourishment, was, as a matter of precaution, included in a ligature. The loss of blood did not exceed one ounce and a half. Death, apparently from exhaustion, occurred in less than twenty-four hours after the operation. A rare case of cystic tumor of the hip, evidently caused by hydatids, was published in 1865, by Dr. Hendry in the British Medical Journal. The patient, a young lady of twenty-one, had suffered from weakness and occasional pain in the left hip and thigh ever since she was ten years old. The swelling, which was unaccompanied by discoloration of the skin, had latterly much increased in size, and the fluctuation was attended by a peculiar crepitation, resembling that of a bursal enlarge- ment. The cyst contained upwards of a pint and a half of semiopaque fluid, of a yellowish tint, intermixed with in- numerable booklets of echinococci and minute cubic crystals of chloride of sodium and cholesterine. The disease had probably originated in the gluteal muscles. A species of elephantiasis, consisting in hypertrophy and fibroplastic degeneration of the connective tissue, is some- times met with upon the buttocks. In a remarkable case of this kind, under my charge at the College Clinic, in 1861, in a lad twelve years and a half old, the tumor, as seen in fig. 840, formed an enormous mass hanging off both buttocks down upon the upper part of the thighs, greatly impeding progression, and causing much annoyance both by its weight, its peculiar position, and its unseemliness. It was nearly thirty inches in circumference, rounded at the extremity, and of a hard, firm consistence. Upon the surface of the tumor were two large ulcers, the seat of a copious discharge of thin, yellowish, fetid pus. The anus was dragged at least three inches beyond its natural situa- tion, and had a very irregular nodulated appearance; the perineum was hard and tumid, the scrotum was enlarged, and the penis was of extraordinary dimensions. The tumor, at its upper part, had a soft, fluctuating feel, as if the tissue around had been infiltrated with serum, as was, in fact, the case; for a very large quantity of this fluid was suddenly discharged at one of the ulcers soon after the lad fell into my hands, followed by great subsidence of the swelling. As the general health was progressively declining, the removal of the tumor was promptly decided upon. An elliptical incision being made, so as to include the ulcerated surface, the flaps were gradually raised, but such was the intimate adhesions between the skin and the substance of the morbid growth that it was impossible to make a clean dis- section. The only place where satisfactory separation could be effected was at the upper Fig. 840. Fibrocystic Tumor of the Nates. CHAP. XIX. AFFECTIONS OF THE COCCYX. 1063 part of the tumor, previously alluded to as having been the seat of serous infiltration. Here the boundary line was well marked. The attachments were also very firm to the gluteal muscles, the fibres of which were very pale, and intimately intermingled with the abnormal structures. Several small serous cysts were opened during the operation, which was, in other respects, unattended by anything remarkable. Some large veins were noticed, but they did not bleed much, and only a few small arteries required ligation. The lad, under chloroform, bore the operation well, and made a good recovery. The tumor, after re- moval, weighed eight pounds, exclusively of the fluid lost during the operation. It was of a whitish color, and of dense, firm consistence, grating under the knife. Its microscopic char- acters, fig. 841, as ascertained by Dr. Packard, afforded a beautiful illustration of the fibrous structure, all the cells being nucleated, and most of them having more than one nucleolus. The synovial burse, naturally existing upon the tuberosity of the ischium, is liable, from constant pressure and other causes, to chronic enlargement, attended with more or less pain and inconvenience, especially in sitting and riding. The tumor varies in size from a hickory-nut to that of a small orange, is deep- seated, immovable, and of a globular or ovoidal shape. In its earlier stages, it imparts a peculiar vermicular sensation to the thumb and fingers, but as it increases in size it be- comes soft, and distinctly fluctuates. The structures around are generally a good deal tender and indurated. When doubt exists respecting the diagnosis, the exploring needle must be used. The treatment consists in emptying the cyst, and mopping it well with tincture of iodine; or, instead of this, the cavity may be stuffed with lint, wet with a weak solution of subsulphate of iron, a very safe, and, generally, a very effectual procedure. If the case be obstinate a small eschar may be formed upon the most prominent part of the tumor with Vienna paste ; or, what is preferable, the cyst may be thoroughly divided with a delicate tenotome inserted subcutaneously. Excision is only to be thought of when suppuration has taken place, eventuating in a complete change in the natural structure of the sac. 7. AFFECTIONS OF THE COCCYX. The most common causes of coccyodynia, an affection originally described by the late Dr. Nott, of Mobile, are difficult and protracted parturition, attended with excessive pres- sure of the child’s head, the effects of cold, as that arising from sitting on damp or wet grass, and various kinds of injury, as fractures, dislocations, contusions and concussions, leading to irritation, if not actual inflammation, of the osseous tissue, the periosteum, and other structures connected with the coccyx. There is a class of cases in which the suffering is, apparently, mainly dependent upon sympathy from disorder of the uterus, rectum, or urinary bladder. Coccyodynia, as a result of injury, was originally described by Smetius, in the latter part of the sixteenth century. The affection is not confined to females, although it is much more common in them than in the other sex. The characteristic symptom of the disease is pain, generally of a dull, heavy, aching, or gnawing nature, sometimes sharp, lancinating, darting, or shooting, attended with exquisite tenderness of the coccyx, extending about in different directions, and liable to be aggravated by pressure, sitting, walking, and defecation, especially when there is much straining. Very frequently the suffering is greatest in the erect posture. The pain varies in degree in different cases, but it is always more or less severe, and is sure, eventually, to be followed by marked disorder of the general health, rendering life utterly miserable. In one of my cases it extended nearly over the entire length of the spine, and was ac- companied by exquisite morbid sensibility of the whole system. In the great majority of instances the pain is strictly of a neuralgic character, and is then generally influenced in the degree of its severity by atmospheric vicissitudes, and by whatever has a tendency Fig. 841. Microscopic Characters of a Fibrocystic Tumorof the Nates. 1064 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. to derange the more important functions of the body. When the disease is fully estab- lished, the patient is unable to walk without great distress, and in sitting he is usually obliged to support the weight of the body upon one buttock. Even recumbency is often intolerable on account of the pressure of the bed upon the affected bone. The disease frequently endures for years without any material amelioration. It occurs in both sexes, but it is by far most common in women, especially in such who have borne children. The diagnosis of coccyodynia is determined by the history of the case, by a careful ex- amination of the parts, and by the absence of disease in the surrounding structures. The suffering often resembles that occasioned by anal fissure, an affection always readily dis- coverable with the speculum. In many cases the coccyx will be found to be more or less distorted in shape, being thrown either forwards, backwards, or to one side: occa- sionally it is straight. In one of my cases it formed nearly a right angle with the sacrum, and encroached greatly upon the rectum. The milder cases of the disease occasionally yield to the use of antineuralgic remedies, especially arsenic and strychnia, either alone or aided by quinine, opiate suppositories, hypodermic injections of morphia, and change of air, with particular attention to the diet, bowels, and secretions. Constipation must always be carefully guarded against. In the more rebellious cases, the operation originally suggested by Simpson affords the best chance of relief. This consists in the subcutaneous division, by means of a narrow, long- bladed tenotome, of the muscles connected with the coccyx, so as to isolate the bone com- pletely, first at the sides, and then at the extremity, thereby placing it in a complete state of repose. The procedure, which is attended with very little hemorrhage, is generally followed by immediate and permanent relief. When it fails, the only resource is excision of the coccyx, an operation first performed by Dr. Nott in 1844, and described in the next chapter. A small congentital pilocystic tumor is sometimes met with upon the coccyx, in the vicinity of the anus, in the cleft between the nates. Its origin is apparently connected with a sebaceous follicle, which, during its development, intercepts a small tuft of hair, very much as in certain sebaceous formations on the head and face. The tumor, at first hard, dense, and indolent, eventually inflames and suppurates, leaving, if left to itself, an angry, irritable ulcer, the seat of a thin, fetid discharge, more or less painful, and indisposed to heal. The parts around are red and swollen, and sometimes riddled with sinuses. The disease is more common in men than in women, and, although always congenital, may remain a long time in a dormant state, causing little or no inconvenience unless it be accidentally injured or irritated. The treatment consists in laying open the cyst, turning out its contents, and freely cauterizing its surface with nitrate of silver. A rare case of congenital fatty tumor of the coccyx has been reported by Dr. Wilson, of England. The growth was situated over the spines of the vertebrae, in the sacral re- gion, and presented many of the local signs of hydrorachitis, the skin over it being slightly ulcerated, and a deceptive sense of fluctuation being imparted to the fingers. In the course of four months, when it wTas excised, it had increased from the size of a small egg to that of a foetal head. It wras very firmly attached to the back of the coccyx, which was turned upwards and backwards into the tumor. 8. AFFECTIONS OF THE GROIN. Wounds of the inguinal region, whether incised, punctured, lacerated, or gunshot, may be limited to the superficial structures, or they may extend deeply among the glands and muscles, in the latter event, perhaps, dividing important vessels and nerves, and thus leading to frightful, if not fatal, hemorrhage, and other bad consequences. The treat- ment is generally sufficiently simple, but, in order to effect a rapid cure, it is absolutely necessary that the patient should observe strict recumbency with the thigh slightly flexed upon the pelvis, as this affords the best opportunity for the maintenance of accurate appo- sition of the edges of the wound. All motion of the limb must be avoided. Any bleeding vessels are, of course, at once secured; if the iliac or femoral artery is divided, it must be tied both above and below the wound, which should, if necessary, be freely enlarged, to afford ready access to the parts. In most cases, such an injury will prove fatal before the surgeon can reach his patient. Mortification of the toes and feet is apt to follow the division of the principal artery and vein of the limb, especially if some of the anastomotic branches are involved in the mischief. Inflammation of the groin may be common or specific ; more generally the latter, the AFFECTIONS OF THE GROIN. 1065 CHAP. XIX. exciting cause being the chancroidal poison. The disease, in either event, may he limited to the skin and connective tissue, or it may be located principally in the lymphatic glands, either above or below Poupart’s ligament. Chancroidal bubo nearly always occupies the former situation, whereas the swelling of the lymphatic glands, consequent upon the irri- tation of gonorrhoea and injury or disease of the lower extremity, generally occupies the latter, and seldom proceeds to suppuration. In whatever manner the inflammation may have been induced, the object should be to prevent suppuration, by perfect quietude of the part, and by the application of leeches, saturnine lotions, and dilute tincture of iodine, aided by the usual constitutional remedies. If matter form, an early and free incision, made in the direction of Poupart’s ligament, is indicated. The resulting sore should be managed upon general principles, the cure being greatly expedited by laying open sinuses and enjoining recumbency. Abscesses of the groin sometimes form in consequence of irritation in the caecum and sigmoid flexure of the colon, the matter passing down towards Poupart’s ligament, or, perhaps, even beyond it. Such collections, to which the term stercoraeeous may very properly be applied, not only contain fecal matter, but also, at times, ingesta, bits of bones, cherry-stones, and even gall-stones, the impaction of which in the bowel is often the starting-point of the disease. However this may be, the damage inflicted upon the parts is generally so great as to lead to the establishment of irremediable sinuses and fistules. Chronic abscesses occasionally occur here, and are always readily distinguishable by their history and progress. Great care should be taken not to confound such collections with those attendant upon psoas abscess, which, as is well known, often points in the groin, generally above, but sometimes below, Poupart’s ligament, forming, in the latter event, a tumor of variable size and shape, at the upper and inner part of the thigh. A troublesome form of eczema is sometimes met with in the groin, chiefly in young, fat children and elderly women, with a pendulous abdomen. The skin is chafed, red, inflamed, and the seat of a thin, watery discharge, attended with distressing itching. An occasional purge, the avoidance of stimulating food and drink, strict attention to cleanli- ness, and the use of Turner’s cerate, of very dilute ointment of acid nitrate of mercury, or of an ointment made of camphor and chloral, are generally the most effectual remedies. Hypertrophy of the lymphatic glands of the groin, the result of tuberculosis or ordi- nary inflammation, is liable to occur, the enlarged structures forming a hard, irregular tumor, situated partly above and partly below Poupart’s ligament, without any disposi- tion, in many cases, either to advance or recede, owing, apparently, to some disorder of the general health or some local irritation. An occasional purgative and a mild course of alteratives, with the repeated application of tincture of iodine, blisters, and compres- sion, will generally procure the gradual removal of the disease. Angioma of the lymphatic vessels of the groin is met with chiefly among the residents of warm countries, as the East and West Indies, South America, the Mauritius, and the Island of Bourbon. It is most common in young subjects from the fifteenth to the twenty-fifth year, and presents itself as a soft, elongated, compressible tumor, free from pain, reducible, from the volume of an almond to that of a pullet’s egg, without any dis- coloration of the skin, and situated in the upper part of the thigh, just beneath Poupart’s ligament. It consists essentially of dilated and tortuous lymphatic vessels, united by connective tissue, and occupied by a milky fluid, which, whenever any accidental opening occurs, often escapes in great abundance for weeks and even months. In the East Indies the affection is generally associated with chronic enlargement of the lymphatic glands, and with a discharge of chylous urine. In some cases it exists simultaneously in both groins. No treatment is ordinarily required, except when there is a constant copious drainage of lymph, threatening impairment of the general health. In such an event, an effort might be made to obliterate the tumor by means of pins and ligatures, strangulating the enlarged vessels upon the same principle as in a mevus. In a case in the hands of Nela- ton, the tumor was extirpated, the patient, a stout, robust young man, dying soon after the operation from pyemia. Of tumors of the groin, the most common are the fatty, cystic, sarcomatous, and fibrous, to which may be added the enlargements produced by hydrocele of the spermatic cord, varicosity of the saphenous vein, and the undescended testicle. The fatty tumor is not always developed in the groin, but occasionally extends into it from the abdomen by a sort of migratory process. It may acquire a very considerable volume, and is generally easily distinguished by its pendulous character, and by its 1066 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. doughy, inelastic feel. When small and deep seated, however, it might be mistaken for femoral hernia, especially if the patient should be seized with symptoms of intestinal strangulation. The two affections, in fact, might coexist. In a case under my care not long ago in a lady upwards of forty, the fold of the left groin was the seat of a peduncu- lated fatty growth, nearly six inches in length by fully ten inches in circumference. The removal of such a tumor by the knife is usually easily effected, as it seldom adheres very closely, if, indeed, at all, to the sheath of the femoral vessels. A cystic tumor sometimes occurs in the groin. It varies in size from the volume of a hen’s egg to that of the fist, is of a globular or ovoidal shape, and distinctly fluctuates under the finger. Its contents are generally serous. Desault removed from the groin of a girl a hydatid tumor, for which she had previously been advised to wear a truss; and a similar case occurred to Dr. Monro, the cyst in this instance being situated at the upper and inner part of the thigh, where it might readily have been mistaken for a hernia. I have on two occasions removed morbid growths of this kind, extending deeply into the substance of the groin, and requiring caution in the dissection. Care should be taken not to mistake for a tumor of this kind the synovial burse which exists between the capsule of the hip-joint, the body of the pubic bone, and the tendon of the iliac and psoas muscles, and which is liable, in consequence of inflammation, to con- siderable increase of bulk forming a swelling of irregular shape, soft, fluctuating under pressure, and following the movements of the thigh, but receiving no impulse on coughing, as is the case in psoas abscess, with which it is most liable to be confounded. The sac occasionally communicates with the hip-joint. Rest, blistering, and iodinization are the safest remedies. If suppuration take place the cyst should be freely opened. Thefibrous tumor, which is also very uncommon, is generally easily recognized by its tardy progress, its firm consistence, and its close connection with the surrounding struc- tures, processes often extending deeply among the vessels, nerves, and muscles. Hence, the extirpation of such a tumor is commonly attended with much difficulty. A hydrocele of the spermatic cord occasionally projects into the groin, forming a tumor of variable size and shape, but usually easily recognized by its softness, elasticity, and fluctuation, by its tardy progress, by the absence of disease of the skin, and by the unim- paired state of the general health. If any doubt exist in regard to the diagnosis of the case, the exploring needle is employed. A tumor, of considerable size, is sometimes formed by varix of the saphenous vein at its junction with the great femoral. The enlargement, which is most frequently met with in old, fat subjects, in connection with similar disease of the leg, is commonly of an oblong shape, soft, and about the size of a large almond. It does not receive any impulse on coughing, and is readily effaced by pressure upon the upper part of the saphenous vein, but promptly reappears when the pressure is removed. An undescended testicle is sometimes retained in the groin, forming a tumor which, especially if inflamed, might lead to the suspicion of the existence of hernia. The ab- sence, however, of the organ from the scrotum, and the peculiar hardness of the inguinal tumor, together with the sickening sensation caused by compressing it, will always serve to distinguish it from all other affections. Sarcoma of the groin is occasionally witnessed, as in a very remarkable case which came under my notice, in a young lady, twenty years of age. The disease had, apparently, commenced in the lymphatic glands, when she was sixteen, and gradually progressed until, several months before she expired, it involved the entire circumference of the upper part of the thigh and nearly the whole of the corresponding natis, forming an enormous mass, attended with excessive emaciation and great enlargement of the subcutaneous veins, some of which were almost the size of the little finger. A few weeks before disso- lution, the tumor gave way at its summit, throwing out a large, bleeding fungus. In another case of this kind the morbid growth occupied the groin, the inner part of the thigh, and the perineum, to the latter of which it was attached by a broad base, the patient being a man, thirty-six years of age, who had always enjoyed good health until about five months previously. The tumor, which was fully the size of a child’s head at birth, was remarkably tuberculated on the surface, of a soft, spongoid consistence, and the seat of a most copious, fetid discharge. A few days before I saw it, it had given way by ulceration, and bled very profusely. The glands of the groin were extensively implicated in the disease, and several of them, the largest the size of a pullet’s egg, were completely denuded, standing out prominently upon the upper part of the thigh. The tumor, which interfered greatly with defecation, soon proved fatal. OPERATIONS ON THE SCIATIC NERVE. 1067 CHAP. XIX. General Diagnosis—The surgeon, in contemplating the diseases of the groin, will not lose sight of the fact that he has to deal with a region which is often the seat of hernia, both inguinal and femoral, of psoas abscess, and of aneurism, the latter formed either in the course of the femoral artery or in that of the external iliac. lie will, therefore, be slow in making out his diagnosis, and particularly wary in the employment of the knife. He will not forget, on the one hand, that a tumor not aneurismal may, if situated over the track of the femoral or iliac artery, readily receive an impulse from the vessel, so as to lead to a false suspicion regarding its true character; nor, on the other, that an aneurism may actually exist, and yet be free from pulsation, or, perhaps, be even so soft as to simu- late an abscess, especially if it be accompanied with considerable oedema and discoloration of the skin. The great danger of mistake, however, generally arises, not from tumors, but from hernia, which often coexists with various kinds of swellings of the groin, inflam- matory and other, and which, in the event of the supervention of symptoms of intestinal strangulation, might, therefore, occasion great embarrassment, both in regard to the diag- nosis of the case, and the proper course of treatment to be adopted for its relief. The opening of an abscess of the groin overlying a knuckle of small intestine, has been fol- lowed more than once by an incurable fistule. How cautious, then, should the surgeon be in the employment of his knife in a region of such vast importance to health and life ! 9. ANKYLOSIS OF THE HIP-JOINT. Ankylosis of the hip-joint may be produced by various causes, as external injury, rheu- matism, gout, syphilis, and coxalgia, or tubercular disease. Mere contraction of the femo- ral and gluteal muscles not unfrequently occasions serious impediment in the functions of the articulation, independently of any structural changes. The rigidity, however induced, presents itself in various degrees, from the slightest impairment of motion to the complete consolidation of the contiguous surfaces by osseous matter. The manner in which the thigh inclines in ankylosis of the hip-joint is far from being uniform, but, in most cases, it is directed inwards, and Hexed more or less strongly upon the pelvis, the leg being at the same time bent upon the thigh, and the foot raised from the ground. The cases in which the limb is turned out are comparatively rare, and are met with chiefly in connec- tion with partial or complete destruction of the brim of the acetabulum and of the head and neck of the femur, either as a result of injury or disease. Sometimes the limb stands off horizontally, at a right angle with the pelvis. Ankylosis of this joint cannot exist, even in a comparatively slight degree, or for any length of time, without being followed by more or less distortion of the pelvis and loins, in the form of compensating curves; the muscles of the thigh and leg become wasted and rigid ; and the knee is eventually rendered stiff and useless. The true condition of the articulation can seldom be satisfactorily determined without the aid of an anaisthetic. The treatment, in recent ankylosis, consists in breaking up any adhesions that may exist by moving the thigh forcibly upon the pelvis, and then rectifying the position of the limb by appropriate apparatus. Passive motion should be instituted from time to time, and extension, if necessary, maintained by means of a weight attached to the leg, as in the treatment of fractures of the lower extremity. Any muscles that act interferingly should be divided with the tenotome, and it is surprising how much such a procedure generally expedites the cure. When the articular surfaces are completely soldered together by osseous matter, and the ordinary means of relief are unavailing, an attempt should be made to sever the connection by the subcutaneous employment of the chisel and other means, detailed in the chapter on diseases of the joints ; or, if this be inapplic- able, by the subcutaneous section of the neck of the bone, as practised by Mr. Adams, of London. 10. OPERATIONS ON THE SCIATIC NERVE. Operations upon this nerve are now so frequently practised as to render it necessary to say a few words upon the subject. Stretching of the nerve has of late years been per- formed in many cases for the relief of neuralgia; and, although it has frequently failed, a number of cases have been reported in which its employment was attended with success, often it is true, only temporary, but, in some instances, permanent. What the ultimate fate of the operation may be, the future alone can determine. Meanwhile, it may boldly be asserted that the confidence in its efficacy awakened by some of the earlier cases, has greatly waned, and that not a few of those who were its most sanguine advocates have abandoned it altogether. 1068 DISEASES AND INJURIES OF THE EXTREMITIES. CHAP. XIX. Excision of this nerve has been practised, although not frequently, for different pur- poses. The case of Dr. Thomas G. Morton, in which in a young negro, he removed one inch and a half of the nerve for the cure of elephantiasis is well known and is alluded to in the chapter on affections of the skin in the first volume. What the effects upon the disease might have been if the man had survived a longer time, it is of course impossi- ble to say. Unfortunately he died a few months after the operation of phthisis ; but I can bear testimony to the fact that the limb had greatly shrunken in bulk and consistence, while the skin had regained much of its pristine softness and pliancy. To expose this nerve is sufficiently easy. Its direction is indicated by a line drawn from the centre of the space between the tuberosity of the ischium and the great trochanter to the corresponding point between the two condyles of the femur. In the upper part of its course the nerve lies immediately beneath the skin and the femoral aponeurosis, in the hollow between the tuberosity of the ischium and the great trochanter, generally imbedded in a considerable quantity of fat; and may here readily be reached by a bold sweep of the knife, by an incision from three to four inches in length. About the middle of the thigh the nerve separates into its two great popliteal branches, which, so far as I am aware, have never been the seat of any distinct operations. No important bloodvessels are con- cerned in any of the operations upon the main trunk of the nerve. When the nerve is fully exposed, it may be lifted up with the finger, or a stout blunt hook, and be either excised or stretched, according to the object it is designed to accomplish. In the latter case, the limb, after the nerve has been sufficiently stretched, is raised from the table by the nerve. 11. BANDAGES FOR THE INFERIOR EXTREMITY. The ordinary roller for the foot and leg is represented in fig. 842. It will be seen that its application begins at the toes, and that it is continued, by circular and reversed turns, as high up as the knee. Its usual length is from five to six yards; its width from two inches and a quarter to two inches and a half. A roller, of simi- lar length and width, will answer for the thigh, the connection being uninterrupted. Care is taken not to make the reverses over the shin, lest they should provoke ulceration. Particular care is also neces- sary in conducting the bandage across the ankle and knee. In general, compresses will be required to fill up the vacuities between the tendo Achillis and the malleolar processes. For retaining dressings on the knee, as in inflam- mation and wounds of the joint, an ordinary roller may be used ; or, what is more neat and convenient, a piece of muslin, from eight to ten inches in width, and about a yard and a quarter in length, the ex- tremities of which are split to within a short dis- tance of its centre. The latter is then applied to the patella, and the ends, crossed behind the ham, and tied, respectively, above and below the knee, as exhibited in fig. 843. In dropsy and loose bodies of this joint, a special contrivance, known as the elastic knee-cap, described in the first volume, is sometimes employed. Bandages for the groin are rendered necessary in the treatment of various affections, as buboes, abscesses, and wounds, and often after the operation for strangulated hernia and the ligation of the external iliac artery. A very effective contrivance of the kind is a triangular piece of muslin, passed around the thigh, the base being fastened in front, and the apex behind, to a band encircling the abdomen, additional security being given by a side strip, as seen in fig. 844. Occasionally the bandage, depicted in fig. 845, may be advantageously employed. It consists of an ordinary roller, from six to eight yards in length by two inches and a half in width, which is carried around the abdomen and the upper part of the thigh, by circu- lar and reversed turns, until the object for which it is applied has been attained. In Fig. 842. Roller applied to the Foot and Leg. CHAP. XX. EXCISION OF THE CLAVICLE. 1069 most cases, it will be best to extend it around both limbs, as it will thus be less likely to slip and become useless. The spica bandage for the groin and thigh is now seldom em- ployed. Fig. 843. Bandage for the Knee. Fig. 844. Fig. 845. Bandages of the Groin, CHAPTER XX. SPECIAL EXCISIONS OF THE BONES AND JOINTS. 1. TRUNK. EXCISION OF THE CLAVICLE. Extirpation of this bone may be required on account of caries, necrosis, morbid growths, and displacement in consequence of disease. Mr. Davie, of Bungay, many years ago, excised the inner extremity of the clavicle in a case of dislocation backwards from deformity of the spine, the luxated bead causing such a degree of pressure upon the oesophagus as to endanger life by inanition. Having made an incision from two to three inches in length over the bone, in a line with its axis, and severed its ligamentous con- nections with the sternum, he divided the bone about one inch from its articular end, by means of a Key’s saw, the soft parts being protected by a piece of sole-leather. The patient speedily recovered, and survived the operation six years. In my private collec- tion is nearly the whole of the left clavicle, which I removed, in 1849, on account of necrosis, from a lad thirteen years old. In 1813, Dr. Charles McCreary, of Kentucky, excised the right collar-bone at its articulations for scrofulous caries : the patient, a boy of fourteen, survived the operation many years, with an excellent use of the corresponding 1070 SPECIAL EXCISIONS OF THE BONES AND JOINTS. chap. xx. limb. A similar operation was successfully performed in 1852 by Dr. A. J. Wedderburn, of New Orleans, in 1856 by Professor Blackman, of Cincinnati, and in 1860 by Dr. Fuqua, of Richmond. In the latter case, however, the sternal end of the bone was saved. In 1828, Dr. Mott removed the entire clavicle, on the left side, on account of an osteo- sarcomatous tumor, of great hardness, conical in its shape, and four inches in diameter at its base. The operation was one of immense delicacy and dilliculty, requiring nearly four hours for its execution, and more than forty ligatures for the suppression of the hem- orrhage. The patient, notwithstanding, made an excellent recovery, and, by means of an apparatus contrived for the purpose, had a perfect use of the arm, being able to move it in all directions. The history of the case, with a detail of the different steps of the operation, is recorded in the American Journal of the Medical Sciences for 1828. I saw this man in 1880. He was then seventy-two years of age and in the enjoyment of per- fect health, with an excellent use of the corresponding extremity. There is a large, deep, depressed cicatrice, perfectly healthy in appearance and consistence. At the sternal ex- tremity is a partial reproduction of bone, a little over an inch in length. Dr. J. C. Warren, in 1832, removed the clavicle of a man, twenty-four years of age, also on account of osteosarcoma. Death occurred in the fourth week after the operation. Mr. Travers, of London, in 1837, successfully excised the collar-bone for a cystic hema- toid tumor in a lad ten years of age. More recently the entire hone was exsected, for a similar disease, by Dr. Curtis, of Chicago, Professor Von Langenbeck, and Dr. Cooper, of California. The first complete extirpation of the clavicle was performed, in 1732, by llemmer. The hone was involved in a sarcomatous growth weighing five pounds. The clavicle has been removed by Dr. James C. Palmar, on account of gunshot injury; and in 1870 Dr. Paul F. Eve exsected the entire hone affected with chondroma. All the cases had an unfavorable termination, either primarily or secondarily. It is obviously impossible to lay down any definite general rules for the resection of this bone. When its removal is required on account of caries, necrosis, or displacement from disease, the operation is sufficiently simple, a single longitudinal incision, in the axis of the bone, affording ample space for its isolation and detachment. But the case is widely different when the clavicle is buried in a large mass of disease ; when the circumjacent structures are all intimately matted together by morbid deposits; and when not only the great vessels of the neck, but likewise the phrenic nerve and the thoracic duct, are in close proximity to the affected bone, as in the instance of Dr. Mott. Under such circum- stances, the operation is one of extraordinary difficulty, demanding the greatest patience, skill, and anatomical knowledge for its successful execution. The surgeon must proceed with the greatest circumspection, making constant use of the handle of the knife, keeping in close contact with the tumor, tying the arteries as they are divided, and guarding against the entrance of air into the veins, the danger of which is always considerable in the excision of morbid growths at the base of the lower cervical region. Trustworthy assistants must be at hand, and every emergency must be anticipated. EXCISION OF THE SCAPULA. Excision of this bone has now been so frequently performed as not only to establish its feasibility, but to prove that, when the cases are properly selected, it is comparatively de- void of risk. The cases of Mussey, Rigaud, Fergusson, Schuh, myself, and others, in some of which the entire scapula was removed along with a considerable portion of the clavicle, clearly evince what the human body is capable of enduring under dissections of a character apparently the most desperate. Dr. Mussey’s operation was performed in 1837; the patient, six years after the arm had been amputated at the glenoid cavity, had a sar- coma of the scapula and clavicle, both of which were removed in their whole extent. The enormous wound healed almost completely by the first intention, and the man, when last heard from fifteen years after the operation was still well. In 1855, Rigaud, of !Stras- hing, took away, with complete success, the entire scapula, with the external extremity of the clavicle, on account of an osseous growth, from a man 51 years of age, whose arm had been amputated at the shoulder-joint eight months previously. Dr. Victor Von Bruns, in 1853, excised the whole of the scapula, excepting the extremities of the acro- mion and corocoid processes; and Von Langenbeck, two years later, took out the entire bone, preserving the corresponding limb. Professor Schuh, of Vienna, removed nearly the whole shoulder-blade in 1860, on account of sarcoma, in a child eight years of age. A case of successful extirpation of the entire bone along with the acromial end of the clavicle, with preservation of the arm, in a girl eighteen years of age, is related by Dr. CHAP. XX. EXCISION OF THE SCAPULA. 1071 Hammer, in the St. Louis Medical Reporter for 1856. A similar operation was performed in 1867 by Dr. Stephen Rogers, of New York, on account of sarcoma in a child, a little upwards of seven years of age. In both these cases the excision -was effected at two periods; in the former after a lapse of a few days, in the latter of a few months. In October, 1868, Mr. Sidney Jones, of St. Thomas’s Hospital, London, excised the entire scapula, excepting the acromion process, for a chondroma, weighing nearly eleven pounds. His patient, a man, thirty-three years old, died on the fourth day. Dr. Schuppert, of New Orleans, in 1868, removed successfully the whole of this bone from a woman thirty- six years old, the subject of three previous operations, on account of an osteoid chon- droma, weighing nearly six pounds. Hammer, in 1869, and Steele, in 1871, each extir- pated the entire bone, with a fatal result, for sarcoma. Michaux, in 1864, excised the entire bone for sarcoma, the patient dying ten months after from a return of the disease. Dr. Charles B. Brigham, of San Francisco, in 1877, successfully removed the entire scapula along with the head of the humerus, in a man thirty-five years of age, on account of necrosis. Excision of the entire scapula was originally performed by Cumming in 1808. If it be impossible to lay down any specific rules for the performance of excision of the clavicle, it would be still more futile to attempt such an undertaking for the scapula. The truth is, every case must provide its own rules. The following instance, in which, in 1850, I removed nearly the whole of the right scapula for an osteosarcomatous affec- tion, will serve to convey a general idea of the procedure necessary under such circum- stances. The patient was a man, forty years of age, and the tumor, first noticed nine years previously, was fifteen inches in length by fifteen and a half in width at its widest part. The patient being placed recumbent, with the body inclining towards the abdomen, an incision, sixteen inches in length, was made from the superior angle of the scapula to the inferior extremity of the tumor, its direction being obliquely downwards and inwards. Another, beginning about five inches below the upper end of the first, and terminating about the same distance from its lower end, was then carried, in a curvilinear direction, so as to include a small oval flap of the skin in its centre. The integument, which was exceedingly dense and thick, especially at the superior part of the tumor, was then dis- sected from the surface of the morbid growth, first towards the spine, and then towards the axilla. Having detached the elevator and trapezius muscles, I sawed through the acromion process of the scapula immediately behind the clavicle, and then divided the broad dorsal and anterior serrated muscles. Carrying my fingers underneath the tumor, and raising it up, I severed its connections with the ribs, cut the deltoid and other mus- cles of the arm, sawed the neck of the scapula, and thus removed the entire mass with comparatively little difficulty. Several vessels were divided in the early stage of the operation, at the posterior and middle part of the tumor ; but these were easily controlled by the fingers of the assistants. Several arteries near the neck of the bone bled so freely as to demand the ligature after the removal of the morbid growth. About twenty-four ounces of blood were lost. The patient became very faint towards the close of the operation, and cordials were necessary to revive him. The immense wound thus produced was dressed with three interrupted sutures and adhesive strips, and supported by a compress and a broad body bandage. No untoward symptoms occurred after the operation ; nearly the whole wound healed by the first intention ; and, at the end of three weeks, the patient went home, gradually improving in health and strength. From exposure to cold, however, he contracted pleuro- pneumonia, from the effects of which he died three months after the operation. The neck and glenoid cavity of the scapula were unaltered, but the remainder of the bone was completely disorganized. The tumor weighed upwards of seven pounds, and belonged to that class of structures usually denominated osteosarcomatous. The external appear- ances of the tumor are exhibited in fig. 846. The entire scapula has occasionally been removed on account of necrosis or long-stand- ing caries. Such an operation was first performed in 1847 by Sir William Fergusson, by Mr. Syme in 1856, and in 1858 by Mr. G. M. Jones, the disarticulation in the two latter instances being effected at the shoulder-joint, with removal of the acromial extremity of the clavicle. All the patients recovered with a good use of the corresponding limb. I have on two occasions removed nearly the whole of the spine of the scapula for necro- sis ; and a considerable number of cases have been recorded of excision of the acromion pro- cess. The coracoid process has also been extirpated both on account of injury and disease. The statistics of excision of the scapula are highly flattering. Of 56 cases, analyzed by Dr. Stephen Rogers, of New York, including one by himself, in 25, or nearly 50 per 1072 SPECIAL EXCISIONS OF THE BONES AND JOINTS CHAP. XX. cent., at least three-fourths of the bone were removed, with an excellent use of the corresponding arm in 10. From the facts developed in this table, it appears that extirpation of the scapula, either alone or along with a portion of the clavicle, is not attended with any greater danger than extirpation of one-half, two-thirds, three-fourths, or four-fifths of the bone. Of 45 cases of partial excision, 10 died of causes more or less di- rectly connected with the operation, as shock, loss of blood, air in the veins, pyemia, or exhausting suppura- tion, making a total of one in four and a half. On the other hand, not a single patient perished from the effects of excision of the entire bone. Professor G. F. B. Adelmann, of Dorpat, in 1879, published an account of 2G1 excisions of the scapula, of which 66 were total, and 195 partial. Of the for- mer 22 were for injury, with a mortality of 27.2 per cent., and of the latter 43 for disease, with a death- rate of 19 per cent., the lesion of one of the cases being unknown. Of the 195 partial excisions 153 were traumatic, and 41 pathological, the affection in one not being stated, with a mortality of 26.3 per cent, for the determined cases of excision for injury, and of 19.5 per cent, for the resections for disease. EXCISION OF THE RIBS. Caries and necrosis of the ribs, both from disease and accident, are by no means un- common, and often lead to the necessity of excision. These pieces are also liable to different morbid growths, which can only be removed by the interposition of the knife and pliers. The annals of surgery afford numerous examples of excision of the ribs, from a portion hardly an inch in length to nearly the entire bone. Operations of this kind were probably performed at a very early period of the profession, and some very extraordinary cases have occasionally been published of their success. Thus, it is reported of Suif that he cut away from a man two of his ribs, making an opening into his chest capable of ad- mitting the fist, and of the removal, with complete success, of a portion of diseased lung. Incredible as this case may at first appear, it has its analogue in one which occurred in the practice of Dr. Milton Antony, of Georgia. In this instance, the fifth and sixth ribs, which were extensively carious, were removed along with two-thirds of the right lobe of the lung, the patient surviving the exploit nearly four months. The particulars of this remarkable case are recorded in the sixth volume of the Philadelphia Journal of the Medical and Physi- cal Sciences. I have repeatedly excised considerable portions both of the ribs and of their cartilages; and at the College Clinic in 1857, I removed from a negro lad, seventeen years of age, the central pieces of the sixth and seventh ribs, one of which was upwards of six inches in length, on account of scrofulous disease. During the operation, the apex of the heart could be plainly seen pulsating beneath the denuded structures. The boy rapidly recovered, and has ever since been in good health. Formidable operations upon the ribs, affected with various kinds of tumors, for the most part of a sarcomatous char- acter, have been performed by different American surgeons, among whom it will be sufficient to mention the names of John C. Warren, George McClellan, and William Gibson. In caries and necrosis of the ribs, excision may be performed with the greatest facility, as the diseased pieces are always more or less isolated by the morbid action, especially from the pleura, which is usually very much thickened and indurated, and, therefore, not at all in danger of being injured, unless great negligence is displayed. The intercostal arteries, too, are generally out of harm’s way. In necrosis, a slight incision will com- monly suffice to enable the surgeon to effect extraction, but in caries a more extensive incision, made in the axis of the affected bone, will be needed. If the attachments are firm, the knife must be kept close to the bone, and it is safer here, as elsewhere, in simi- lar cases, to use the handle of the instrument than its point. When the ribs are involved in morbid growths, excision will be environed with many difficulties, owing to the fact Fig. 846. Osteo-sarcoma of the Scapula. CHAP. XX. EXCISION OF THE PELVIC BONES. 1073 that the pleura generally retains its normal characters, and that it is then almost impos- sible to separate it from the affected structures without penetrating its cavity; moreover, such tumors are usually extremely vascular, and are apt to project to a considerable dis- tance beneath the surrounding parts. As it respects the incisions necessary in such cases, the most eligible and convenient will be the T-shaped, semilunar, or elliptical. EXCISION OF THE STERNUM AND ENSIFORM CARTILAGE. The sternum has occasionally been excised, not wholly, of course, but in part, on account of caries, to which its substance is very subject in scrofulous and syphilitic persons, and also on account of necrosis, gunshot injury, and compound fractures. Its affections are liable to be complicated with abscess in the anterior mediastinum, thickening of the pleura, and lesion of the costal cartilages. The diseased portions may usually be gouged away or extracted without difficulty, exposure having been effected by a J -shaped or crucial incision. When the bone is largely implicated, without any tendency to spontaneous separation, the removal will be expedited by perforating it with the trephine, to admit the introduction of the elevator. In general, however, its substance is so soft that it may easily be cut away with the pliers, or even a stout, probe-pointed knife. The ensiform cartilage was excised by Odoardo Linoli, in 1852, in a man, twenty-two- years of age, on account of severe suffering, habitually experienced after eating from the pressure of this body upon the stomach. The cartilage was bent inwards, and, when firmly pressed upon, immediately gave rise to gastric distress. During recumbency no inconvenience was felt, but the erect posture almost invariably caused gastralgia and even, at times, more or less vomiting after a hearty meal. The operation perfectly relieved the: distressing symptoms. EXCISION OF THE PELVIC BONES. The bones of the pelvis are liable to caries and necrosis, often attended with trouble- some sinuses, and sometimes requiring extensive operative interference. I have, in one instance, been compelled to remove the tuberosity of the ischium ; in another, a large fragment of the iliac crest; and, on one occasion, a considerable piece of the posterior and lateral part of the sacrum. Exostoses sometimes form upon these bones, and may, unless deeply seated under the gluteal muscles, be easily removed with the knife and chisel. Professor Volkmann, in 1876, reported a case in which, on account of a myeloid tumor, he successfully excised a large portion of the sacrum, division being effected by means of a chisel below the left sacro iliac symphysis. A narrow strip of the bone and the coccyx were left intact. The coccyx may be invaded by caries, from the contact of fecal matter in anal fistule; and a similar effect is occasionally produced by a blow, fall, or kick, or by injury inflicted by the pressure of the child’s head during parturition. Simple contusion or concussion of this bone may give rise to the most distressing and protracted suffering. Dr. Nott, as early as 1832, excised this bone on account of severe and intractable neuralgia seated in its substance, its lower extremity being hollowed out into a mere shell. A vertical in- cision was made behind, along the middle line, when the bone was disarticulated at the second joint, and separated from its muscular and ligamentous attachments. The patient was a female, twenty-five years of age; the wound was long in healing, and a month elapsed before the pains disappeared from their original site. Dr. Nott afterwards repeated this operation, technically called coccygectomy, several times, and it has also been per- formed, with variable success, by Simpson, Godfrey, Mears, myself, and others on account of different diseases. Ollier has removed the coccyx for the relief of osteitis; andVerneuil to facilitate the formation of artificial anus and the excision of the rectum in carcinoma. The coccyx is exposed by an incision carried along the middle of the intergluteal cleft, commencing a few lines above the saccrococcygeal joint, and extending thence downward for about two inches toward the anus. The bone having been thoroughly exposed is then disarticulated and separated at the sides from its muscular and ligamentous connections, after which it is carefully detached from its bed, the finger being all the while, in this stage of the procedure, in the rectum. The operation is by no means an easy one, owing to the naturally strong attachments of the bone to the surrounding structures, and the difficulty is materially increased when the patient is very fat. Very little bleeding attends. The wound is dressed antiseptically with a soft drainage tube in the most dependent angle. 1074 SPECIAL EXCISIONS OF THE BONES AND JOINTS. chap. xx. The instruments required for the operation are, besides, a stout scalpel and forceps, a pair of pliers, a chisel, curved forceps, and the elevators depicted at page 415, Vol. II. A considerable number of cases of this operation have been reported, some with, and some without, a favorable result. Uniform success could not reasonably be expected when we consider the nature of the affections for which excision is generally practised. 2. SUPERIOR EXTREMITY. EXCISION OF THE BONES OF THE HAND. Excision of the head of the phalanx of the thumb has sometimes been practised in com- pound dislocations and fractures, and the success attending the operation has afforded a warrant for performing it in case of caries of its substance. The joint is exposed by a tree lateral incision, and the offending portion removed with the pliers. The cure will be more likely to be satisfactory if a small piece be clipped off from the contiguous bone, as the two raw surfaces, when brought together, will then unite more readily. It is never desirable to exsect any of the digital phalanges, except the distal one; such a procedure would only leave a useless finger, and could, therefore, never become general. When the last phalanx is rendered carious, or deprived of its vitality, as so often happens in whitlow, the proper plan is to remove it through an incision extended along its palmar aspect; and it is well known that, when the periosteum is not destroyed, the bone, under these circumstances, is sometimes partially regenerated. Excision of all the carpal bones has occasionally been attempted, generally in connec- tion with that of the articulating extremities of the radius and ulna, but I am not aware that it has ever, in a single case, been followed by any satisfactory results. On the con- trary, the disease for which the operation was performed has nearly always returned, and eventually led to the necessity of amputation of the forearm. It is questionable, therefore, whether the operation is worthy of repetition. It is different, however, when only a few of the carpal bones are in a carious state; then excision of the affected pieces should be .practised by all means, for if pains be taken to remove all the morbid structure, and no serious injury is inflicted upon the soft parts, particularly the sheaths of the tendons, there will be a very reasonable prospect of a good result, the hand not only preserving its use- fulness, but also its symmetry. In several cases in which I adopted this method the re- sult was most satisfactory. In an instance in the care of Mr. Butcher, of Dublin, the magnum, cuneiform, trapezoid, and unciform bones, together with a part of the lunar, and two-thirds of the fourth and fifth metacarpal bones, were excised, and yet a very useful hand was left. The site of the piece to be removed will usually be indicated by a fistu- lous opening; if any formal incision is necessary, it should be made upon the dorsal sur- face of the hand. A gouge and mallet are indispensable instruments in the operation. The metacarpal bones have frequently been removed in part, or in whole, for caries, necrosis, or external injury. The operation, which is sufficiently simple, consists in making a longitudinal incision along the dorsal aspect of the bone, in separating it from the soft parts by keeping the knife close against its surface, and in disarticulating it in the usual way. The carpal end of the bone, if sound, should be left, and in that case the division should be effected with the pliers. As the object is to preserve the finger, the extensor tendon is carefully drawn aside during the operation. The metacarpal bone of the thumb may be treated in a similar manner, the phalanges being retained ; and, although the member may not, for a time, be of any material use, yet as the soft parts become consolidated it will be found to be very serviceable, to say nothing of the import- ant part which it plays in preserving the symmetry of the hand. In 1858 I removed the metacarpal bone of the right index finger for a gentleman, thirty-three years of age, on account of a gunshot injury, leaving the tendons of the extensor and flexor muscles intact, and the consequence was a most excellent state of the finger. EXCISION OF THE WRIST-JOINT. Excision of the wrist-joint, originally performed by Mr. Cooper, of England, in 1758, has been practised much less frequently than that of the other articulations, and in the cases in which it has been done the result has not been at all encouraging. The opera- tion, besides being awkward and difficult on account of the importance of the structures concerned in it, and the peculiar conformation of the joint, is extremely liable to be fol- lowed by permanent ankylosis of the wrist, and stiffness of the fingers. Another objection CHAP. XX. EXCISION OF THE BONES OF THE FOREARM. 1075 is that, when the carpal bones are involved in the disease, there is apt to be a return of the morbid action, eventually necessitating amputation of the forearm. Hence some sur- geons prefer amputation in the first instance to the risk, pain, and inconvenience of exci- sion without the certainty of a final cure. In opposition, however, to this decision, it may be urged that a stiff hand with the preservation of the mobility of even some of the fingers is very greatly to be preferred to no hand at all, both on the score of utility and seemliness, and that there are few persons who, if the matter were left to their own choice would not rather submit to excision, if it afforded any reasonable prospect of success, than to the unconditional loss of so important and valuable a member. There are two methods according to which this operation may be practised; in one the incisions are made along the inner and outer margins of the limb, in the other over its dorsal aspect, in the form of a semilunar Hap, with the convexity downwards. When the disease necessitating the operation is limited to the ulna and radius, the former plan is to be preferred, but the latter, as affording more room, when the carpal bones participate in the disorganization. Whichever procedure be adopted" care is taken not to divide the extensor tendons of the thumb and fingers, as this would compromise their future useful- ness, and thus frustrate the main object of the excision. The ends of the radius and ulna are removed on the same level, either with the pliers or with a narrow saw; in the flap opera- tion it may be necessary, during the division of the bones, to protect the soft parts with a spatula or a strip of leather. During the after-treatment, the forearm, bent nearly at a right angle with the arm, is well supported with two light splints, and the thumb and fingers are kept semiflexed, in order that, when the cure is completed, they may be more easily approximated. In many cases extension and counterextension are desirable, in which event the apparatus of Von Langenbeck, fig. 847, will be found most useful. Passive motion may be instituted at the end of a few weeks. The statistics of this operation are very limited. The tables of Dr. Culbertson contain 85 determined cases of excision for disease, of which 75 recovered, the majority of them Fig. 847. Yon Langenbeck’s Extension Apparatus for Resection of the Wrist-joint. having a more or less serviceable hand; 10 died, and 10 underwent subsequent amputa- tion. Plxcision of the wrist joint for gunshot wounds, as indicated by the tables of Dr. Gurlt, has been practised 133 times, with 112 recoveries, 1 doubtful, and 20 fatal results, the mortality rate being 15.15 percent. Of 119 of these cases the operation was primary in 39, with 4 deaths; 8 were intermediate, with 3 deaths; 53 were secondary, with 12 deaths; 7 were late excisions, all being successful; and 12 were of uncertain date, with- out a death. Consecutive amputation was required in 9.24 per cent. Of 1G cases in which its ultimate result was known only 1 was favorable. EXCISION OF THE BONES OF THE FOREARM. The bones of the forearm may require extirpation in part, or in whole, for caries, gun- shot injury, or chronic enlargement. Dr. Compton, of New Orleans, in 1853, excised both the radius and ulna, except the inferior extremity of the former, on account of a compound, comminuted fracture, two months after the accident. The greater portion of the periosteum, detached during the progress of the resulting inflammation, was left in the wound. The patient, a boy, fifteen years of age, made an excellent recovery, with a very good use of the hand. The forearm was three inches shorter than natural, and flexed at a right angle with the humerus. Dr. Robert B. Butt, of Virginia, in 1825, exsected the lower two-thirds of the ulna of the left side, in a man twenty-five years old, who, several years previously, had received 1076 SPECIAL EXCISIONS OF THE BONES AND JOINTS. a punctured wound in the wrist-joint, causing violent inflammation of the whole limb as far as the elbow, and ultimately terminating in hypertrophy and caries of the ulna, with immense thickening of the periosteum. Three months after the operation, the man had so far recovered as to be able to pursue his occupation of a house-joiner, flexion, extension, and rotation of the joints being as free and uninterrupted as they had ever been. In 1853 Dr. Carnochan performed a similar operation, taking out the entire ulna, which, as in the case of Dr. Butt, was excessively enlarged from one extremity to the other, measuring, at the base of the coronoid process, five inches and a half in circumference, and weighing nearly eight ounces. Ilis patient, a man, thirty years of age, was of a strumous habit, and the disease was supposed to have been occasioned by a severe sprain of the arm. No untoward symptoms occurred during the after-treatment; very little de- formity was perceptible when the wound was healed; and the functions of the hand and forearm wrere preserved in a-remarkable degi’ee. Mr. Jones, of Jersey, has also removed the whole ulna; and Dr. George Williamson, in his Notes on the Wounded from the Mutiny in India, refers to a similar case in which, on account of disease, he exsected this bone along with the head and neck of the radius, and the lower end of the humerus, the patient regaining an excellent use of his limb. Dr. C. S. Muscroft, of Cincinnati, ex- sected the entile ulna successfully, in 1870, on account of caries, in a man forty-two years old; and Professor Hutchison, of Brooklyn, was equally fortunate, in 1873, his patient being a girl, sixteen years of age. The entire radius was exsected by Dr. Carnochan, in 1854, on account of caries, hypertrophy, and eburnation, caused by a severe blow upon the upper part of the forearm, the patient, a man, twenty years old, recovering with such an excellent use of the limb as to be able to write with ease and rapidity. When last seen, six years after the opera- tion, the parts remained perfectly sound, but the hand was not quite in its natural axis, as it inclined a little outwards, while the styloid process of the ulna formed an abnormal prominence on the inside of the wrist. The bone was exsected from joint to joint. An operation of a similar kind, with an equally fortunate result, was performed in 1859 by Dr. Choppin, of New Orleans, upon a boy, fourteen years of age. In this case, however, the inferior articular extremity of the bone was retained, as it wras found to be free from disease. Dr. C. C. Field, of Easton, Pennsylvania, in 1878, excised the entire radius on account of caries and necrosis, the patient making an excellent recovery. In 1857 I excised, at the College Clinic, somewhat more than the upper half of the bone, along with the outer condyle of the humerus, for scrofulous disease of several years’ standing, the patient being a young man in dilapidated health. He recovered well from the operation, but of the ultimate result I am unable to give any account, as the case was soon after lost sight of. The appearance of the limb, prior to the operation, is exhibited in fig. 848. Mr. Erichsen states that he has resected the whole radius, with the exception of its articular head, wdiich was sound, and that a useful arm was left. Excision of the lowrer chap. xx. Fig. 848. Caries of the Elbow-joint, as seen before Excision. four-fifths of this bone was performed by Dr. Carnochan, in 1857. His patient, a woman, thirty-one years of age, made an excellent recovery, the functions of the hand being so little impaired that she was able to attend to her household duties nearly as well as before the operation. The bone was greatly diseased and enlarged. Excision of the entire radius is performed by making a longitudinal incision along the posterior and outer aspect of the forearm, from the wrist to the elbow, and in detaching the bone carefully from its connections, with the precaution of inflicting as little injury as 1077 CHAP. XX . EXCISION OF THE ELBOW-JOINT. possible upon the surrounding structures. In caries, the bone is occasionally so slightly adherent that the periosteum may readily be peeled off from it by means of the handle of the knife, as happened in my case of partial excision. When the attachment is very firm, the rule is to keep the knife as closely against the bone as possible. Removal of the ulna is effected upon the same principle, but in this case the incision is carried along the pos- terior and inner aspect of the limb. In neither operation is it necessary to divide any of the principal arteries of the forearm, and hemorrhage from the smaller branches may be moderated by compression of the brachial by the fingers of an assistant. When the entire ulna or radius is removed, the proceeding will be facilitated by giving the wound, at each extremity, a curvilinear direction, or a short transverse cut may be extended from it at these points, either outwards or inwards, according to the situation of the bone concerned. Excision of portions of the bones of the forearm has been practised for gunshot injuries, with very encouraging results. Of 287 cases, tabulated by Dr. S. W. Gross, 252 re- covered, and 35 died, the ratio of mortality being 12.19 per cent. Both bones were the seat of the procedure 29 times, of which 5, or 17.24 per cent., were fatal; the radius was excised in 130 cases, with 13 deaths, a ratio of mortality of 10 per cent. ; and the ulna was excised 128 times, with 17 deaths, or a mortality of 13.28 per cent. Seven of these cases required consecutive amputation. EXCISION OP THE OLECRANON. Excision of the olecranon may be required for caries, or caries and necrosis. The operation is also occasionally demanded on account of gunshot and other injuries. A longitudinal incision being made over the posterior part of the elbow, the process is de- tached from the tendon of the extensor muscle, and divided with the pliers or a narrow saw. The wound is accurately approximated by suture, plaster, and collodion, the limb is maintained at rest in the straight position, and, in due time, passive motion is insti- tuted, to preserve the use of the joint. Dr. Gurdon Buck, in 1842, exsected the olecranon on account of hypertrophy of its substance from external injury, followed by total loss of flexion and extension, although pronation and supination partially remained. The patient recovered from the effects of the operation, but the limb, instead of being benefited, became permanently stiff. EXCISION OF THE ELBOW-JOINT. Excision of the elbow-joint has been so frequently practised, and the success attending it has been so flattering, that it is now universally accepted as one of the established operations in surgery. Complete excision was first performed by the elder Moreau, in 1794. Wainman, of Shripton, England, had sawed off the lower end of the humerus, in a case of compound dislocation, in 1758; and, in 1775, Justamond, of London, cut away the olecranon and two inches of the ulna for disease. The younger Moreau repeated the operation, in 1797, after which it fell into desuetude in France until it was revived, in 1819, by Roux, who became one of its warmest advocates. In England, the elbow was first completely excised by Stansfield, of Leeds, in 1818; in Ireland, by Crampton, in 1823; in Scotland, by Syme, in 1828; and in the United States, by John C. Warren, in 1834. The operation is usually required on account of caries, or caries and necrosis, of the heads of the contiguous bones, and should always be preferred to amputation of the arm, when it is possible to preserve a sufficiency of osseous matter to leave a good limb. Experience has proved that the danger of excision of the elbow-joint is, in general, very slight, when the operation is limited to the articular extremities of the bones; when the medullary canal of the humerus is exposed, there is always risk of myelitis, erysipelas, and pyemia, and the same is true, although in a less degree, of the medullary canal of the radius and ulna. Besides, the shorter the excised pieces are, the greater, other things being equal, will be the probability of a serviceable limb ; nevertheless, there should be a considerable interval between the ends of the bones, otherwise it will be difficult to counteract the tendency to reunion. In regard to the mode of operating, surgeons have hitherto failed to agree upon any particular standard, for the reason, doubtless, that no one method is applicable to all cases. Mr. P ark, by whom the procedure was originally suggested, although never practised, thought the object might be attained by a single longitudinal incision along 1078 SPECIAL EXCISIONS OF THE BONES AND JOINTS. CHAP. xx. the posterior part of the elbow, as in fig. 849, from Erichsen, and the excision has often been effected in this way. Yon Langenbeck, whose experience with this operation is very great, prefers this method to all others, and I am sure, from what I have seen of it, that nothing better could be desired, whether for complete or partial excision. Moreau em- ployed an H'l*ke cut, by means of which he obtained two large flaps, which, reflected in opposite directions, exposed the parts very freely. Some, again, as Jicger and Liston, Fig. 849. Excision of the Elbow-joint. avail themselves of a X-shaped incision with the horizontal limb on a line with the inner condyle, while others, among whom I formerly included myself, advocate a semilunar one, with the convexity downwards, on the ground that the wound affords more ready drainage. In performing the operation, the patient should incline somewhat towards his abdo- men ; and the incisions should be sufficiently ample to give the surgeon free room for the accomplishment of his design. An assistant is ready to compress the brachial artery, in the event of there being any likelihood of much hemorrhage, which, however, will rarely be the case, unless the articular vessels, which will necessarily be divided, have become much enlarged from protracted irritation. Care is also taken not to injure the ulnar nerve, as it courses along the inner margin of the olecranon. If the semilunar incision be adopted, the knife should be drawn across the back part of the limb, from the superior extremity of one condyle to that of the other, for a distance of about two inches and a half; the flap being then raised, the ligaments, if still remaining, are cautiously severed, and the tendon of the three-headed extensor muscle detached at its insertion. The instrument is next passed closely around the olecranon, and this process removed with the pliers. The joint being thus fairly exposed, the heads of the radius and ulna are liberated from their connections, and thrust through the wound by forcibly bending the joint and pushing the forearm upwards. The saw is now applied, and the diseased structure excised, with the precaution of avoiding, if possible, the attachment of the two-headed flexor and anterior brachial muscles, as their separation would seriously compromise the future usefulness of the extremity, The articular end of the humerus is removed in a similar manner. In cutting off’ the bones the ulnar nerve is drawn to one side with a blunt hook,; but it is not necessary to protect the parts in front of them, as the brachial artery lies securely under cover of the anterior brachial muscle. In the operation of Von Langenbeck, the incision is carried along the posterior surface of the joint, through the tendon of the triceps muscle towards the inner condyle, for a distance of at least four inches, of which two are above and two below the centre of the articulation. The soft parts are detached in the usual manner, the periosteum is carefully preserved, and the bones are severed with the saw and pliers. Partial excision is conducted upon the same principles as complete. When only one bone is diseased or injured, the articular extremities of the other two must be cut away, experience having shown that, if this precaution be neglected, the operation is not only more dangerous to limb and life, but very liable to be followed by irremediable ankylosis. In performing any operation of this kind upon the elbow the periosteum should be scrupulously respected, and it is not less proper, whenever practicable, to raise with the CHAP. XX. EXCISION OF THE ELBOW-JOINT. 1079 chisel and hammer along with this membrane, as suggested by Professor Yoight, thin layers of bone at the points of attachment of important tendons and ligaments. In very young children excision of this joint is seldom necessary, as any diseases, unless far advanced, will generally disappear, in time, under proper local and constitutional treat- ment. If ulceration be present, the affected structures should be thoroughly scraped, as an important aid to success. During the after-treatment the limb is placed in an easy, flexed position, in a tin case, with an opening opposite the elbow to facilitate the drainage, upon an angular splint, or, what is better than either, upon Heath’s apparatus, delineated in fig. 850. By means of Fig. 850. Heath’s Splint in Excision of the Elbow. this contrivance, which is furnished with screws and a central hinge, the forearm can readily be maintained at any desired length and angle. The ends of the bones should be kept in tolerably close proximity with each other; for, as they are destined to unite by fibro- ligamentous tissue, it is important that this substance should be as short as possible. As the cure progresses, the forearm is gradually Hexed, until, at length, it is brought to a right angle with the arm, passive motion being frequently practised to prevent permanent ankylosis. When the after-treatment is judiciously conducted, there is not only usually no danger from the operation to the patient’s life, but every reason to hope for a good result as it respects the use of the limb. Many of the persons subjected to this operation are after- wards able to pursue, with great satisfaction, their former occupation. Mr. Cock, of London, in 1857, had under his charge a man whose elbow had been excised, eighteen years previously, by the late Mr. Key, on account of scrofulous caries. He had enjoyed, throughout the whole interval, a very excellent use of the limb until a short time before his admission, when, in consequence of an attempt to work with it in a new position, dis- ease again appeared, requiring a slight operation, which promised to be followed by further relief. The case affords a beautiful illustration of the triumphs of conservative surgery. Excision of the elbow-joint on account of gunshot injuries has lately engaged much attention among military surgeons. I)r. Gurlt has collected 1438 cases, with 1054 recov- eries, 35 doubtful, and 349 fatal results, the mortality-rate being 24.87 per cent. Of 1334 of these operations he has ascertained that 393 were primary, with 4 unknown results, and 84 deaths; 116 were intermediate, with 3 unknown results, and 33 deaths; 690 were secondary, with 9 unknown results, and 194 deaths ; 14 were late excisions, and all were successful; and 121 were excisions of uncertain date, with 9 unknown results, and 11 deaths. In 7.04 per cent, conservative amputation was necessary. Of 355 cases in which the condition of the limb was known 104 were favor- able, the joint being movable in 67, and ankylosed in 37, and 251 were unfavorable. Stromeyer and Esmarch have con- clusively shown, contrary to the opinion generally received, that partial excisions are followed by better results as regards the mobility of the joint than total operations, a fact which sustains the views of the latter surgeon that the motion does not depend so much upon the extent of the parts excised, as upon the retention of a portion of the synovial membrane. Consecutive amputation is occasionally required, as in the case delineated in tig. 851, in which, on account of perfora- tion of the elbow-joint by a conoidal ball, two inches of the lower extremity of the right humerus, along with the olecra- non process, were excised, by Dr. He wit. Two months sub- sequently the arm was removed near the shoulder. Fig. 851. Front view of an Excised Elbow. 1080 SPECIAL EXCISIONS OF THE BONES AND JOINTS. CHAP. xx. Of 145 cases of excision of the elbow-joint for disease, tabulated by Ileyfelder and Bceckel, 125 recovered and 20 died. In 7 cases, subsequent amputation was rendered necessary, and 94 of the successful cases regained useful arms. These facts correspond very closely with those deduced by Dr. Hodges from an examination of 119 cases, of which 104 recovered and 15 died, consecutive amputation being performed 15 times. Of the 89 recovering without amputation, 77 had more or less useful limbs. In 470 amputa- tions of the humerus, 157 proved fatal, or in the ratio of about 33 per cent. Of 377 cases analyzed by Culbertson 41, or 10.8 per cent., were fatal. It will be thus perceived that the results of these statistics are decidedly in favor of excision of the elbow. EXCISION OT THE HUMERUS. Excision of the shaft of the humerus is sometimes required on account of gunshot in- juries, or fractures caused by severe falls, railway accidents, or machinery in rapid motion. In the first two Schleswig-Holstein campaigns, resection of the ends of the fragments was practised for the cure of gunshot lesions in 9 cases, of which 4 died, while of the remain- ing 5 several had very defective limbs. Subsequently resection was abandoned, the sur- geons limiting themselves for the most part to the immediate removal of the splinters; and of 32 cases thus treated only 5 died, the others making excellent recoveries, with useful limbs, although in many the humerus had been terribly shattered by cartridge shot. At Constantinople, as stated by Baudens, portions of the shaft of the humerus were ex- cised 4 times, of which 2 died and 2 recovered. The table, collected by Dr. S. W. Gross, however, shows much more favorable results. Thus, of 207 cases, occurring in our Army and Navy, in the Schleswig-Holstein wars, and in the Italian hospitals, during the war of 1859, 152 recovered and 55 died, yielding thus a ratio of mortality of 26.57 per cent. These results are more encouraging than those of amputation of the arm for gun- shot injuries, since of 3968 cases of the latter description, 2766 recovered and 1202 died, a percentage of mortality of 30.29. Expectant treatment, however, affords far more encouraging results in this class of injuries than either excision or amputation. Thus, of 1008 cases, inclusive of 693 that occurred in our late war, tabulated by Dr. Gross, 799 recovered and 209 died, the mortality ratio being 20.73 per cent., which is 9.56 per cent, less than that of amputation of the arm, and 5.84 per cent, less than that of excision in the continuity of the humerus. In 211 cases recorded by Demme, the time required for a cure varied from forty to sixty days, and in five instances a false joint formed. In none did consecutive necrosis take place, while of 240 amputations of the arm which came under his observation, necrosis of the stump occurred in 30. Professor Yon Langenbeek has several times exsected the entire humerus on account of gunshot injury, the patients making a good recovery, with a very excellent use of the limb. In one of the cases the head and upper half of the bone were removed soon after the acci- dent, and five months subsequently the lower half along with nearly an inch of the radius and ulna. The new bone was about half the size of the original, but the condyles were well formed, and the superior extremity strikingly resembled the natural head. In a pathological case, operated upon in 1864, Yon Langenbeek removed at different intervals the entire humerus, ulna, and radius, with a sound cure and a very serviceable limb, the muscles having been left adherent to the periosteum, which was itself disturbed as little as possible. The entire humerus, together with the heads of the radius and ulna, was cut away, in 1864, by Dr. James B. Cutter, of New Jersey, on account of extensive necrosis, the effect of a gunshot fracture of the superior extremity of the bone, exsected by another surgeon three days after the accident. Billroth, in 1877, reported a case of total resection of the humerus on account of caries and necrosis in a lad twelve years old. EXCISION OF THE SHOULDER-JOINT. Excision of this articulation is frequently rendered necessary on account of caries and necrosis of the head of the humerus, or of this bone and of the contiguous surface of the sca- pula. It has also been done, in numerous instances, on account of various morbid growths, of gunshot injury of the shoulder, attended with laceration of the soft parts and commi- nution of the upper extremity of the humerus. The head of the humerus has been suc- cessfully removed on account of unreduced dislocation by Brainard and Warren ; by Blackman for chronic rheumatic arthritis; and by Bickersteth on account of exostosis. For the cure of caries of this bone the operation was first formally performed, in 1771, EXCISION OF THE SHOULDER-JOINT. 1081 by Mr. James Bent, of Newcastle, England, although a nearly similar procedure had been executed by Schaeffenbergsin in 1726, and by Thomas, of Pezenas, in Languedoc, in 1740. When proper care is exercised, as in the selection of the cases, and in the mode of opera- tion, I believe that it will seldom be followed by any bad effects, especially in pathologi- cal cases, while the patient will usually have a very good use of his limb. Less impair- ment of function, other things being equal, will necessarily ensue when a small than when a large portion of bone is removed. In an instance in which Lenton excised the entire humerus, except two inches of the lower extremity, the arm remained permanently stiff’. Various methods have been proposed and executed for the removal of the shoulder- joint. Thus, some content themselves with a vertical incision, extending from the acro- mion process down through the belly of the deltoid, nearly as far as the insertion of this muscle ; some, again, prefer a \/-shaped cut, the base looking upwards ; Moreau, who per- formed the operation a number of times, made a quadrilateral flap with the base below ; Morel fancied that the easiest way of accomplishing the object was to make a semilunar flap over the most prominent part of the shoulder, not unlike that made in amputation ; Mr. Syme employed two incisions, a perpendicular one through the middle of the deltoid, and an oblique one extending upwards and backwards from the inferior angle of the first. Professor Von Langenbeck makes a vertical incision from the anterior border of the acro- mion process, midway between the two tubercles of the humerus, in the direction of the long tendon of the biceps, from three to four inches in length, detaches the subscapular and spinate muscles, opens the capsule of the joint, raises the periosteum, and saws off the bone at its neck or at the upper portion of the shaft, as may be found necessary. I)r. W. P. Moon, who has performed this operation four times, twice successfully, on account of gunshot injury, gives a decided preference to an incision carried along the posterior border of the deltoid muscle. The advantages claimed in this procedure are, greater facility of exposing and removing the head of the humerus, more ready drainage, greater rapidity of cure, and a rounder and fuller state of the shoulder after recovery. Finally, the late Professor Joseph Pancoast preferred a curvilinear cut, under the impression that it yielded more room for the necessary manipulations. It cannot be de- nied that some of these methods afford the surgeon most ready access to the joint, and enable him to effect excision of the humerus with the greatest facility ; but then they have the disadvantage, and a very serious one it is, of inflicting most severe injury upon the deltoid muscle, in consequence of the oblique and more extensive division of its fibres, and of thus greatly protracting the cure, as well as materially enhancing the danger. It is for these reasons that I have always limited myself, in the operations which I have performed upon the scapulo-humeral articulation, to the simple perpendicular in- cision, as depicted in fig. 852 ; and I believe this will gene- rally be found to answer every purpose, while it is entirely free from the objections here adverted to. In one of my cases, treated in this manner, I was enabled to remove, with- out difficulty, upwards of four inches of the humerus, and the recovery was most satisfactory. The operation is generally the more easy because, in caries of the joint, there is nearly always very considerable atrophy of the deltoid muscle with absorption of the subcutaneous fat. The incision should begin immediately beneath the acromion process, and, descending nearly in a straight line, through the cushion of the shoulder, terminate within a short distance of the inferior attachment of the deltoid. The knife is carried down, at the first stroke, to the bone, which is then thoroughly liberated from its con- nections with the soft parts by means of a stout, blunt-pointed bistoury, passed closely around its neck, so as to sever the tendons of the subscapnlar and spinate muscles, the long head of the biceps being left intact. If this do not afford sufficient space, a hori- zontal incision should be made along the anterior border of the acromion process, so as to impart to the wound the outline of the letter L or T. The capsular ligament is gene- rally destroyed by the disease, but, if any portion remain, it must be divided in the usual way. If more than the head of the bone requires removal, it will be necessary to separate any fleshy fibres that may be attached to the shaft. This step of the procedure CHAP. XX. Fig. 852. Appearance of the Wound after Excision of the Head of the Hume- rus. 1082 SPECIAL EXCISIONS OF THE BONES AND JOINTS. may be greatly facilitated by the use of the instrument depicted at p. 415, fig. 305. The bone is now pushed through the wound by depressing the elbow backwards, and the whole of the diseased portion sawn off, the soft structures being carefully protected from the teeth of the instrument. If the glenoid cavity is involved in the morbid action, the CHAP. xx. Fig. 853. Lossen’s Extension Apparatus for Resection of the Shonlder-joint. affected substance is scraped or cut away, the acromion process being dealt with, if need be, in a similar manner. Sometimes it is necessary to remove the head of the humerus and a large portion of the scapula, as in a case which occurred to Mr. Jones, of Jersey. The bleeding vessels being secured, the cavity is next washed out with cold water, the Fig. 854. Fig. 855. Flap Operations in Excision of the Head of the Humerus, sinuses, if any exist, are properly pared, and the edges of the wound are approximated by suture and bandage, the arm being secured to the side of the body, and the forearm 1083 CHAP. XX . supported in a sling. To favor discharge, a small tent or drainage-tube should be inserted into the lower angle of the wound. When extension is deemed desirable, the apparatus of Lossen, fig. 853, will fulfil the indications. The posterior circumflex artery is necessarily divided in this operation, and is fre- quently the only vessel that requires ligation. The axillary artery, vein, and plexus of nerves are entirely beyond the reach of the knife. In the flap operation, the incisions may he made so as to represent the shape of a IT, as in fig. 854, from Erichsen, or the outline of a V, as in fig. 855. In either case, the deltoid muscle is extensively divided, and easy access af- forded to the articulation. The procedure, however, is one of great severity, liable to be followed by grave consequences. The diseased appearances of the head of the humerus, in one of my cases, are well illustrated in fig. 856. The bone was sawn off' upwards of an inch and a half below its tube- rosity. The specimen affords conclusive evidence of the im- possibility of a cure, under such circumstances, by ordinary methods. The patient was a seafaring man nearly forty yeai’S of age, sent to me by Dr. J. L. Pierce, of Bristol, Pennnsylvania. Dr. Gurlt has tabulated 1661 cases of excision of this joint for gunshot injuries, with 1067 recoveries, 27 doubtful res- sults, and 567 deaths, the mortality rate being 34.70 per cent. Of 1453 of this number he found that 559 were primary, with 3 doubtful results, and 177 deaths; 129 were intermediate, with 1 doubtful result, and 68 deaths ; 618 were secondary, with 4 unknown results, and 241 deaths; 27 were late excisions, with 1 death ; and 120 were of uncertain date, with 9 unknown results, and 21 deaths. In 1.65 per cent, con- secutive amputation was necessary. The ultimate results of 213 cases were favorable in 94, and unfavorable in 119. In 88 of the former the joint was movable. These facts are, practically, of the deepest interest, as showing the bad effects which may he ex- pected from interference after the occurrence of severe inflamma- tion with incipient suppuration. During our late war, in addition to the head of the humerus, portions of the clavicle, or of the coracoid and acromion processes and neck of the scapula, were excised in 29 instances with only 4 deaths, the result being as satisfactory as that of the ordinary operation. In many instances several inches of the shattered shaft of the humerus were removed along with the head of the bone, as in fig. 857, and several recov- eries are reported with fair motion. In this country, removal of the shoulder-joint was first prac- tised for gunshot wound by Dr. William Ingalls, of Boston, in 1813, the patient, a soldier, making a good recovery with a toler- ably useful limb. In the American war with Great Britain, in 1812-14, three successful cases of excision of the shoulder-joint occurred on account of gunshot injury. In one of these, under the charge of Dr. Henry Hunt, of Washington City, the extremity of the humerus, a portion of the clavicle, and the acromion and coracoid processes were removed, but not until after the man had become greatly exhausted by copious suppuration and extensive sloughing. Of 115 cases analyzed by Dr. Culbertson, in which the shoulder-joint was excised for disease, 94 recovered, and 21, or 18.26 per cent., were fatal, the limb having been useful in more than three-fourths of the successful cases. 3. INFERIOR EXTREMITY. EXCISION OF TIIE BONES OF THE FOOT. The principal articulations of the lower extremity which require to be dealt with in this way are those of the hip, knee, and ankle ; excision is occasionally practised upon some of the tarsal and tarso-metatarsal joints, and the procedure not unfrequently results in a good use of the foot. But I am quite sure that such an operation should never be INFERIOR EXTREMITY. Fig. 856. Caries of the Head of the Humerus. Fig. 857. Excision of nearly the up- per half of the Humerus for Gunshot Injury. 1084 SPECIAL EXCISIONS OF THE BONES AND JOINTS. chap. xx. performed upon the metatarso-phalangeal articulations and upon the joints of the toes, for the reason that the ankylosed and abbreviated member could not fail to he sadly in the way of the patient’s convenience and comfort when he comes to wear his boot. The rules which apply to the excision of the bones of the metacarpus and fingers are alto- gether irrelevant here, on account of the difference in the uses to which these parts are subjected. The hand is essentially a prehensile organ ; hence, even if only one finger, although that should be the little one, or the metacarpal portion of the thumb, can be preserved, we shall render the possessor a most valuable service. The foot, on the con- trary, is an organ of support, serving to receive and sustain the weight of the body dur- ing progression, and in the erect posture. The longer and broader, therefore, it is, the better able it will be to perform its important offices. But there is another view of the subject which must not be overlooked in a parallel of this kind ; it is this, that, while the hand is perfectly free, the foot is constantly incased in a tight boot or shoe, a circum- stance which renders it absolutely essential to the comfort of the patient that the whole limb, but more particularly the toes, should be as free from prominences and cicatrices as possible. It is for these reasons that the toes, when fatally injured or diseased, are never removed at their articulations or in their continuity, but always at their metatarsal junc- tions ; when the operation is practised at these sites, as it occasionally is by young and thoughtless surgeons, the stump is always in the patient’s way, and usually requires secondary amputation. Moreover, it is not only important that the foot should be free from painful and inconvenient scars and prominences, but that it should be firm and solid, otherwise it cannot possibly serve the purposes of a basis of support. We may excise a metacarpal bone, and yet, if proper care be taken during the after-treatment, the corres- ponding finger will retain, not only its symmetry, but also, in a considerable degree, its usefulness. But the result is very different when we remove a metatarsal bone without the toe with which it is articulated ; as soon as the support afforded by that bone is gone, the member is unable to sustain itself, and, as a consequence, it constantly drops away from its fellows, to the great discomfort and annoyance of the individual. I believe, then, that excision of the bones and joints of the toes and metatarsus, ought, as a general rule, to be superseded by amputation, as altogether more likely to leave a serviceable and sym- metrical limb. Kramer excised the metatarso-phalangeal articulation of the great toe on account of caries as early as 1824, and a similar operation was performed three years subsequently by Roux. The tendency which occasionally arises during the after-treatment in the ex- tensor tendons to pull the end of the toe upwards, may be promptly counteracted by their subcutaneous division, although in general this will not be necessary. Cases of this opera- tion, followed by an excellent use of the great toe, have been reported by Pancoast, Regnoli, Fricke, Butcher, and others. Examples of the successful excision of the anterior extremity of the first metatarsal bone, in complicated dislocation, are mentioned by Textor, Josse, and others, the first of these surgeons having performed the operation as early as 1822. Blandin, Roux, and Jobert each removed the anterior half of this bone for caries and cystic degeneration ; and the posterior extremity of the first phalanx of the great toe has been excised in two instances, with excellent results, by Champion. Excision of this joint has been repeatedly practised for the relief of the distortion oc- casioned by bunions, consisting in the abduction of the head of the metatarsal bone of the corresponding extremity of the first phalanx of the great toe. Dr. Rose, of New York, in 1874, reported a number of cases in which the operation was followed by excel- lent results, the deformity being removed without any material mutilation. The objections that have been urged here against excision of the toes and metatarsus cannot apply to exsection of the bones of the tarsus ; the utility of the operation has, in fact, been tested in numerous instances, and, although it is impossible to lay down any specific rules for its performance, yet any surgeon of ordinary skill or anatomical knowl- edge may undertake it with a reasonable hope of success. The great difficulty of the pro- cedure depends upon the close and intimate manner in which the different pieces of the tarsus are connected together, the thickness of the plantar tissues, and the course and depth of the plantar arteries. This, however, may generally be overcome by attacking the bone to be removed either from the margin of the foot, or from its dorsal surface, where the soft parts are comparatively sparse and unimportant. A useful guide to the diseased bone is commonly afforded by one or more sinuses, the situation of which is nearly always indicated by a red papule of granulations, and more or less discharge of sanious fluid. CHAP. XX. EXCISION OF THE BONES OF THE FOOT. 1085 Caries of the foot is the disease for which excision is most commonly required, and ex- perience long ago demonstrated that the tarsal bones are those which are most liable to suffer in this way. Not unf'requently, however, the heads of the metatarsal bones parti- cipate in the lesion, and occasionally, again, they are its exclusive seat. It rarely happens, according to my observation, that only one bone, either of the tarsus or meta- tarsus, is affected ; in general, at least two or three pieces are in a carious condition, and cases arise where every one suffers, the foot presenting a horribly swollen and deformed mass, full of sinuses, and the seat of excessive pain. Under such circumstances, of course, nothing short of amputation, promptly performed, affords any chance of relief. When the caries is limited to the cuneiform bones, to those bones and the heads of some of the metatarsal bones, or, lastly, to the cuneiform bones and the adjoining portions of the cuboid and navicular bones, excision deserves a decided preference over amputation, and I am satisfied that the operation, if properly executed, that is, in a bold and uncompro- mising manner, the surgeon removing all the diseased structure, will generally be fol- lowed by highly flattering results. I have repeatedly extirpated nearly the whole of the cuneiform bones, together with the heads of several of the metatarsal, and also con- siderable portions of the cuboid and navicular, and yet the patient had a most excellent and useful foot, answering all the purposes of the natural limb. Access is easily obtained by a large horseshoe flap, with the convexity downwards upon the dorsum of the foot, care being taken not to injure the sheaths and tendons of the extensor muscles. The re- moval of the affected bones, whether in part or in whole, must be effected by the cautious use of the gouge and mallet, aided by strong, narrow, probe-pointed knives, and long- bladed, slender pliers. Several mops must be at hand for sponging out the deep cavities made in the operation ; and the bleeding, which, however, is seldom profuse, must be con- trolled, after the excision is completed, by compression, with or without styptics, according to the exigencies of the case. The calcaneurn is so important a bone as a basis of support for the body, and for the attachment of the tendo Achillis, that every means should be employed to save as much of it as possible by chiselling and scraping away every particle of diseased structure. The cavity left by the operation is always filled up with new osseous matter, even if it amounts merely to a shell of bone ; caries, necrosis, and comminuted fracture are the causes demanding the operation. Carnochan, Mor- rogh, C. R. Greenleaf, and Hunter McGuire have reported cases of successful excision of the entire bone, an operation first performed in 1814, by Monteggia. I have myself on three occasions removed the whole of the heel portion of the calcaneurn for necrosis. When the entire bone requires ex- cision, the best mode of procedure is that recommended by Mr. Erichsen, inasmuch as we are thereby enabled to pre- serve the integrity of the sole, a circumstance of great conse- quence to the patient after his recovery from the operation. In most of the methods heretofore practised the incisions are directed to be carried into the plantar region, so that the cicatrices are afterwards subjected to the pressure and friction of the shoe during progression, and thereby rendered liable to the occurrence of pain, induration, and ulceration. In the case reported by Dr. Carnochan the sole was not entered, but as the proceeding was somewhat more complicated than that suggested by the English surgeon, I feel inclined to accord the latter the preference. “ The patient,” says Mr. Erichsen, “lying on his face, a horseshoe incision is carried from a little in front of the cal- caneo-cuboid articulation around the heel, along the sides of the foot, to a corresponding point on the opposite side. The elliptic .flap thus formed is dissected up, the knife being carried close to the bone, and the whole under surface of the os calcis thus exposed. A perpendicular incision, about two inches in length, is then made behind the heel, through the tendo Achillis in the mid line and into the horizontal one. The tendon is then detached from its insertion, and the two lateral flaps dissected up, the knife being kept close to the bones, from which the soft parts are well cleared, as in fig. 858. The blade is then carried over the upper and posterior part of the os calcis, Fig. 858. Excision of the Calcaneum. 1086 SPECIAL EXCISIONS OF THE BONES AND JOINTS. chap. xx. the articulation opened, the interosseous ligaments divided, and then, by a few touches with the point, the bone is detached from its connections with the cuboid, which, together with the astragalus, must then be examined, and, if any disease is met with, the gouge should be applied. By this operation all injury to the sole is avoided, and, the open angle of the wound being the most dependent, a ready outlet is afforded for the discharges.” When the parts are thoroughly cicatrized, the patient may walk about with the aid of a shoe with a high heel stuffed with horse-hair, but great care must be taken for a long time not to bear too much weight upon it. The cure, however, unfortunately, is not always permanent, owing to the outbreak of disease in the neighboring structures, and the consequent necessity of further interference. Of 10 cases collected by Mr. T. M. Greenhow, of New Castle, England, by whom the operation was first placed upon a sure and solid foundation, amputation of the foot was ultimately required in 2. Dr. Vincent, of Paris, in 18G9, published an elaborate memoir upon excision of this bone, based upon an analysis of 79 cases, in only G9 of which, how- ever, the results are known. Of these 49 recovered with useful limbs ; 5 recovered with little use of the limbs; 5 died, and in 10 subsequent amputation was necessary. Chil- dren and adolescents retained good limbs in at least eight cases out of nine ; whereas in adults, the operation failed in half of the cases. Of 42 cases of partial excision of this bone, analyzed by Mr. Henry Hancock, of Lon- don, tbe operation in 25 was performed for caries, in 13 for necrosis, and in 4 for injury. Of the 25 cases of caries, 14 recovered, of 7 the result is not given, 1 died, 1 submitted to amputation, and 2 underwent excision a second time. Of the 13 cases of necrosis, 4 got well, and of the 4 cases of injury 3, the result of 7 of the former being undetermined. Partial excision of the calcaneum was first performed two centuries ago by Formius for the removal of a musket-ball. Excision of the astragalus was first performed by Fabricius Hildanus in 1G70. Of 109 cases, analyzed, in 18GG, by Mr. Hancock, 7G recovered with good and useful limbs; 2 underwent secondary amputation, with one recovery; 16 died, including the one in which secondary amputation had been performed; and in 14 the results are not known. The operation was required in G4 for compound dislocation ; in 20 for simple dislocation ; in 10 for caries; in 4 for compound fracture; in 1 for necrosis; and in 10 the causes are not stated. Of 144 cases collected by Poinsot, 26, or 18 per cent., were fatal. Flattering as these statistics apparently are, they should be received with a great deal of reserve. In the first place, they are very limited, and secondly, their results are alto- gether too favorable. Many fatal cases have, doubtless, occurred, that have never been reported at all; and of the patients that survived the immediate effects of the operation not a few probably suffered afterwards either from a return of disease, as in the case of caries and necrosis, or, as in the case of accident, from destructive inflammation of the neighboring bones, with which the astragalus is so intimately united, and which must necessarily sustain more or less injury during the exsection, however carefully executed. The operation, moreover, is one of extreme difficulty. Considering all these circum- stances, it is questionable whether, in the great majority of cases, it would not be better to sacrifice the limb than to attempt to save it. At all events, it would certainly be well, in every instance of this kind, for the surgeon to place himself mentally in the situation of his patient, and to ask whether, if he were the subject of grave injury or disease of the astragalus, he would prefer excision to amputation. If he had all the facts on both sides of the question, on the one hand, the great danger of excision, the violent inflammation which would be sure to follow it, and the probability of a relapse of the disease; and, on the other, the comparative safety of amputation, the freedom from subsequent suffering, and the certainty of an excellent stump, one which might be readily adapted to an artificial limb, he would hardly hesitate as to the course he would pursue. He would unquestionably decide in favor of the removal of the leg above the ankle, or at the joint by Pirogoff’s or Syme’s method. When excision of the entire astragalus is performed for caries, limited to its own sub- stance, the best plan is to expose the ankle-joint at its anterior and outer aspect, by a semilunar flap, with the convexity downward, taking care not to injure any of the more important soft parts. The bone is separated, first, from its connections with the tibia and fibula, then from those with the calcaneum, and finally from those with the navicular bone. After its lateral attachments have been severed, the disarticulation will be ma- terially facilitated by inclining the foot forcibly backwards, at the same time that an attempt is made with a stout pair of forceps to draw the astragalus out of its bed in the opposite direction. The cutting must be done with a thick, narrow, probe-pointed knife, EXCISION OF THE BONES OF THE FOOT. 1087 CHAP. XX. kept close against the bone in order to avoid the plantar arteries, especially the internal, which would otherwise be in danger. The operation being completed, the calcaneum is brought up into the gap between the two malleolar prominences, where it is carefully main- tained by appropriate apparatus, the foot resting at a right angle with the leg. Great attention is required during the after-treatment to prevent retraction of the heel by the action of the gastrocnemial muscles. Slight motion is occasionally procured between the contiguous surfaces, but, in general, there will be permanent ankylosis. The limb will necessarily be somewhat shortened. I have in my possession a cast, kindly presented to me by Dr. James II. Hutchinson, of this city, which admirably exhibits the appearances of the foot and ankle after the removal of the entire astragalus. The patient was a boy, eleven years of age, on whom Dr. Peace performed the operation, at the Pennsylvania Hospital, in 1858, on account, of a hurt received seven months previously. When the lad was discharged the sore had closed, and he was in excellent health, as I ascertained by a personal examination. The foot, which had a tendency for a time to turn inwards, was nearly at a proper angle, and only three-quarters of an inch shorter than the sound one. Some motion existed at the ankle-joint. Partial removal of the astragalus may be effected with the gouge, and it will frequently be well, here as elsewhere, for the surgeon, when he begins the operation, to take some sinus in the neighborhood of the ankle-joint as his guide, a slight enlargement of the open- ing being often sufficient to enable him to obtain ready access to the seat of the disease. In a case of caries of the astragalus and calcaneum, Mr. T. Wakley, of London, removed both these bones, together with the malleolar extremities of the tibia and fibula, recovery taking place with a strong and useful foot. Dr. J. C. Whitehill and Dr. T. G. Morton have each reported a case of successful excision of the entire astragalus and calcaneum on account of external injury. Excision of the cuboid and navicular bones does not require any particular notice. When both these bones are involved in disease, the other pieces of the tarsus, and even those of the metatarsus, are also very apt to suffer, and then the question will arise whether Chopart’s amputation should not supersede resection. When the cuboid alone is carious, it may easily be dug out with the gouge, but the operation will probably neces- sitate the removal of the fifth metatarsal bone with the little toe. Partial excision of the navicular bone may be effected in a similar manner. In 1857, Dr. J. T. Bradford, of Kentucky, successfully exsected the entire calcaneal and cuboid bones, together with a small portion of the astragalus, on account of caries, in a lad, fifteen years of age. An excellent recovery ensued, with a good use of the foot, the patient being able, by means of a padded shoe, to walk with great facility, and to wrork regularly on his farm. Dr. H. J. Bigelow, of Boston, in 1855, removed the whole tarsus, excepting the calca- neum and astragalus, along with the heads of the second and third metatarsal bones. The operation was soon afterwards successfully imitated by Mr. Skey. In a case reported by Mr. Statham, the cuboid and external cuneiform bones were exsected at a first opera- tion, the scaphoid and remaining cuneiform at a second, and at a third the heads of the second and third metatarsal bones, with a small portion of the astragalus, the patient recovering with an excellent use of the foot, with very little alteration in its natural appearance. Dr. P. T. Conner has successfully removed the entire tarsus, thereby saving the remainder of the foot. Dr. P. Heron Watson, of Edinburgh, in 1874, published an account of a case of exci- sion of the “ anterior tarsus and base of the metatarsus,” in which he exposed the diseased structures by carrying an incision along each side of the foot from three to four inches in length, the external one extending from the centre of the outer margin of the plantar surface of the calcaneum, as far forward as the middle of the metatarsal bone of the little toe, and the internal from the neck of the astragalus, to a corresponding po int of the metatarsal bone of the great toe. The soft parts were then carefully raised from the dorsal and plantar surfaces of the diseased tarsal bones, the thumb of the left hand serv- ing as a guide to the knife. The astragalo-scaphoid and calcaneo-cuboid articulations were severed with a stout, curved probe-pointed bistoury, and the shafts of the metatarsal bones divided with a narrow saw and a pair of cutting pliers. The operation of Dr. W atson was repeated by Professor Dawson, of Cincinnati, in 1874, upon a little girl seven years of age, with a result as gratifying as in the case of the Scotch surgeon. The dissection, which must be performed with the greatest possible care, in order to avoid injury to the plantar arteries, will be greatly facilitated by the use of the elastic roller. 1088 SPECIAL EXCISIONS OF THE BONES AND JOINTS. CHAP. xx. Any oozing of blood that may arise after the operation is over, is easily arrested by pack- ing the wound with lint wet with subsulphate of iron. The operation is, of course, followed by a good deal of shortening and flattening of the foot, although the latter may, in some degree, at least, be prevented by keeping a rubber pad constantly applied to the hollow of the foot during the after-treatment. EXCISION OF TIIE ANKLE-JOINT. The ankle-joint not unfrequently suffers from scrofulous caries, as seen in fig. 859, from a patient at the College Clinic; it is also liable to necrosis, especially in compound fractures and dislocations, followed by excessive inflammation. For the relief of these lesions the surgeon usually resorts to amputation of the lower part of the leg, and there can be no question that, as a general rule, it is by far the most expedient procedure, involving hardly any risk to life, and affording an excellent stump. In caries, however, Fig. 859. of long standing, where the disease is limited to the articular surfaces of the joint, without any serious implication of the surrounding tissues, excision may be practised with a reasonable prospect of success, a strong and useful, although somewhat shortened, limb being left. The operation was first performed on account of disease, in 1792, by the elder Moreau, but, until lately, has not had a place in surgery, and even now professional sentiment is much divided in regard to it. It is done most conveniently by making two vertical incisions extending along the inner and outer margins of the leg, from the level of the ankle to a height of from two and a half to three inches; the lower angle of each cut is then connected by a semilunar one carried across the upper part of the instep, and the flap thus marked off being dissected up, the joint is exposed, the soft structures carefully detached from the two bones, and the articular ends turned out, and sawn off*, if possible, on the same level, as in fig. 8G0. If the astragalus is diseased, the affected part is now removed with the gouge or pliers, when the raw osseous surfaces are placed in accu- rate apposition, and so maintained until consolidation has occurred, passive motion being duly attended to in order to obtain a short fibro-ligamentous rather than a bony union. In detaching the soft parts from the tibia and fibula, and severing their extremities, the utmost care must be taken not to injure the tibia! arteries or the tendons of any of the long muscles of the foot. The periosteum should also, if possible, be preserved, as such a procedure greatly promotes the formation of new bone. In a case of excision of the ankle-joint, reported by Dr. McMurtry, of Kentucky, in 1880, the entire astragalus, Caries of the Ankle-joint. Fig. 860. Caries of the Inferior Extremities of the Tibia and Fibula. 1089 CHAP. XX. EXCISION OF THE KNEE-JOINT. the articular ends of the tibia and fibula, and a portion of the heel-bone were removed, the patient recoveidng with an excellent use of the limb. In view of the accumulated experience in regard to the successful suturing of tendons and nerves, the late Professor Hueter recently modified the operation of excising the ankle-joint, by dividing all the soft tissues around its front, when, the foot having been extended, the periosteum is elevated and the bones sawn off. The divided superficial and deep peroneal nerves, and the tendons of the anterior tibial, extensor of the big toe, and common extensor are then united by catgut sutures, and the wound dressed in the ordi- nary manner. In cases in which the disease is limited to the ankle-joint and the calcaneum, Mikulicz, of Vienna, performs what he terms osseoplastic resection. This is done by carrying an incision across the sole of the foot down to the bones from just in front of the tuberosity of the scaphoid to a point just behind the tuberosity of the fifth metatarsal bone. Prom the extremities of this cut, a second incision is extended on each side upwards and back- wards, to the corresponding malleoli, and united by a transverse incision through the posterior circumference of the leg down to the bones. The foot being flexed, the joint is opened from behind; the astragalus and calcaneum are carefully separated from the soft parts; and the knife is carried through the medio-tarsal articulation. The malleoli and the articular surface of the tibia, along with those of the cuboid, and scaphoid bones, are then removed and brought in apposition. In the only case in which this operation has as yet been practised, the subject, at the expiration of four months and a half, walked on the heads of the metatarsal bones as in equinus. Dr. Spillman has tabulated 73 cases of excision of this joint for disease, of which 50 recovered, 14 died, and 6 underwent subsequent amputation, the result being undeter- mined in 3, affording thus a mortality of 20 per cent. Of the determined cases, in 20 the outer malleolus alone was removed, with 4 deaths, and one consecutive amputation, while both bones were excised in 50, with 10 deaths, and five subsequent amputations, the mortality being in each instance 20 per cent. Of 68 cases of this operation on account of compound fracture or dislocation, analyzed by Dr. Spillman, 15 failed; that is, 11 perished, and 4 submitted to subsequent amputation, with 2 deaths. Of 117 determined cases, collated by Culbertson, 107 recovered, and 10, or 8.54 per cent., died. Of 150 cases, collected by Dr. Gurlt, in which the ankle-joint was excised for gunshot injury, 94 recovered, 5 were doubtful, and 51 were fatal, thereby affording a mortality of 35.17 per cent. In 12.95 per cent, consecutive amputation was necessary. Of 137 of these operations 7 were intermediate, with 3 deaths; 127 were secondary, with 4 unknown results, and 44 deaths; 1 was a successful late excision; and 2 were of uncertain date, of which one died. The ultimate results of 55 cases were favorable in 29, and unfavorable in 26. In 8 of the former the joint was mobile. Of 16 cases of subperiosteal resection of this joint, performed by Professor Von Langenbeck, in the German-Danish war of 1864 and the Bohemian war of 1866, on account of extensive gunshot injury, for the most part of a very complicated character, 13 recovered, and 3 died. In some of the cases as many as three and four inches of the tibia and fibula were removed. All of the operations were secondary, and the periosteum, being much thick- ened, was completely preserved, along with the interosseous ligament, so far as it was present. The cure in most of the cases took place without any material shortening, an abundance of osseous material having formed in the direction of the exsected bones. To these cases may be added an operation, performed by Von Langenbeck on a Prussian officer, wounded at the Alma, in which four inches of the tibia, with the greater part of the astragalus, were removed, with the result of recovery with ankylosis without shorten- ing ; and a successful case in the hands of Neudorfer, in Schleswig, in which, all the joint surfaces having been excised, the foot was preserved, with free motion and only one inch of shortening. It is thus seen that the mortality from subperiosteal excision of this articulation is only 16.66 per cent., a far better result than has been obtained from other methods. EXCISION OF TIIE KNEE-JOINT. It is not a little remarkable, wrhen we consider the great size of the knee-joint, the importance of the structures which surround it, and the intimate sympathetic relations which exist between it and the rest of the system, that it should have been the first articulation which was subjected to excision for the relief of disease. The only plausible explanation which can be given of it is the fact that it is so frequent a seat of white 1090 SPECIAL EXCISIONS OF THE BONES AND JOINTS. CHAP, xx. swelling, or scrofulous ulceration, which, until after the middle of the last century, was never thought of being treated in any other manner than by the removal of the affected parts by amputation of the thigh. Excision of this joint was first performed by Mr. Filkin, of North wdch, in Cheshire, in 1762; as, however, no account of it appeared in print, no attention was attracted to it until the publication of the famous case of Mr. Park, of Liverpool, in 1781. Moreau, of France, executed it in 1792, upon a young man, laboring under wdiite swelling. In 1809 the operation wras performed by Mulder, of Groningen, in 1823 by Crampton, of Dublin, and in 1829 by Syme, of Edinburgh, the latter repeating it soon after in another case. From this period nothing of special interest occurred in regard to excision of the knee-joint until 1850, when it wras revived by Sir William Fergusson. One of the most able and zealous champions of the operation, is Mr. Butcher, of Dublin, one who lias perhaps done more than any one else to reduce it to rule. In this country the operation was, I believe, first performed by Professor R. A. Kinloch, of Charleston. It is not, of course, every case of diseased knee-joint that is proper for excision. The operation should, as a general rule, be refrained from when there is very extensive struc- tural change of the bones, rendering it necessary to go much beyond their articulating extremities; wdien the morbid action is of a strumous nature without well defined limits; and when the patient is so young that interference with the shafts of the femur and tibia would inevitably be followed by a serious arrest of development of the limb. In all such cases amputation should take the place of resection. In regard to the manipulations, various plans have been suggested, any one of which will afford ready access to the diseased bones, but they are all objectionable, on the ground that, the most dependent part of the wound being closed, there is no outlet for the dis- charges. To remedy this difficulty it has been proposed to pierce the posterior wall of the wound, and to insert a gum-elastic tube to carry off the fluids as fast as they are secreted; a circumstance of paramount importance both as it respects the speedy restoration of the parts and the prevention of pyemia. There can hardly be any doubt that many, if not most, of the accidents that have followed this operation have been due, directly or indi- rectly, to the accumulation of pus in the bottom of the wound, and its consequent injurious action upon Ihe bones, irritating and eroding their substance, and burrowdng more or less extensively among the soft parts. Such, however, is the character of the tissues behind the articulation as to render it impracticable to approach the femur and tibia in that direction, or to leave the operator any choice in regard to the place of election. Mr. Park readily accomplished his purpose by means of a crucial incision, the centre of which corresponded with the superior extremity of the patella, the perpendicular cut being Fig. 861. Fig. 862. Upper End of the Tibia Excised. Fig. 863. Excision of the Knee-joint. Lower End Femur Excised. nejirly six inches in length, while the horizontal one reached almost half around the limb, which was in an extended position. Moreau, on the other hand, made an H -shaped EXCISION OF THE KNEE-JOINT. 1091 chap. xx. incision, that is, a longitudinal incision along each side of the thigh and leg, between the vasti and flexor muscles, and a transverse one just below the patella. Professor Yon Lan- genbeck carries a curvilinear incision along the inside of the joint, between the patella and inner condyle through the substance of the inner vastus, opens the joint at once, pushes the patella with its ligament outwards, and then divides the bones, saving the patella, if not diseased. I prefer myself, as does also that excellent operator, Dr. Humphry, of Cambridge, England, a large semilunar, (J -shaped or horseshoe flap, as seen in fig. 861, made by carrying the knife across the upper part of the leg, from one condyle to the other; this being carefully raised, affords a sufficient opening for dividing the ligaments, separating the soft parts, and turning out and sawing off the ends of the bones. In gene, ral, not more than an inch of the femur, fig. 862, should be removed, and a still smaller slice should, if possible, be taken from the tibia, fig. 863; sometimes, however, it is necessary to cut off much more, the tibia, for example, below its articulation with the fibula, and the femur above its condyles, and yet a useful limb be left. If any sinuses are found to extend into the substance of these bones, after they have been sawn off, they should be followed up with the gouge, and every particle of disease scooped out, with the same care and patience that the dentist drills out the cavity of a tooth preparatory to the introduction of the plug. Any burses that may have been exposed in the operation should also be removed, lest they occasion suppuration, and so retard the cure. In most cases of disease of the knee-joint, requiring excision, the patella is implicated in the morbid process, and should, therefore, be removed along with the other bones; this course, however, necessarily involves the division of the tendon of the four-headed exten- sor muscle, and consequently the loss of any action which that muscle might exert upon the movements of the leg, in the event of the formation of an artificial joint during the progress of the case. Hence, the preservation of the tendon becomes a matter of great interest, as tending to augment the strength and usefulness of the limb. This can only be accomplished, however, when there is but little disease of the tibia and the patella; for, when the tubercle of the former bone is obliged to be exsected, the tendon or ligament necessarily loses its attachment, and had, therefore, better be removed with the latter. All the ordinary procedures contemplate the ablation of the patella, and I am quite satis- fied that it is, as a rule, the most judicious practice, even when this bone is perfectly healthy. When the patella is retained, its articular surface should be divested of car- tilage, to promote its union with the surface of the femur, also previously rendered raw. If, notwithstanding this precaution, consolidation fail to occur, and the patella be found to interfere with the cure, lying loose under the integument, and thus keeping up irrita- tion, no time should be lost in removing it altogether. It might be supposed that, during the sawing of the bones, the popliteal artery, would necessarily be endangered, but this is not the case, the vessel lying altogether beyond the line of the instrument. The hemorrhage, indeed, is usually very slight, ligation of the articular branches being all that is generally required. During the after-treatment the limb should be retained in the extended position, if much substance has been removed, but slightly flexed under opposite circumstances, in order to place it in the most favorable condition for usefulness in the event of ankylosis, which is so liable to happen after ex- cision of the joints, notwithstand- ing all the precautions that may be taken to prevent it. Among the more suitable con- trivances for accomplishing this object is Mr. Butcher’s box, fig. 864, the sides of which can be let down by hinges ; it is well padded with horse-hair, and readily admits of the requisite degree of extension and counter- extension of the limb. Mr. Price’s apparatus, delineated in fig. 865, also answers admirably well. It consists of a McIntyre’s splint, of thin tinned iron, with a foot-board, between which and the leg there is an open space, in order that there may be no pressure upon the heel and the ten- do Achillis. The portion of the apparatus corresponding to the popliteal space is slightly convex upwards, with a view of insuring more accurate apposition of the ends of the bones. A short splint, well padded, should be applied in front of the thigh, while a long one, Fig. 864. Butcher’s Box for After-treatment in Excision of the Knee. 1092 provided vvitli a central iron hoop and a perineal strap, should be stretched along the outside of the limb. Dr. Pack- ard has employed with good ef- fect a contrivance, sketched in fig. 570, Vol. I., in the chapter on fractures; and occasionally the limb may be swung, with great advantage and comfort in Salter’s apparatus, shown in fig. 866, or in that of Esmarch, re- presented in fig. 867. One of the most annoying oc- currences to be guarded against is the tendency which the tibia has to be drawn outwards and backwards, by the action of the flexor muscles of the thigh. The best means of counteract- ing this disposition is the band- age, applied from the hip down- wards, the leg being invested in the usual way; or, this fail- ing, the subcutaneous section of the tendons of the offending muscles. When osseous union is expected, the bones should be sawn off a little slopingly behind, so as to enable the parts to afford the degree of flexion essential to the production of a serviceable limb. In this case the extremity should be placed over a double inclined plane, and be well supported with lateral splints, to prevent bow- ing of the leg. The statistics of this operation are of deep interest. In regard to the earlier cases, those of Filkin and Park completely recovered, the patient of the latter having obtained so sound a limb as to be able to go to sea and perform all the duties of a sailor. Moreau’s patient died, several months after the operation, of dysentery; of Crumpton’s two cases, one recovered with a good limb, and the other perished at the end of three years and a half, exhausted by hectic irritation and the repeated attacks of ery- sipelas. Of Mr. Syme’s patients, one got well and the other died. Culbertson has collected the statistics of 597 determined cases of resection of this joint for disease, of which 419 recovered, 354 being cured without any other operation, and 65 by secondary amputation. Of these 354 cases the result was good in 246, or 40.8 per cent. The best results were obtained between the ages of five and fifteen. More than one-third die in early childhood, and the danger increases from puberty with advanc- ing age. The principal causes of death are shock, pyemia, erysipelas, and exhaustion. Assuming that these data afford a fair average result, it will be perceived that the mortality from excision of the knee-joint is considerably greater than from amputation of the thigh in its inferior half. Nevertheless, no one can doubt that excision should always, in favorable cases, have the preference, on the principle that a natural limb, even when crooked, is preferable to an artificial one. Amputation possesses a decided advantage over excision when the patient is worn out by hectic irritation, and when the latter ope- SPECIAL EXCISIONS OF THE BONES AND JOINTS CHAP. XX. Fig. 865. Price’s Apparatus for After-treatment in Excision of the Knee. Fig. 866. An Excised Knee swung in Salter’s Apparatus. Fig. 867. Esmarch’s Apparatus for Eesection of the Knee-joint. CHAP. XX. EXCISION OF THE KNEE-JOINT 1093 ration would be followed by so much shortening of the leg as to render it comparatively useless as an organ of progression. The operation, as might have been supposed, has varied greatly, in regard to its results, in the hands of different surgeons. Thus, Professor Humphry, of Cambridge, England, had, up to 1868, 39 cases, in which he had excised this joint, mostly on account of chronic disease, of which 28 recovered, with sound, firm, useful limbs; 2 died, one, apparently, without any connection with the operation; and 9 underwent amputation, followed by 4 deaths. The late Mr. Jones, of Jersey, performed the operation fifteen times with only one death. Mr. Thomas Smith, of London, had, up to 1868,14 cases, with a loss of 2; and Kocher, of Berne, has operated 52 times, with only 6 deaths. Dr. Gurlt has tabulated 146 cases of excision of the knee-joint for gunshot injury, with 33 recoveries, 2 doubtful, and 111 fatal results, the rate of mortality being 77.15 per cent. Of these 4.31 per cent, underwent consecutive amputation. Of 116 of these cases 20 were primary, with 20 deaths ; 10 were intermediate, with 9 deaths; 70 were secondary, with 62 deaths; 2 were late ex- cisions, and both were fatal; and 4 were of uncertain data, with 2 deaths. The ultimate results were ascertained in 9 cases, of which 8 were favorable, and the joint was movable in 1. The mortality of total excisions, a speci- Fig. 868. Excised Knee-joint. A round Ball rests in the Inner Condyle. Fig. 869. Fig. 870. Shortening after Excision of the Knee. Excision of the Knee Two Years after the Operation, men of which is illustrated in fig. 868, is greater than that of partial excisions by 33 per cent., while primary operations are less dangerous by 21.91 per cent, than secondary resections. 1094 SPECIAL EXCISIONS OF THE BONES AND JOINTS. chap. xx. In operating upon young persons, Professor Humphry suggests the propriety of mak- ing the section through the epiphysis, and not through the shaft of the bones, lest, their growth being thus arrested, great deformity from shortening should occur. These effects are strikingly illustrated in the adjoining cut, fig. 8G9, taken from a case of Mr. Pemberton, of Birmingham. The patient, at the time of the operation, was twrelve years of age, and the amount of bone removed was rather more than three inches and a half, of which about two inches and a half belonged to the femur. Six years after the operation the limb was nine inches shorter than the other. A similar case has been reported by Dr. Keith, in a boy whose knee was excised at the age of nine. Five years afterwards the limb was seven inches shorter than the other, and looked, when com- pared with it, like a mere appendage to the body. It would thus appear that a useful limb cannot be obtained when this operation is performed through the shaft of the bone before the completion of the ossific process, the epiphysis being indispensable to its full development. The annexed cut, fig. 870, affords a good idea of the result of the operation in the adult. The drawing was taken two years after the operation, which was performed by Mr. Hancock. EXCISION OF THE PATELLA. The patella, although not often diseased, is occasionally affected without the femur and tibia participating in the morbid action. In a man under my care, some years ago, the bone was completely exposed, and almost entirely necrosed, from frost-bite, its surface being as black as charcoal, and its substance greatly softened. By means of the gouge I cut away nearly the whole thickness of the bone, leaving merely its inner table, pared the edges of the ulcer in the soft parts, and, using warm water-dressing, succeeded in effecting an excellent cure, the joint gradually recovering from the stiffness into which it had been thrown by its protracted disuse. A case in which the entire patella was removed on account of necrosis, the result of a fall, was reported in the North American Medico-Chirurgical Review for I860, by Dr. O. B. Knode, of Missouri. Although the cavity of the articulation was exposed during the operation, the patient, a man, twenty-one years of age, made an excellent recovery, followed by a good use of the limb. Of 11 cases of excision of the patella, analyzed by Dr. Oskar Heyfelder, 9 recovered, and 2 died, one from gangrene, the other from suppuration. In 8 cases the resection was complete, in 3 partial. The causes necessitating the operation were, in 5 cases, caries, in 3 fracture, and in 3 gunshot injury. In 3 of the cases which survived the ex- cision subsequent amputation was required. EXCISION OF THE BONES OF THE LEG. Excision of the long bones of the lower extremity can be practised only to a certain extent, as the removal of any considerable portion would deprive the limb of its solidity, and so render it useless as an instrument of progression and support. Several inches of the shaft of the femur might be exsected, and yet, if osseous union occurred, the thigh would answer an excellent purpose. In badly-treated fractures the limb is often shortened to this extent, the patient walking well afterwards with the aid of a high-heeled shoe. A loss of several inches of the body of the tibia would be a serious accident unless it were accompanied by a corresponding loss of the fibula, in which case, solid union taking place, a good leg might result, while, if the fibula retained its integrity, the limb would not be sufficiently firm for locomotion. To the above statements the fibula forms a striking exception. The loss of a portion of this bone, or even the whole of it, except its malleolar extremity, does not, as is well known, materially affect the functions of the leg and foot. Excision of the entire fibula, originally proposed by Desault, was first executed by Percy and Laurent; Seutin has also performed the operation, and other surgeons, as Beclard and Elliot, have removed considerable pieces of it; generally on account of caries, caries and necrosis, or hyper- trophy from syphilitic disease. A case of excision of the entire fibula for fibro-cartilagi- nous degeneration of that bone was reported, in 1858, by Dr. A. R. Jackson, of Chicago. The patient, a female, thirty-seven years of age, made a good recovery with a useful limb. In performing the operation, the bone, exposed by a longitudinal incision, is cai’efully 1095 CHAP. XX. EXCISION OF THE HIP-JOINT. isolated at its superior extremity, and either disarticulated from the tibia or divided with the pliers. Taking now hold of this part, and using it as a handle, the operator cau- tiously detaches the remainder of the bone from its muscular connections, and, lastly, from the tibia and astragalus below, keeping all the while the point of his knife as closely against the osseous surfaces as possible. The exsection is usually attended with a good deal of hemorrhage, and, unless proper circumspection be exercised, the peroneal artery may be wounded. During the after-treatment care must be taken to prevent inversion of the foot, to which there is generally a decided tendency whenever the external malleolus is removed. Excision of the shaft of the tibia is a less dangerous operation than amputation of the leg, as is shown by the subjoined table, compiled by Dr. Heyfelder:— Causes. Number. Survived. Successful. Partial. Died. Fractures . 65 47 43 4 18 False-joints 11 11 10 1 0 Deformities 16 15 14 1 1 Curvatures . 11 11 11 0 0 Original disease . 22 20 19 1 2 Total 125 104 97 7 21 Of excision of the bones of the leg on account of fracture three-fourths are completely, and one-fourth partially, successful, five-sixths surviving the effects of the operation. Of amputations of the leg, on the contrary, for all causes, one-third die ; after primary opera- tions one-half. Of 172 cases of excision of the bones of the leg on account of gunshot injuries, tabu- lated by Dr. S. W. Gross, 137 recovered, and 35 died, or in the ratio of 20.34 percent., which is less than that of amputation of the leg for gunshot injuries by 13.71 per cent. In 19 of the above cases, portions of both bones were excised, with 4 deaths; the tibia was the seat of the operation 72 times, with 15 deaths; and the fibula was excised in 81 instances, with 16 deaths. EXCISION OF THE HIP-JOINT. Excision of the head of the femur was originally performed in 1821, by Mr. Anthony White, of London, and, although it was soon afterwards repeated by Ilewson, of Ireland, Oppenheim and Textor, of Germany, Seutin, of Belgium, and Brodie, of England, itwras not until after its adoption by Sir William Fergusson that it met with general favor in Great Britain. In France it wras performed for the first time by Roux in 1847, and in this country in 1852, by Professor Henry J. Bigelow. The whole of the hip-joint was originally removed by Mr. Hancock in 1856. The operation is now seldom practised for injury, as it is nearly always fatal ; and the great objection that has been urged against it in coxalgia, is that the morbid action often extends to the acetabulum, if not also to the pelvic cavity ; some, indeed, have even gone so far as to assert that this is always the case in the more confirmed stages of the disease, which, however, is not true, as my dissections fully satisfy me. But, granting, for the sake of argument, that it is, the fact would not, in my opinion, constitute a valid objection against the procedure, seeing how easy it would be, in most instances, to gouge out all the carious structure, and thus leave the parts in a condition for gradual repair. When the acetabulum is deeply involved, a cir- cumstance, however, which cannot always be determined beforehand, either from the symptoms or an examination with the probe, the case will, of course, be proportionately more unfavorable, but even then we need not despair of an ultimate cure, provided the operation is conducted with the requisite care and skill. Left to itself the disease, in this condition, nearly always proves fatal, life being gradually worn out by hectic irrita- tion and profuse discharge. Assuredly, then, unless the patient is utterly prostrated, both science and humanity would dictate the propriety of interference in the hope of rescuing him from his impending fate. I am satisfied that conservative surgery has not yet had fair play in this class of cases of hip-joint disease ; the objection, I conceive, ought not to lie against the operation, but against the time at which it is performed, which is often too late to afford the benefits which it would otherwise be capable of conferring. When the head and neck of the thigh-bone alone are diseased, exci- sion, early and judiciously practised, will not only prevent much suffering, but be instrumental in saving many lives. When the disease has committed such ravages as are displayed in fig. 871, from a drawing of one of my clinical cases, it is im- possible for any surgeon to produce a good result. In contemplating the manual part of the operation, several plans suggest themselves to the consideration of the surgeon. In the first place, he may adopt the method followed by White, of making simply one longitudinal incision, in the axis of the head and neck of the bone, of which he was thus readily enabled to remove four inches ; in many cases a curvilinear incision answers a good purpose; some operators employ a T, L, or V-shaped incision ; others again, form a semilunar flap of the gluteal muscles, with the convexity downwards. This plan of incision has the advantage not only of allowing free access to the joint, but also of affording an easy outlet for the discharges at the lower and outer angle of the wound. The superior extremity of the femur, being thus exposed, is thrust through the opening, as seen in fig. 872, from Erichsen, by carrying the limb across the sound one, rotating it inwards, and then pushing it up, when it is to be divided immediately below the limits of the morbid action, fig. 873, by means of a narrow saw, the soft parts being carefully protected from injury during the movements of the instrument. The great trochanter, however sound, should always be included in the operation, otherwise it will be sure to interfere more or less seriously with the healing process by projecting into the wound, and obstructing discharge. Any disease that may exist in the acetabulum, whether at its margins or in its bottom, is to be freely removed with the gouge, chisel, knife, or scraper. There is seldom much bleeding, but a few small arteries may require ligation. 1096 SPECIAL EXCISIONS OF THE BONES AND JOINTS CUAP. XX. Fig. 871. Ravages of Hip-joint Disease. Fig. 872. Fig. 873. Excision of the Hip-joint. Portion of Femur removed for Hip-joint Disease. An important point in this operation is to retain as much of the periosteum as possible over the great trochanter, so as to preserve the attachment of the muscles which are in- serted into that prominence. This can always be easily done by carrying an incision perpendicularly over that projection, and thus raising the membrane with the handle of a scalpel, or, what is preferable, a special scraper. By this procedure the parts are placed, in every respect, in a much more favorable condition for future usefulness, the periosteum pouring out new bony matter during the progress of the cure, and thus affording the rotator muscles of the thigh a much firmer support for the exercise of their peculiar functions. The wound is approximated in the usual way, a drainage-tube being inserted at the chap. xx. EXCISION OF THE IIIP-JOINT. 1097 external and inferior angle ; and the limb, placed in the straight position, is supported with a carved splint, with a window opposite the joint, to admit of the necessary exami- nation and dressing. Until the primary effects of the operation are over, all attempts at extension and counterextension will be likely to prove extremely painful, if not positively mischievous; but by degrees this must be scrupulously attended to, lest the limb, when well, be too short to be either seemly or useful. The object may, generally, be readily attained either with a bracketed Desault’s splint, Sayre’s wire cuirass, or with the apparatus of Fergusson, depicted in fig. 874, the extension in the latter case being made from the Fig. 874. Fergusson’s Apparatus for the After-treatment in Excision of the Hip-joint. opposite thigh by means of a laced socket having a band attached to the upper extremity. One of the difficulties experienced after the operation is to keep the end of the femur in contact with the acetabulum. The length of femur requiring to be excised must, of course, be very variable. Some- times mere removal of the head with a portion of the neck will suffice, but most commonly it will be necessary to include more or less of the shaft. In a case operated upon by Dr. William H. White, of Delaware, he excised the head of the bone along with about four inches of the shaft, and succeeded in effecting an excellent cure, notwithstanding that the patient, a man, nearly thirty years of age, had been greatly exhausted by long-continued suffering from coxalgia. Dr. Culbertson, in 1876, analyzed 470 cases of this operation, in only 426 of which, however, the results are known. Of these 234 recovered, and 192 died, thus affording a mortality of 45.1 per cent.; 167 were examples of complete excision, of which 77, or 46.1 per cent., died; 221 were instances of partial excision, with 97 deaths, or a mortality of 43.9 per cent.; and of 38 cases, in which the form of operation is not stated, 18, or 47.4 per cent., perished. Of the 234 recoveries, 166 were reported as having useful limbs. In 35 cases, collected by Dr. Good, in which the shortening of the limb is noticed, the least amount was six lines, and the greatest four inches. The tables of Dr. Culbertson show that partial excision of the hip-joint is nearly as dangerous as when the operation involves both the thigh-bone and acetabulum. The most favorable age for the operation is from the fifth to the tenth year, the mortality being then only 32 per cent.; before the fifth year it is 38 per cent., and after the tenth year it rises rapidly until it reaches 55 per cent, for all periods of life. It will thus be perceived that the mortality from this operation is immense, a circum- stance which is not surprising when it is remembered that it is often performed, as a dernier resort, when all other means of relief have failed, and when life is rapidly ebbing away under the wasting effects of the disease. Even in comparatively recent cases, the operation is always a dangerous one. Annandale, in 1876, reported 22 cases, in only 5 of which external sinuses existed, and yet in 8 death occurred, at periods varying from three to eighteen months. Doubtless, too, the results of the operation are much more favorable in the hands of some surgeons than in those of others. As a proof of this, it may be stated that, of 12 cases in the practice of Mr. Erichsen, only 2 proved directly fatal; 5 completely recovered, 3 were lost sight of after they had left the hospital, and 2 died from constitutional disease, one eleven months and the other two years after the operation. Of 45 cases recorded by Mr. Croft, in 1879, 18 were cured, of which 14 had movable joints; 11 still remained under treatment, 6 died from causes directly referable to the operation, 1 was fatal from diphtheria, and 9 were relieved, but died from other causes. Mr. T. Holmes, on the other hand, up to 1868, had 7 deaths out of 19 cases, in 6 of which the fatal issue was due to the direct effects of the operation, 5 of them dying of pyemia, and 1 of gangrene of the wound. 1098 SPECIAL EXCISIONS OF THE BONES AND JOINTS. The time and causes of death are various. In some death occurs within the first week, ten days, or a fortnight after the excision, either from inflammation, excessive suppuration, secondary hemorrhage, erysipelas, pyemia, or phlebitis. In others the patient recovers from the immediate effects of the operation, but falls a victim, at a variable period, to intrapelvic abscesses, caries or necrosis, phthisis, Bright’s disease, enlargement of the liver, tubercular meningitis, or some other intercurrent malady. In many cases the operation is performed imperfectly, or after the disease has made such progress as to render recovery absolutely impossible. Serious involvement of the acetabulum materially en- hances the danger of the operation. Dr. Hodges, in 1861, found a mortality of 51.72 per CHAP. xx. Fig. 875. Fig. 876. cent, when the acetabulum was gouged, scraped, or cauterized, and 44 per cent, in cases of non- interference. Amputation at the hip-joint is rendered neces- sary when excision is inapplicable, and life is threatened by hectic irritation, profuse dis- charge, or other causes. Great care should be taken in its performance to guard against hemorrhage, the smallest quantity of which might occasion irreparable mischief. Under the most favorable circumstances, the operation is an experiment which must often be followed by fatal results. Of twelve cases tabulated by Professor Ashhurst, seven recovered. The appearances of the limb after excision of the hip-joint for coxalgia are well illustrated in fig. 875, from a case of Mr. French, of London. The drawing was taken twelve years after the operation. Dr. Gurlt has collected 139 cases of ex- cision of this joint on account of gunshot injury, fig. 876, of which 16 recovered, 1 was doubt- ful, and 122, or 88.40 per cent., died. Of 119 of these cases, 35 were primary with 2 re- coveries, 1 unknown result, and 32 deaths; 16 wrere intermediate, with 1 recovery, and 15 deaths; 64 were secondary, with 7 recoveries and 57 deaths; and 4 were late excisions, with 1 recovery and 3 deaths. The ultimate result in four was favorable, motion being preserved in 3. Dr. Hodges has constructed from a variety of sources a table of 21 cases of removal of the head of the femur, spontaneously separated from the rest of the bone, of which 5 proved fatal. EXCISION OF THE GREAT TROCHANTER. Excision of the great trochanter is occasionally required on account of caries of its substance. It was first performed by Tenon, in 1798, and has since been repeated in a considerable number of instances, for the most part with a very gratifying result. The Excised Head and Neck of Left Femur. Appearance of tlie Limb Twelve Years after Excision of the Hip-joint. SUPERIOR EXTREMITY. 1099 CHAP. XXI. principal operators have been Velpeau, Textor, J. F. Heyfelder, Teale, Willard Parker, and Fergusson. The latter had two cases, one of which proved fatal at the end of the first week, from an attack of erysipelas. The operation itself is not difficult, the carious prominence being easily exposed by a longitudinal or slightly curvilinear incision, and removed with a small saw, gouge, or pliers ; the hemorrhage is usually inconsiderable. The two circumflex arteries are endangered only when the knife is obliged to be carried deeply and extensively around the base of the trochanter. The excision of the bone will be much facilitated if the limb is thoroughly inverted during the operation. When more room is required than usual, the surgeon may make a X -shaped incision, with the base downwards, to afford a better outlet for the discharges. Great care is taken, for obvious reasons, not to open the capsular ligament of the hip-joint. CHAPTER XXL SPECIAL AMPUTATIONS. 1. SUPERIOR EXTREMITY. AMPUTATION OF TIIE HAND. The fingers may require removal either in their continuity or at their articulations. When the distal phalanx alone is involved, as when it is in a carious or necrosed condi- tion, the operation should, if possible, be limited to the bone, the nail and soft parts being preserved. In disease of the bone from whitlow, such a procedure is nearly always feasi- ble, and, when the periosteum has not been destroyed, it is not unfrequently followed by a reproduction of the phalanx, although rarely in a perfect manner. It is only, therefore, when the parts have been crushed by ma- chinery or some other cause, that, as a general rule, the finger should be cut off at the last joint. The operation is performed by making a short, semilunar incision from one side of the finger to the other, on its dorsal surface, its convexity presenting towards the nail, as seen in fig. 877. Turning back the in- tegument, the knife is inserted into the articulation, and, the ligaments being divided, is drawn forwards, in close contact with the palmar aspect of the bone, so as to form a large convex flap, which is then retained by several points of suture. Amputation of the finger in the continuity of the second phalanx may be performed either by the circular method, or by two flaps taken laterally or from the dorsal and palmar surfaces, the bone being divided by a pair of sharp pliers. It is hardly necessary to add that it is always desirable to save as much of the member as possible both on ac- count of utility and seemliness. Excepting the index finger, amputation should never be performed at the first phalan- geal articulation, as the stump thus left would not only be disfiguring, but inconvenient. Hence, when the operation is required, it is much better to remove the bone at its junc- tion with the metacarpal bone. This may readily be done by making two lateral flaps by circumscribing the posterior extremity of the first phalanx by two long, semilunar incisions, fig. 878, commencing at the centre of the knuckle of the metacarpal bone behind, and terminating at the middle of the palmar aspect of the member on a level with the web of the contiguous fingers. During the disarticulation, the finger is forcibly flexed, so as to afford an opportunity of severing the extensor tendon above the joint, as it would other- wise be in the way of the stump. Before approximating the flaps, the projecting portion Fig. 877. Amputation of the Finger at the Distal Articulation. 1100 SPECIAL AMPUTATIONS. of the knuckle of the metacarpal bone should be cut off with the pliers, as in fig. 879, in order to give the parts a more seemly appearance. Generally, two small arteries require the ligature. During the cure, the fingers must be confined upon a carved splint, other- wise they may overlap each other, and thus become, in a great measure, useless. CHAP. XXI. Fig. 878. Fig. 879. Amputation of the Finger at the Metacarpo-Phalangeal Joint. Eemoval of the Bone with the Pliers. In amputating the index finger, a very useful stump may be formed by disarticulating the middle joint, especially in laboring subjects, or in those engaged in mechanical pur- suits. In the rich, on the contrary, the hand will present a more seemly appearance if the finger be removed at its connection with the metacarpal bone. The stump left in the removal of the index-finger will be greatly improved if the radial margin- of the metacarpal bone be cut oft obliquely from behind forwards so as to diminish the size of the knuckle. A simi- lar plan may be adopted in amputation of the little finger. In the annexed cut, fig. 880, the two bones are left intact. It is seldom that all the fingers are sim- ultaneously affected by disease, so as to require removal at the metacarpo-phalan- geal joints, but such a procedure may be- come necessary on account of accidents crushing the bones and extensively bruis- ing and lacerating the soft parts. The operation, which is sufficiently easy, is performed by making two flaps, one on the dorsal and the other on the palmar aspect of the hand, by two incisions, slightly convex in front, the posterior extending over the roots of the fingers, about three-quarters of an inch in front of their junction with the metacarpal bones, while the anterior one is carried across the hand on a line with the web of the fingers. The best plan is to form the dorsal flap first, and then, after having reflected it back, and divided the tendons and ligaments, to fashion the other by cutting from above downwards, and from behind forwards. The appearance of the stump will be greatly improved if the projecting portion of each knuckle of the metatarsal bones be sloped off a little with the pliers. A useful, and not unseemly, stump may be formed by amputating the metacarpal bones in their continuity, leaving, perhaps, the thumb or one of the fingers, the principal flap being taken from the substance in the palm of the hand. In case of accident, crushing the bones of these pieces, the operation might be performed through their posterior extremities, from a third of an inch to three-quarters of an inch in front of their junction with the second row of carpal bones, or even at the carpo-metacarpal articulations, although, from the irregularity of the contiguous surfaces, the task would by no means be Fig. 880. Amputation of the Index and Little Fingers. CHAP. XXI. AMPUTATION OF THE HAND. 1101 an easy one, nor would the resulting stump be as smooth as it ought to be, either for use- fulness or seemliness. Cases occur, both from accident and disease, demanding the removal of one of the metacarpal bones along with the corresponding finger. The operation is executed by making a triangular incision over the back of the hand, the apex of which is directed towards the wrist, while the base extends around the root of the finger in front, hardly any integument being sacrificed. The extensor tendon being cut far back, the bone, isolated from its muscular connections, is either separated at its carpo-metacarpal articu- lation, or divided in its continuity, in a sloping manner, by means of the pliers. Amputation of the thumb at the distal joint, or in the continuity of its first phalanx, may be performed in the same manner as amputation of the fingers, and, therefore, does Fig. 881. Fig. 882. Amputation of the Thumb and Metacarpal Bone. not require any particular notice. When both its bones are fatally implicated, whether by disease or accident, the hand will exhibit a much more seemly appearance if the member be removed at the carpo- metacarpal joint. For this purpose a triangular incision is made along the radial aspect of the hand, beginning about an inch in front of the styloid process of the radius, one line extending towards the centre of the web between the thumb and index finger, while the other passes around the outside of the head of the metacarpal bone, a little behind the joint, both meeting in front of the palm, as represented in fig. 881. The muscles being now detached, and the extensor tendons severed behind, the disarticulation is readily effected by bending the thumb forcibly inwards towards the ulnar margin of the hand. In performing the operation, the hand is placed in a state midway between pronation and supination, the fingers being fully extended and the thumb abducted. Care must be taken not to sacrifice much integument in making the incisions. When the flaps are properly shaped, they usually unite by the first intention, and leave a very insignificant cicatrice. The annexed cut, fig. 882, shows the appearance of the hand after the parts are healed. The little finger is sometimes removed along with the metacarpal bone, at its junction with the unciform bone. Two incisions are made over the back of the hand, extending from the carpo-metacarpal articulation forwards, along each side of the root of the finger, and terminating at the centre of its palmar aspect, on a line with the web which connects it with the ring finger. The soft parts are now carefully detached from the bone, which is then forcibly flexed and disarticulated by inserting the knife into the back of the joint. Un- less this rule be closely followed, the operation will prove difficult, on account of the peculiar conformation of the articulating surfaces of the two bones. A useful stump may sometimes be made, in disease or accident of the hand and fingers, by preserving the carpus, or the carpus and a portion of the metacarpus. The adjoining sketch, fig. 883, kindly sent to me by Dr. Lente, represents a case of this description. Notwithstanding the loss of a large portion of the integument, the darts cicatrized very firmly, and the patient derived great comfort from the use of an artificial hand, the motions of the wrist-joint re- maining unimpaired. Of 6224 amputations of the thumb or fingers, in hospital and army practice, tabulated by Professor Ashhurst, 189, or 3.3 per cent., died; while of 1083 partial amputations of the hand, 72, or 6.6 per cent., were fatal. Appearance of the Hand after Amputa- tion of the Thumb. Fig. 883. Amputation through the Metacarpal Bones. 1102 SPECIAL AMPUTATIONS. CHAP. XXI. AMPUTATION AT THE WRIST. Disarticulation at the wrist should always be preferred to amputation of the forearm whenever it is practicable, inasmuch as the mutilated extremity affords a much longer lever, which may afterwards be used with great advantage for various purposes, at the same time that it is more easily adapted to an artificial hand. I have repeatedly seen persons who, after this operation, enjoyed an amount of action in the limb that was truly astonishing, and who expressed very great satisfaction at having so good a weapon of defence in accidental pugilistic rencounters, the long stump enabling them to deal a most powerful blow. The operation is performed by making two flaps, an anterior and pos- terior, about two inches long, the convexity looking forwards towards the hand, as shown in fig. 884. They should be formed by cutting from without inwards, as we are thus enabled to give them a much better shape. The incision should extend from the styloid process of the ulna to that of the radius, which should previously be felt for, and then taken as guides to the knife. The disarticulation is effected by inserting the instrument into the posterior part of the joint, the hand being forcibly flexed, and held perfectly Fig. 884. Fig. 885. Amputation at the Wrist. Wrist, Carpal, and Metacarpal-joints. prone at the time. This step of the operation will be greatly facilitated if the surgeon bear in mind the peculiar conformation and arrangement of the two surfaces of the joint, as seen in fig. 880. The hand being removed, the styloid processes are cut oflf on a level with the cartilaginous incrustation of the ulna and radius, when, the arteries of the wrist being tied, and the extensor and flexor tendons, if necessary, properly retrenched, the flaps are approximated and retained in the usual manner. Of 176 cases of amputation at the wrist on account of gunshot injuries, tabulated by Dr. S. W. Gross, 125 recovered, and 51, or 28.97 per cent., died ; the ratio of mortality being greater by 8 per cent, than that of removal of the forearm. Thirty-nine of these operations were performed in the Army and Navy during the war of the Rebellion, with only 2 deaths, or a percentage of mortality of 5. The French surgeons in the Crimea lost nearly one-half of their cases. AMPUTATION OF TIIE FOREARM. The forearm may be removed in its continuity in any portion of its extent, but when the surgeon has his choice, the operation should be performed as low down as possible, for the reason that, as stated in the preceding paragraph, the longer the stump is the more useful it will be. The flap method is the one which I usually prefer, but the circular also answers exceedingly well, and is regarded by many as altogether superior to it. When the patient is very fleshy, it is best to form both flaps by transfixion, one on the anterior and the other on the posterior surface of the limb, as seen in fig. 886 ; under opposite circumstances, one should be fashioned by cutting from without inwards, and the other by CHAP. XXX. AMPUTATION AT THE ELBOW-JOINT. 1103 cutting from within outwards, as w'e are thus enabled to give them a more suitable shape and size. The extremity is held in a state midway between pronation and supination, the brachial artery is compressed by a tourniquet or the fingers of an assistant, the inter- osseous structures are divided on a level with the retracted flaps, and the saw is worked Fig. 886. Flap Amputation of the Forearm. in such a manner as to sever both bones simultaneously, or, if practicable, the ulna a little before the radius, as the latter, from its more direct connection with the hand, affords a better support during the operation, and thereby prevents splintering of the osseous tissue. This occurrence, however, may generally be effectually obviated if the surgeon, during the sawing of the two bones, takes care to apply his thumb and fingers strongly to the interosseous space. In performing the circular operation, it is advisable, on account of the smaller quantity of tissue, to draw the soft parts forcibly back by means of a three-tailed retractor, but such a procedure is never necessary when the amputation is done as here described. The radial, ulnar, and inter- osseous arteries alone generally require ligation. I have seen cases of amputation of the forearm about two inches or two inches and a half below the elbow, with a most excellent result, the stump being rounded off and well shaped, perfectly movable, and quite serviceable. The annexed drawing, fig. 887, taken several years after such an operation, exhibits the appearance of the limb. Teale’s amputation is seldom employed in the removal of the forearm. It is not only more troublesome than the ordinary methods, but it is mainly applicable to cases of gunshot and other injuries at- tended with great loss of substance. It is executed upon the same principle as amputa- tion of the leg. Dr. S. W. Gross has tabulated 24G2 cases of this operation on account of gunshot inju- ries, of which 1954 recovered, and 508 died, thus affording a percentage of mortality of 20.62. Nearly one-fourth of these cases occurred in the Army, with a mortality of only 16.52 per cent. AMPUTATION AT THE ELBOW-JOINT. Amputation at this joint was, until a comparatively recent period, seldom performed ; a circumstance the more surprising when it is considered what an admirable stump it leaves, what little risk it involves, and how promptly the parts usually heal. Besides these advantages, which experience has fully established, the operation is one of the most easy in surgery, and may, therefore, be performed by any one who has a competent knowledge of the anatomy of the articulation. Two flaps are formed, the principal one in front of the elbow, at the expense of the muscles in that situation, and the other, which is entirely cutaneous, behind, the length of the former varying from two and a half to three inches, according to the diameter of the limb. The forearm being slightly flexed, so as to bring the sharp edge of the coronoid process on a line with the articular surface of the humerus, the surgeon transfixes the structures in front of the joint, on a level with the two condyles, and, carrying the knife downwards in close contact with the bones, thus forms the anterior flap, taking care not to give it too great a degree of convexity. The posterior flap is made by drawing the knife across the back part of the limb, in a somewhat semilunar direction, the ends of the incision connecting themselves with those of the preceding one. The next step of the operation consists in dividing the ligaments Fig. 887. Short Stump of the Forearm. 1104 SPECIAL AMPUTATIONS. which unite the radius and ulna to the humerus, and in sawing the olecranon process from before backwards, leaving all that portion which lies above the level of the joint, and which receives the insertion of the three-headed extensor muscle. It is not necessary to interfere with the articular cartilage of the humerus, but it will improve the shape of the stump if the inner trochlea of that bone be cut off on a line with the other surface, as may usually he readily done in severing the olecranon. The history of this operation is both curious and instructive. The first case occurred in 1536, in the hands of Ambrose Pare, in a soldier, who had been wounded in the forearm and who made a rapid recovery. In 1671, it was performed, unsuccessfully, by Christian Ramphtun, a German military surgeon. After that period it was again practically lost sight of until 1819, when it was revived by Textor. In this country it was first per- formed in 1822, by Dr. Mann, of the Army, who was one of its most enthusiastic advocates, and whose patient made a good recovery. Dr. C. W. F. Uhde, of Brunswick, in 1865, furnished an analysis of 67 cases of this operation, including 2 by himself, of which 55 recovered, and 12 died. Of these cases, 31 occurred in the hands of Salleron, of Lyons, during the Crimean war, with a loss only of 5. The operation, in 47 of the cases, was performed on account of gunshot injury, and in the remainder for caries, fractures, and other lesions. Of 93 amputations at the elbow-joint for gunshot wounds, tabulated by Dr. S. W. Gross, 28, or 30.10 per cent., were fatal. AMPUTATION OF THE ARM. In amputation of the arm, the same general rules are applicable, as it respects the point of election, as in the removal of the forearm, already described. The stump should be as long as possible; and the best covering for it is obtained by taking two flaps, one from the anterior and the other from the posterior aspect of the limb, the former being usually formed last, as it contains the brachial artery. The soft parts being firmly grasped, and held away from the bone, the trans- fixion is effected in the usual manner, the knife being carried downwards for a distance of two and a half to three inches, according to the dimensions of the limb, as shown in fig. 888. When the muscles are very large and firm, the surface of the flaps should be rather concave, to prevent redundance of sub- stance. The bone being sawed, the brachial artery and its branches are se- cured, and the flaps approximated by suture and plaster. The circulation of the limb, during the operation, is controlled by compression of the axillary artery, or of the subclavian above the clavicle. Amputation of the arm by Teale’s method is performed upon the same principle as amputation of the thigh. It is chiefly advisable in cases of injury attended with great loss of the soft parts. The ordinary flap and circular operations are generally preferable. The statistics of this operation, for the relief of disease and ordinary accidents, are sufficiently flattering. Amputation of the upper arm in gunshot wounds is much more disastrous than resection of the elbow-joint for similar lesions. Of 7292 cases of the former, tabulated by Dr. S. W. Gross, 2034 proved fatal, while of the latter only 349 out of 1403 died. AMPUTATION AT THE SHOULDER-JOINT. Of the numerous plans that have been devised for amputating the shoulder-joint, I shall content myself with an account of the following, an acquaintance with which will enable the surgeon readily to meet any emergency that may arise in practice, whether civil or military. In performing these operations, the circulation in the limb must be controlled by compressing the subclavian artery above the clavicle, either by means of CHAP. XXI. Fig. 888. Amputation of the Arm. 1105 CHAP. XXI. the handle of a large key, or, what is much better, the compressor, described and de- lineated in the chapter on amputations, Vol. I. p. 517. The head and chest should be elevated by pillows, and the shoulder brought over the edge of the table, so as to allow the knife the most perfect freedom. Amputation of the shoulder-joint is one of the most easy operations in surgery. Ilich- erand long ago remarked that it might be performed with the same celerity as an adroit carver separates the wing of a partridge, and nothing is more true, although I have occasionally seen a case in which the surgeon consumed time enough not only to cut up the whole bird, but also to devour it. 1. One of the best methods of per- forming this operation is that of Baron Larrey, which conists in making two oval flaps, one in front and the other behind, as in fig. 889, each being from three to three inches and a half in length. The limb being held horizont- ally away from the body, with the hand in the prone position, the knife is intro- duced immediately beneath the acro- mion process of the scapula, and car- ried down through the centre of the belly of the deltoid muscle, for about two inches and a half, when, chang- ing the line of direction, from about the middle of this incision, it is drawn around the upper extremity of the hu- merus, as far down as the posterior fold of the axilla, the flap thus formed ex- hibiting a well-marked convexity in front. A similar flap is then made on the opposite side, terminating at the an- terior fold of the axilla, when the elbow is carried forcibly backwards, behind the level of the trunk, to facilitate the disarticulation, which is effected by cutting closely from above downwards, around the margin of the glenoid cavity, and uniting the two flaps by a trans- verse cut made from within outwards. Instead of forming the flaps as here directed, they may be made by trans- fixion or cutting from within outwards, although the former is, on the whole, the better method. 2. Supposing the left shoulder to be the subject of amputation, the knife is introduced at the inferior margin of the axilla, as in fig. 890, and brought out about half an inch beneath the clavicle, just beyond the acromion process. By now drawing the instrument downwards, in close contact with the humerus, a large flap is formed, maiidy at the expense of the deltoid and broad dorsal muscles. The capsular ligament being put upon the stretch by carrying the elbow across the front of the chest, disarticulation is readily effected, and the other flap formed by cutting the soft parts on the antero-internal portion of the limb, as in fig. 891. When the right shoulder is the seat of operation, the transfixion must be commenced above. 3. Lastly, an excellent stump may be formed by making the flaps at the outer and inner aspects of the joint. The elbow being elevated so as to depress the head of the humerus, and the cushion of the shoulder raised, the knife, supposing the left side to be the subject of the operation, is thrust in at the posterior margin of the deltoid and brought out at the anterior, the flap being formed almost exclusively of the substance AMPUTATION AT THE SHOULDER-JOINT. Fig. 889. Larrey’s Amputation ; the knife, as here represented, is entirely too long. Fig. 890. Amputation at the Shoulder. 1106 SPECIAL AMPUTATIONS. CHAP. XXI. of that muscle. The soft parts being held up, the exposed joint is entered in the usual manner, and the other flap made at the expense of the structures in the axilla, by cutting from abctve downwards. Fig. 891. Amputation at the Shoulder, the Joint being Exposed. Amputation at the shoulder-joint may be attended with the entrance of air into the veins of the axilla, as in a case recorded by Roux, in which, almost before the disarticulation was completed, the man fell back dead upon the table. Such an event would be most likely to occur when there is great condensation of the surrounding tissues from inflam- matory deposits favoring canalization of the veins. The statistics of this amputation are less flattering than might have been anticipated from a consideration of the size of the articulation and the nature of the structures con- cerned in its execution. From the tables of Dr. Stephen Smith, published in 1853, it appears that, of 71 cases occurring in American and European hospitals, 34 proved fatal, thus showing a mortality of nearly 50 per cent. Of 1392 operations on account of gun- shot injuries, collected by Dr. S. W. Gross, 883 recovered, and 509, or 36.56 per cent., died. Of these, so far as could be ascertained, 178 were primary, with 46 deaths, and 95 were secondary, of which 61 were fatal, the mortality of the latter exceeding that of immediate amputation by 38 per cent. It is said that Larrey and his colleagues in the wars of Napoleon had amputated at the shoulder-joint in upwards of 100 cases, more than 90 of which recovered. AMPUTATIONS ABOVE THE SHOULDER-JOINT. Several instances have been recorded of recovery after the arm and scapula had been completely torn away by machinery ; and surgeons, profiting by a knowledge of this fact, have not hesitated to remove these parts for the relief of injury and disease. In 1830 Gaetani Bey, of Cairo, successfully performed an operation of this kind upon a boy, four- teen years of age, on account of extensive laceration and fracture of the shoulder. After amputation at the glenoid cavity, the scapula was found to be much shattered, and was accordingly taken away, along with the projecting end of the clavicle. The late Profes- sor Dixi Crosby, in 1836, removed the entire superior extremity, including the scapula and clavicle, affected with osteosarcoma, the patient, a man thirty years of age, making a rapid and permanent recovery. The tumor measured thirty-seven inches in diameter. Two years later, Dr. George McClellan cut off the arm along with the scapula in a youth of seventeen, on account of an enormous sarcomatous tumor. Very little blood w-as lost during the dissection, and the patient survived the operation upwards of six months, when he died from a recurrence of the disease. Amputation above the shoulder-joint was successfully performed by Dr. Mussey, in 1845, on account of sarcoma. The removal included the entire scapula, the arm, and the outer half of the clavicle. A similar operation was performed, in 1846, by Dr. Gilbert, of this city, upon an elderly gentleman, the subject of a large sarcomatous growth of the shoulder. In this case, however, only a portion of the scapula was taken away. The CiXAP. XXI. AMPUTATION OF THE FOOT. 1107 patient recovered from the immediate effects of the operation, but died some months afterwards from a return of the malady. Sir William Fergusson twice removed the upper extremity along with the scapula and a portion of the clavicle for malignant disease. In one of the cases complete recovery followed ; in the other the man died within forty-eight hours after the operation. Mr. Vincent Jackson, of England, in 1864, amputated the right arm at the shoulder-joint along with the scapula on account of injury, the patient dying from exhaustion the next morning. In 1876, I performed a similar operation upon a man nearly fifty years of age on account of an enormous osteosareomatous growth of the left scapula, death occurring on the same day from shock and hemorrhage. In amputating in this situation the surgeon should take care, first, to save a sufficiency of integument, and, secondly, to prevent undue hemorrhage. The incisions should ex- tend, on the one hand, from the superior angle of the scapula along the upper border of that bone, and, on the other, from the anterior surface of the clavicle, nearly as far in- wards as its middle, around the shoulder-joint, and thence down to the inferior extremity of the scapula, in a line with its axillary margin. The flaps thus marked out should then be rapidly dissected up, with as much soft substance as possible, and the different muscu- lar connections severed. The collar bone should be sawn through near its middle, but not until after the separation of the scapula, as the weight of the arm, by drawing down the shoulder, will greatly facilitate this step of the proceeding. The axillary artery should be divided last, and instantly tied. If the tumor, necessitating the operation, is uncommonly bulky, it might be well to secure the subclavian as a preliminary step, but this will seldom be required. After the bleeding has ceased, the wound is closed in the usual manner, and every effort is made to insure its rapid healing. The lungs should be watched with special care. Of 51 cases, tabulated by Professor Ashhurst, 38 recovered, and 13, or 25.5 per cent., died. 2. INFERIOR EXTREMITY. In performing the more important amputations of the inferior extremity, the circula- tion is usually most effectually controlled by compression of the femoral artery, in the upper portion of its course, by means of the tourniquet, or, if the patient is very thin, by the fingers of a trustworthy assistant, against the pubic bone. In removing the foot and lower part of the leg, the compression may be applied to the popliteal artery. In describ- ing amputation at the hip-joint, special mention will be made of the manner of preventing hemorrhage in that operation. In ordinary cases the use of Esmarch’s bandage effectually prevents the loss of blood, but in its absence the common roller may be advantageously employed, the surgeon, before applying the tourniquet, elevating the limb, and pressing the blood out of the superficial veins from the heel upwards. This precaution is particularly important in weak, anemic subjects, in whom the loss even of a few ounces of blood is often followed by the most serious consequences. AMPUTATION OF TIIE FOOT. The toes are never removed in their continuity or at the phalangeal articulations, inas- much as the stump thus left would only be in the way of the patient, and thus occasion serious inconvenience, if not positive suffering, from being constantly impinged upon by the shoe or boot. It is for this reason that the operation should always be performed at the metatarso-phalangeal joints; and this may be readily done, when all the toes are involved, as, for example, in gangrene and frost-bite, by taking the principal flap from the plantar aspect of the foot. The amputation is commenced by making an incision across the back of the limb, from one side to the other, immediately in front of the meta- tarso-phalangeal articulations, which, the integument having been dissected up, are then entered with the knife, an ordinary narrow-bladed scalpel, and successively divided from above downwards, the operation being finished by carrying the instrument forwards to a level with the web of the toes, in order to obtain a sufficiently large covering from the sole of the foot. There is no necessity for cutting off the ends of the metatarsal bones. Any bleeding vessel that may exist being ligated, the plantar flap is stitched in place, and maintained by adhesive strips, aided by an appropriate bandage. When only one of the smaller toes is to be removed, the operation should be performed with oval flaps, fig. 892, as in amputation of the fingers at the metacarpo-phalangeal articu- lation. The disjunction will be facilitated by forcibly flexing the toe. The extensor tendon should be divided above the joint. 1108 SPECIAL AMPUTATIONS. CHAP, xxi. When the small toe is removed, whether alone, or along with the adjoining one, the stump will be much more seemly, as well as more useful, if a small portion of the cor- responding metatarsal bone be cut off, so as to give the part a sloping appearance, as in Fig. 892. Fig. 893. Amputation of the Toe at its Metatarso- phalangeal Joint. Amputation of the Big Toe through the Metatarsal Bone. one of my cases at the Philadelphia Hospital. In the ordinary operation the stump is very angular, and the consequence is that it is constantly irritated by the pressure of the shoe. When the great toe requires removal, the operation should be performed through the continuity of the metatarsal bone, and not at the metatarso-phalangeal articulation, as in this case the large head of the metatarsal bone would sadly interfere with the wearing of the boot. Two incisions are made along the dorsum of the foot, commencing at an acute angle a short distance in front of the internal cuneiform bone, passing around each side of the toe anteriorly to the joint, and terminating at the centre of the web which con- nects the big toe with the adjoining one. The soft struc- tures being carefully detached, the metatarsal bone is sawn through in a sloping direction, including fully one- half of its length. The sesamoid bones are removed along with the flexor tendon of the toe. The wound usually heals very promptly, and the cicatrice, corresponding with the dorsum of the foot, is seldom productive of in- convenience wlien the patient begins to walk, especially if proper attention has been paid during the operation to the preservation of the integument. The appearance of the parts is well show'n in fig. 894, representing the ap- proximation of the wound by suture. Removal of the entire metatarsal bone is effected with a large flap, extending from a little in front of the meta- tarso-phalangeal joint to a few lines beyond the internal cuneiform bone. Mr. Key, of London, in 1836, in a case of severe in- jury, took away the w hole of the outer part of the foot, leaving only the great toe with the calcaneum, astragalus, scaphoid, and internal cuneiform bone, followed by a very useful limb. A similar case with equally gratifying results was more recently reported by Mr. Birkett. In fact, in the foot, as in the hand, conservatism hardly knows any limits ; what in former times w’ould have been condemned as only fit for the knife, is now, with the light of modern science and more enlarged ex- perience, often most advantageously retained. It is here that the rule, to save all and sacrifice nothing, applies with peculiar force. Fig. 894. Appearance of Parts after Amputa- tion of the Big Toe with its Metatarsal Bone. 1109 CHAP. XXI. The foot is sometimes removed at the tar so-metatar sal junction. The operation, how- ever, is seldom practised, as the diseases and accidents requiring such a procedure are generally confined entirely to the metatarsal bones ; besides, such is the manner in which these pieces are connected to each other and to the metatarsal bones that it is one ot unusual difficulty. When deemed necessary, it should be executed according to the plan originally practised, in 1797, by Mr. Hey, ot Leeds, and described in his Practical Ob- servations on Surgery. The operator, taking the tubercle ot the filth metatarsal bone and the projection of the scaphoid as his guides, forms a large convex flap on the plantar surface of the foot, by carrying his knife as far forwards as the ball of the toes. In order to give more precision to his incision, a line may previously be traced in ink across the foot, along which the knife is then passed in the transfixion ; or, what is preferable, the flap is made by cutting from without inwards, and from before backwards. I he latter is the method which I generally adopt, because it enables us to give the flap a rounder and smoother shape, thereby avoiding the necessity ot trimming it after the operation is com- pleted, as is usually the case when performed in the ordinary way. The dorsal flap, represented in fig. 895, is comparatively small, and is composed entirely of integument; it is slightly convex, and is easily made with a large scalpel. The soft parts being dissected up, each joint is entered separately, the disarticulation being expedited by bending the anterior extremity of the foot forcibly back- wards. In executing this step of the operation, it is important to remem- ber the oblique shape of the fifth meta- tarsal bone, at its articulation with the cuboid, and the peculiar manner in which the head of the second metatarsal bone is locked in between its fellows, as well as the dis- tance to which it projects behind the level of the tarso-metatarsal junction. Owing to these circumstances, it is generally extremely troublesome to disengage it; and hence it is always best to leave it, by sawing through its body on a line with the other joints. The stump, after removal of the parts, in Iley’s operation, is seen in fig. 896. The plantar and dorsal arteries being secured, the flaps are carefully adjusted, and the limb is supported, in an easy and relaxed position, upon its outer surface, to counteract the action of the gastrocnemial muscles, which might otherwise draw the foot out of place. In caries, as well as in injury of the metatarsal, cuneiform, cu- boid, and scaphoid bones, the foot may occasionally be removed in such a manner as to leave merely the astragalus and calcaneum, the principal flap being obtained from the sole. The operation is usually known as Chopart’s amputation, but the name of Mr. Syme is also generally associated with it, as he was the means of reviving it by recalling to it the attention of the profession in Great Britain and this country. Of the utility of this procedure in the class of cases under consideration, there can be no doubt; I have not only employed it several times myself, but have seen it repeatedly executed by others, and, in almost every instance that has come within my notice, the result has been most satisfactory. The stump, although short, is extremely useful, affording an admi- rable support for the limb, the person generally walking well with- out the assistance of a cane. In one of my cases, the individual, a young countryman, was able, in less than six months after the operation, to plough and do all the usual work of a farm hand with the greatest facility and comfort. In performing the operation a short flap is made in front of the foot, by an incision extending around its dorsal surface, from one side of the member to the other, in a cur- vilinear direction, the convexity looking forwards, as in fig. 897. It should begin pre- cisely midway between the outer malleolus and the head of the fifth metatarsal bone, which indicates the site of the calcaneo-cuboid articulation, and terminate on the inner AMPUTATION OF THE FOOT. Fig. 895. Hey’s Amputation. Fig. 896 Stump after the Removal of the Parts, in Key’s Ope- ration. 1110 SPECIAL AMPUTATIONS. CHAP. XXI. margin of the foot, directly opposite, at the astragalo-navicular articulation. The integu- ment being dissected up, the blade of the knife, which should be sharp-pointed, and at Fig. 897. Fig. 898. least six inches in length, by half an inch in width, is thrust into the two joints just mentioned, and, being brought out below, is next carried forwards, in close contact with the bones, as far as tbe ball of the toes, in order to form the inferior and main flap. The only arteries which usually require to be tied are the dorsal and two plantar. The ex- tremity of the plantar flap should be well rounded off before it is stitched to the dorsal, and during the cure special care should be taken to keep the gastrocnemial and other flexor muscles completely relaxed, by placing the leg upon its outer suface over a pillow. From neglect of this precaution the stump is liable to be re- tracted, so that the cicatrice, by constantly coming in contact with the ground, is apt to ulcerate and cause severe suffering. If such a contingency should arise, the proper remedy will be the subcutaneous division of the tendo Achillis ; an operation which need never be performed in anticipation of this occurrence, since it may always be effectually avoided by taking the requisite care during the after-treatment. The adjoining drawing, fig. 898, taken from life, exhibits the ordinary appearance of the stump. It is not always easy to hit the two joints concerned in this operation. The effort will be most likely to succeed if, after the anterior flap has been sufficiently raised, the foot be placed at a right angle with the leg, and the point of the knife be inserted about one inch in front of the tibia. Dr. Tripier, of Lyons, in view of the ill results of Chopart’s amputation, has suggested, as a substitute for it, the formation of a single flap, of an oval shape, the incision being commenced at the outer side of the tendo Achillis, and carried forward below the outer malleolus, so as to encircle the foot opposite the tarso-metatarsal joint. The soft structures are dissected from the bones in the usual manner as far back as the cuboid and scaphoid bones, which are next disarticulated. The next step consists in detaching the periosteum from the inferior and posterior surface of the calcaneum, as high up as the sustentaculum, and sawing the bone on a level with that process, at a right angle with the vertical axis of the leg. The poste- rior tibial muscle is divided as high up as possible, and the wound man- aged in the usual manner. The advantages claimed for this procedure are that the cancellous structure of the calcaneum admits of more thorough examination for the detec- tion of foci of disease, that the soft parts being divided farther back, shorter flaps are required, than in Chopart’s operation, and, lastly, that the sawn surface of the calca- neum being horizontal, it supports the weight of the body without any tilting on a broad Chopart’s Amputation. Stump after Chopart’s Amputation. Fig. 899. Lines of Incision in Amputations of the Foot. 1111 CHAP. XXI. AMPUTATION AT THE ANKLE. base. Mr. P. J. Hayes, of Dublin, lias performed Tripier’s amputation several times with very gratifying results. Dr. S. F. Forbes, of Toledo, Ohio, in 1874, introduced to the notice of the profession an amputation of the foot, which he regards as superior to that of Hey and Chopart. He has performed it in a number of instances with the result of an excellent stump in all. The flaps are made as in Chopart’s method; and, after the cuneiform bones have been separated from the scaphoid, he saws the cuboid through on a line with the surface left by the detachment of the other pieces. The annexed cut, fig. 899, affords a good idea of Chopart’s, Hey’s, and Forbes’s processes. Dr. Forbes very properly lays great stress upon the after-treatment. To prevent retraction of the knee from the action of the gastro- cnemial muscles, a hollow splint is worn on the back part of the leg until all tendency of this kind is effectually overcome. AMPUTATION AT THE ANKLE. Although amputation at the ankle-joint has long been known to the profession, the credit of popularizing it is justly due to the teachings and influence of Professor Syme, who first performed it in 1842. He afterwards repeated it upwards of thirty times, and his example has now been so frequently followed by others, in America as well as in Europe, that it may be regarded as one of the established operations in surgery. 1 per- formed it for the first time it was ever done in this country, in 1851, with the aid of Pro- fessor Pattison, in the presence of the medical class of the New York University, upon a young woman, affected with extensive caries of the tarsal bones. She made a good re- covery, but the disease subsequently broke out in the tibia, and necessitated the removal of the leg. A brief abstract of the case was published at the time in Reese’s Medical Gazette. Less dangerous than amputation of the limb in its continuity, the operation is particularly adapted to cases of caries of the posterior tarsal bones, especially of the astra- galus and calcaneum, without any involvement of the ends of the tibia and fibula. When such a complication exists, except in a very slight degree, the limb should be taken off higher up, otherwise it will be difficult, if not impossible, to prevent a recurrence of the disease. Syme’s amputation, for so this operation is now generally distinguished, is performed with two flaps, one of which is taken from the front and the other from the sole of the foot, the two meeting at the outer and inner ankle. The best instrument is a large scalpel; the foot is placed at a right angle with the leg, and the circulation is controlled in the Fig. 900. Fig. 901. Fig. 902. Amputation at the Ankle-joint. Mode of Removing the Calca- neum in Syme’s Amputation. Stump after Syme’s Operation. usual manner. The operation is commenced by making a perpendicular incision from the centre of one malleolus to that of the other directly across the sole of the foot, and then carrying another, of a curvilinear shape, with the convexity looking forward, over the fore part of the limb, so as to join the two points of the former at an angle of 45°. The lines 1112 of these cuts are well seen in tig. 900. The anterior flap :s now carefully raised, the astragalus disarticulated, and the posterior flap dissected off from the calcaneum, by pass- ing the knife closely over its surface, as in fig. 901, in order to avoid wounding the tibial artery. The tendo Achillis being severed from its connections, the operation°is finished by sawing away the two malleoli and a thin slice of the tibia, barely enough to include its cartilaginous incrustation. The posterior flap thus formed, consisting of the thick and hardened cushion of the heel, affords an admirable covering for the exposed bones, to winch it usually unites by the first intention, and which afterwards enables them to bear pressure with great facility. I he only objection to it is that, unless special care be taken in its adjustment, it may form a sac for the accumulation of matter, thus greatly retarding the cure. This, however, is generally easily prevented by the proper application of the bandage in dressing the stump at and for some time after the operation. Should this con- tingency, however, arise, relief must be afforded by a small puncture through the plantar surface of the flap. I he appearance of the stump, after the parts are healed, is shown in fig. 902. In performing this operation there are three points requiring special attention. The first is not to have any redundancy of flap, as will seldom happen if they are both shaped in the manner here described; the second is not to cut any holes into the posterior flap while severing its connections with the calcaneum ; and the last is not to divide the pos- t( i i°r tibial artery prior to its separation into its plantar branches, otherwise sloughing of the soft parts might ensue from deficient nourishment. If these precautions be observed, it will be difficult to make a bad stump. When the cure is completed the limb will be from an inch to an inch and a half shorter than natural. hen, fiom disease, or injury, the flaps cannot be formed according to the plan now laid down, they may be taken from the sides of the limb, including as much of the integu- ment of the heel as possible. The operation is easy enough of execution, but the cica- tiice after the healing of the stump will be much in the way of the patient’s comfort, and may lead to the necessity of amputating higher up. Of 219 cases of this operation, collected in 1866, by Mr. Henry Hancock, 17 died, 13 underwent secondary amputation, of 6 the result is unknown, and 183 recovered so com- pletely as to he able to walk well. All the cases occurred in civil practice, the amputa- tion having been performed in nearly three-fourths on account of caries. The operation of Mr. Syme was modified in 1852 by Mr. Pirogoff, of Russia, by retaining a portion of the calcaneum, and thus imparting greater length and rotundity to the stump. It is performed as in the ordinary disarticulation of by making a curvilinear incision around the foot in front, and a perpendicular one under the sole, extending from the fore part of one malleolus to that of the other. The anterior flap being dissected up, the knife, a short, stout bistoury or scalpel, is introduced into the joint, so as to divide the different liga- ments, and detach the astragalus. The saw is now applied just behind the as- tragalus, and moved obliquely down- wards and forwards, in order to separate the anterior portion of the calcaneum, as seen in fig. 903. The operation is completed by removing the two malle- olar projections, along with a thin layer of the articulating extremity of the tibia, tying the vessels, and stitching the flaps accurately together. The advantages of this procedure are that it affords not only a longer stump, but one that is better adapted to bear pressure, that there is no danger of wounding the posterior tibial artery, and that the posterior flap is not so liable to form a pouch for the lodgment of pus. Its disadvantages are the tardiness of . . ., the cure, and the fact that the disease necessitating a resort to the knife may recur in the retained portion of the bone. The latter objection does not, of course, apply with equal force when the operation is per- formed on account of injury. When the dressing is completed, the upper surface of the SPECIAL AMPUTATIONS. CHAP. XXI. Fig. 903. Mode of Sawing the Calcaneum in PirogofF *s Amputation. CHAP. XXI. AMPUTATION OF THE LEG. 1113 calcaneum is in immediate contact with the lower surface of the tibia and fibula, to which it gradually unites by osseous matter. In operating upon the cadaver, I ascertained as stated in the first edition of this work issued in 1859, that an excellent stump may be made by bringing the wedge-shaped por- tion of the heel-bone up between the malleolar processes of the tibia and fibula, their cartilaginous surfaces being previously well abraded. It is worthy of consideration whether the parts, if thus treated upon the living subject, would not afford a better support for useful progression that the ordinary procedure. Within the last few years several cases have been reported in which this modification afforded excellent results. Several other modifications of this operation have been proposed; as that of Bontecou, of making the plantar flap from within outwards by carrying the incision from the poste- rior border of one malleolus to the other; of Pirrie, of sawing the calcaneum from below upwards instead of from above downwards; and that of cutting off the projecting ends of the tibia and fibula before disarticulating. I am not aware, however, that any material advantage is gained by any of these procedures. Of 58 cases of this amputation, collected by Hancock, from the practice of British sur- geons, 5, or 8.62 per cent., terminated fatally. Suppuration in the course of the tendons was observed in 11, 5 suffered secondary amputation, and -13 recovered with useful stumps. Of the latter 25 were performed for caries, and 18 for accidents. When the cure is com- pleted, the patient is generally able to walk without the aid of a cane, the limb being not more than about half an inch shorter than in the natural state. Ashhurst has tabulated 273 cases, with 28 deaths, or a mortality of 10.2 per cent. In amputation of the foot all the bones except the astragalus are sometimes removed, with the effect of a very useful stump. The operation known as Ligernolles’s amputation is performed in the same manner as Syme’s operation, that is, one flap is made in front and the other behind, the latter being dissected off'from the heel with the greatest possible care. Sometimes the projecting end of the astragalus may be advantageously sawn off. Before the dressings are applied a small hole is made in the heel flap and a tent inserted to promote drainage. This operation leaves a somewhat longer stump than that of Syme, and should therefore supersede it whenever the case admits of it. A very long, useful and seemly stump may sometimes be formed by removing the foot with all the tarsal bones, excepting the astragalus, although such a procedure cannot often be required, inasmuch as this piece is usually diseased along with its fellows. The ope- ration, denominated the subastragaloid amputation, is performed in the same manner as that of Syme, excepting that the ankle-joint is left intact. After the soft parts have been dissected up, the scaphoid and calcaneum are detached from their connections with the astragalus, the bistoury being passed between their contiguous surfaces. The plantar arteries are cut long, to prevent sloughing of the heel flap. In what is known as Hancock’s amputation, a modification of the subastragaloid opera- tion, the tuberosity of the calcaneum is retained and attached to the lower surface of the astragalus, from which, in case of disease, a slice is removed. The operation, it will be perceived, bears the same relation to these two bones that Pirogoff’s modification does in Syme’s. The necessity for such a procedure must necessarily be very infrequent. My opinion of the usefulness of the stump left by these different operations at and near the ankle-joint is not, from what I have seen of it, very favorable. It may answer very well when the patient is wealthy; but if he be poor, and obliged to work for his daily subsistence, he will generally get along much better with an artificial limb than with a stump that affords, even under the most propitious circumstances, only a very miserable basis of support, and is, besides, constantly liable, from the slightest causes, to pain, irri- tation, and ulceration. AMPUTATION OF THE LEG. The leg should always, if possible, be amputated at its inferior third, that is, about three inches or three inches and a half from the ankle ; for here, as elsewhere, the rule is to afford the patient a long stump, for the more ready adaptation of an artificial limb. Moreover, statistics serve to show that the mortality after the operation when performed here is remarkably small, the danger increasing as we approach the knee. Of 106 am- putations of the leg in this situation, reported by the Parisian surgeons, only 13 proved fatal. The state of the parts, however, concerned in the injury or disease requiring the operation does not often leave us room for choice, and hence we are generally obliged to 1114 SPECIAL AMPUTATIONS. cut off the extremity much higher up than would otherwise be desirable. The mode of performing the amputation must necessarily vary according to the portion of the leg which is the subject of it. When the operation is performed in the inferior third of the leg, two flaps are formed from the sides of the limb, by cutting from without inwards ; or, instead of this, one may be made in front, and the other behind, as depicted in fig. 904. Composed entirely of CHAP. XXI. Fig. 904. Fig. 905. Amputation of the Leg at its Inferior Third. integument in front, they receive a considerable quantity of muscular substance behind, and should each be from two inches to two inches and a half in length. The in- terosseous tissues are divided on a level with the retract- ed flaps, and the two bones are sawn in such a manner as to sever the fibula before the tibia. Three principal arteries usually require the ligature. The edges of the wound are approximated vertically, to facilitate drain- age. Fig. 905 exhibits the shape of the stump as ob- tained from a sketch from life. The circular operation makes an excellent stump ; it is especially adapted to removal of the leg in the lower tliiul of its length, where I have practised it in a number of instances, and, in all save one, with the most gratifying results, the persons being able to walk with great facility, with the aid of an artificial limb. In the exceptional case, the wound gapped, and the bones became necrosed some days after the operation, owing, apparently, to some defect in the constitution, which ultimately caused the death of the patient. The eversion of the flap in this operation will be greatly facilitated, especially when, as sometimes happens, tlit parts aic oodcimitousj by a vertical cut9 carried, along its inner or outer surface. Teale’s operation, fig. 906, not often performed in this country, furnishes a very useful and seemly stump. The outlines of the flaps are traced with ink. The lateral incisions are made first through the skin, and the horizontal one down to the bones. The Ion" flap consisting of all the tissues in front of the tibia and fibula, is then dissected up, after which the slioit posterior one is raised in a similar manner from the bones and interosseous liga- ment behind as far as the point where the saw is to be applied. The anterior tibial ves- sels, cut only once, are included in the anterior flap. The long flap, instead of being made in front, may occasionally be advantageously made behind. Amputation of the leg at its superior extremity should never be performed above the tubercle of the fibula, or above the attachments of the hamstring muscles, which are so necessary to control the movements of the stump. The stump should gene- rally be at least three inches in length, otherwise it will hardly be able to subserve any useful purpose, and it would be better, in such a case, to remove the Stump after Amputation of the Lower Part of the Leg. Fig. 906. Teale’s Operation. CHAP. XXI. AMPUTATION OF THE LEG. 1115 limb at the knee. Two flaps are formed in this operation ; one, which is entirely cuta- neous, in front, by cutting from without inwards, and the other behind, at the expense of the muscles of the calf, by cutting from within outwards as seen in fig. 907. The latter should not be less than four inches in length, and, in very robust subjects, may even re- quire to be longer. The anterior flap is formed by making a semi- lunar incision across the front of the limb, from the inner edge of the tibia to the outer edge of the fibula; it is detached by a few strokes of the knife, and held up by an assistant. The instrument is then inserted at the external angle of the preceding cut, and brought out at the correspond- ing point of the opposite side, care being taken, in performing this part of the operation, not to thrust the extremity of the knife between the two bones; an oc- currence which always betrays haste and embarrassment, if not actual want of anatomical knowl- edge. Transfixion being effected, the knife is drawn rapidly downwards, in close con- tact with the posterior surface of the bones, for the distance of several inches, when it is made to cut its way out, in order to give the flap a proper degree of convexity. As soon as this has been accomplished, the flap is retracted by the assistant, the interosseous struc- tures are divided at the requisite height, and the two bones are sawn in such a manner as to sever the fibula before the tibia. The principal arteries will next claim attention, and it will generally be found that three, the anterior and posterior tibial, and interosseous, will require to be tied. When the amputation is performed very high up, the popliteal may be the only vessel demanding ligation, especially if it extend unusually far down before it separates into its terminal branches. The next step of the operation is the retrenchment of the posterior flap by shaving off its redundant muscular substance, so as to adapt it more smoothly and accurately to the exposed bones. I consider this procedure as indispensable to the obtainment of a good, seemly, and useful stump, and, as the patient is in a state of anaesthesia during its execu- tion, it cannot be a cause of suffering. I rarely allow the flap to be more than half an inch in thickness. Any considerable nervous trunk that may exist in the flap is now divided on a level with the bones, and the operation is completed by sawing off’ the ante- rior edge of the tibia, lest, if permitted to remain, it should interfere with the healing of the wound, or, in time, cause so much pressure as to induce ulceration in the cicatrice. Ollier recommends the preservation of a short flap of periosteum to serve as cover for the raw surface of the edge of the bone; but I do not think that the procedure possesses any advantage whatever over the ordinary one. Great annoyance is often experienced in this operation in securing the arteries, espe- cially the anterior tibial when it has been divided immediately after its passage through the interosseous ligament. The short stump thus left is sure to retract and bury itself among the surrounding structures in such a manner as to render it very difficult to seize and ligate it. A long time is occasionally consumed in fruitless efforts of this kind, the vessel, perhaps, in the meanwhile bleeding very freely. A good plan is to detach the parts in which it is contained from the surrounding structures, and to include them all in one ligature, drawn with more than ordinary firmness ; or, what is far preferable, to apply an acupressure needle, as this can always be removed within forty-eight hours after the operation. It is usually in vain to attempt to draw out the artery with the forceps or tenaculum ; indeed, even if this could be done, it would be extremely difficult, if not im- possible, to tie the ligature sufficiently tight to enable it to hold its place until a sound, adherent clot has formed. The bleeding from the nutrient artery of the tibia generally soon ceases of its own accord. If it prove troublesome, it may readily be arrested by plugging the foramen through which it passes with a piece of soft wood, or, what is better, a little slip of perios- teum. Fig. 907. Amputation of the Leg above its Middle. The knife, as here represented, is too long. 1116 SPECIAL AMPUTATIONS. CHAP. XXI. During the after-treatment the limb should be constantly maintained in the extended position, by means of a well-padded posterior splint, otherwise the stump will be permanently retracted by the action of the hamstring and gastrocnemial muscles, so as to interfere mate- rially with the use of an artificial substitute. Should such a contingency occur, despite the best directed efforts of the sur- geon, relief must be sought in tenotomy and passive motion, conjoined, if need be, with suitable apparatus to reclaim the functions of the knee-joint. The appearance of the stump, made after the above fashion, is represented in fig. 908, from one of my patients. A very beautiful and useful stump may be formed in the upper and middle portions of the leg after Professor Sedillot’s method, practised by that distinguished surgeon for the first time in 1840, and often repeated since by him, as well as by others, with excellent results. It consists, as will be seen from the annexed cut, fig. 909, of two flaps, one long and the other short, taken, respectively, from the outer and inner part of the limb. The knife is entered at the outside of the crest of the tibia, at a suitable distance from the knee, swept around the outer surface of that bone and of the fibula, pushed out at the middle line behind, and carried down a distance of four to four inches and a half accord- ing to the diameter of the limb. A short internal flap, about one-third of the length of the other with a slight degree of convexity, is then formed, when, the interosseous structures being severed, and the muscu- lar fibres divided down to the bones, the latter are sawn through in the usual manner. The size and shape of the stump, and the manner in which the flaps are united, are shown in fig. 910. The flaps in this operation may be taken entirely from the common integument, a procedure which is particularly desirable in very muscular subjects. As amputation at the middle of the leg is performed in the same manner as at the superior extremity, it does not require any special notice. It is proper, however, to add that a very good stump may be formed by taking the flaps from the sides, as in the lower operation, although I have always preferred the other method. Fig. 908. Stump after Amputation of the upper part of the Leg. Fig. 909. Fig. 910. S6dillot’s Amputation of the Leg. The Stump in Sfedillot's Amputation of the Leg. Of 4011 amputations of the leg on account of gunshot injury, tabulated by Dr. S. W. Gross, 1360, or 34 per cent., were fatal. AMPUTATION AT TIIE KNEE-JOINT. Amputation at the knee-joint was originally performed by Fabricius Hildanus in 1581. In modern times it is said to have been first executed by Hoin, and, although his exam- ple was soon after followed by several of his contemporaries, yet the operation gradually fell into neglect, chiefly, it would appear, because of the timidity of surgeons to meddle CHAP. XXI. AMPUTATION AT THE KNEE-JOINT. 1117 with the larger articulations. An attempt to revive it accompanied by a report of a number of successful cases, was made by Velpeau in 1830, but with so little effect that the subject was again forgotten, and the operation proscribed from our systematic treatises until within a comparatively short time ago. Since then much lias been urged in com- mendation of it, especially by Dr. Markoe, of New York, and Dr. Brinton, of this city, and it is now universally accepted both in this country and in Europe as one of the estab- lished procedures in surgery. The first amputation at the knee-joint, in America, was performed, in 1824, by Professor Nathan Smith, of New Haven, the patient recovering without any untoward symptoms. The reasons which may be alleged in favor of this operation are, first, that the stump, being longer than in amputation of the thigh in its continuity, is more under the control of the patient, and, consequently better able to bear the weight of the body upon an artificial limb, thus permitting progression without the aid of crutches ; secondly, that, as there is no retraction of the muscles, there is less risk of exposure and exfoliation of the bone; thirdly, that the liability to pyemia is generally diminished from the fact that there is no injury inflicted upon the medullary canal; fourthly, that the wound is less than in the removal of the limb in its continuity ; and, finally, that the statistics of the operation ex- hibit a smaller rate of mortality than amputation of the thigh. It need hardly be stated that disarticulation of the knee should never, as a matter of choice, be performed in pre- ference to amputation of the leg in its continuity ; such a procedure involving more risk to life than the other, would not be justifiable ; for, as remarked elsewhere, the nearer the knife approaches the lower part of the trunk the greater is the mortality from the effects. There are two principal methods of performing this amputation, the relative merits of which have not yet been fairly determined by statistics. The one consists in making a long flap in front, the other in making it behind, at the expense chiefly of the gastrocne- mial muscles. Both operations are sufficiently easy, but when the surgeon has his choice he will, I think, be able to effect a more rapid cure, as well as make a better stump, by adoping the former procedure. In the anterior operation, as it may be called, the knife is carried across the fore part of the leg, at least three inches below the head of the tibia, in a semilunar direction, from the anterior margin of one hamstring muscle to that of the other; the flap is then carefully raised, the ligament of the patella divided, the disarticulation effected from be- fore backwards, and the posterior short flap formed from the superior extremity of the gastrocnemial muscle, care being taken to preserve as much skin as possible. The pa- tella, completely denuded of cartilage, is retained to fill up the gap between the two con- dyles, and thus add to the rotundity of the stump. Another advantage is that the line of the wound, alter the approximation of the flaps, is brought into a more dependent position, thereby admitting of the more ready exit of the discharges. Great care should be taken during the after-treatment that the patella is not drawn up by the action of the extensor muscles. Should such a tendency arise, it will be best counteracted by flexing the thigh strongly upon the pelvis, aided, if this be insufficient, by the subcutaneous division of the extensor tendon. In the posterior process, the principal covering of the bone is obtained from the muscles of the calf of the leg. The operation is commenced by drawing the knife across the centre of the patella, from one side to the other, the articulation being fully opened at the first incision. The integument is then dissected from the patella, as high up as the superior extremity of this bone, which is next liberated from its tendon, and left adherent to the tibia. Introducing now the knife into the joint, the connecting structures are rapidly severed, and the main flap formed by carrying the instrument downwards, to a suitable distance, behind the bones. The operation is completed by removing the con- dyles of the femur, the saw being held in such a manner as to separate a larger portion of the inner than of the outer of these prominences, so as to give the stump a perfectly horizontal direction. Or, what is preferable, because less likely to be followed by suppu- ration and other mischief, while the stump is equally good after the cure, the condyles, unless diseased, are left intact, the flaps being brought in direct contact with their articu- lating surfaces. Various modifications of the knee amputations have been suggested and practised, of which those of Gritti, of Italy, and Carden, of England, are, perhaps, the most important. In Gritti’s operation, which was first performed in 1857, and which is an application of the osteoplastic method, similar to that in Pirogoff’s amputation at the ankle, two flaps are formed, an anterior long one, rectangular in shape, and a posterior short one. The con- 1118 SPECIAL AMPUTATIONS. chap, xx i. dyles being divided through their base, and the patella abraded behind, the raw surfaces of the two bones are carefully approximated and maintained in place by appropriate dressing and the thorough relaxation of the four-headed extensor muscle until complete union has taken place. The stump thus formed is an excellent one. In the operation of Mr. Carden, the flap, composed solely of tegumental material, is raised in front of the joint, of sufficient length and width to fall over the stump in the form of a hood. The soft structures are divided all around straight down to the hone, which is then sawn off' a little above the plane of the muscles, in sucli a manner as to include the condyles without laying open the medullary canal. The patella is also removed. The only objection to this operation is that there is not always a sufficiency of substance on the hack part of the limb. To remedy this defect a short posterior flap, slightly convex, and composed exclusively of integument, may be made, as suggested by Mr. Joseph Bell, of Edinburgh. Mr. Carden, up to 18G4, had performed this operation thirty times ; in seven cases for injury with six cures, and in twenty-four cases for disease with a loss ot lour. Dr. William Stokes, of Dublin, has performed what he calls the supracondyloid ampu- tation of the thigh, differing from those of Gritti and Carden, chiefly in that the hone is sawn oflf above the condyles, from half to three-quarters of an inch beyond the ante- rior superior edge of the cartilage of incrustation, and yet sufficiently low to prevent exposure of the medullary canal. The anterior flap is oval, not rectangular, and two- thirds longer than the posterior. The patella, denuded of cartilage, is placed in even contact with the extremity of the femur, thus preserving the attachment of the four- headed extensor muscle. Professor Stephen Smith, of New York, strongly advocates the employment of lateral flaps, on the ground of more easy drainage, and less danger from pressure of the stump in progression from the artificial limb. The operation is performed by carrying two incisions, commencing about one inch below the tubercle of the tibia, downwards and forwards over the most prominent part of the side of the leg, until they reach the poste- rior surface, when they are curved towards the middle line, and then continued directly upwards to the centre of the joint. The flaps are entirely tegumental, and the internal one may be a little longer and fuller than the outer, so as to form a thorough covering for the corresponding condyle of the femur. The patella is retained, and the ligatures are brought out at the posterior angle of the wound. In addition to the advantages above referred to, this amputation recommends itself by its simplicity and the facility of its exe- cution. The adjoining cuts, figs. 911 and 912, afford good illustrations of the appearance of the flaps and of the stump after the completion of cicatrization. Fig. 911 Fig. 912. The late Professor Joseph Pancoast, on several occasions, performed amputation at the knee-joint with three flaps ; an anterior, semilunar in shape, with the convexity extending three inches below the tuberosity of the tibia, and two posterior lateral ones, much shorter, and well rounded off. The patella is retained, and the entire operation may be performed with the scalpel. Amputation of the Knee AVith Lateral Flaps, Appearance of the Stump in Smith’s Amputation. 1119 CHAP. XXI. AMPUTATION OF THE THIGH. In young subjects, prior to the age of puberty, the limb may sometimes be advantage- ously severed at the junction of the epiphysis with the shaft of the bone instead of at the knee-joint, the surgeon thus avoiding all the risk of pyemia and osteomyelitis. Disunion is effected by gentle force, conjoined, if necessary, with the use of the knife, the employ- ment of the saw being prejudicial. The end of the bone, rounded and nodular, bleeds hardly any, and leaves a stump well suited for the adjustment of an artificial leg. The great objection to this amputation is its liability to interfere with the subsequent growth of the limb. After these various operations the popliteal artery, and generally also several of its branches, will require ligation. The popliteal vein often bleeds profusely, either because of the pulsation imparted to it by the accompanying artery, or because of the unyielding nature of the tissues in which it is imbedded, and should, in such an event, be at once tied. In the operation by the long posterior flap, the union of the wound will be greatly expedited by bringing the ligatures out through a small orifice in the centre of the flap. "W hatever method of operation be selected, there are three points in amputations at the knee-joint worthy of special consideration, an abundance of integument, the retention of the patella, and accurate union of the wound. The patella, inserted into the hollow between the condyles, soon becomes firmly adherent in its new situation, and adds greatly to the beauty and value of the stump. The tendency which sometimes exists to displace- ment of this bone by the action of the extensor muscles may be counteracted by the sub- cutaneous division of its fibres, or, when this is deemed inadvisable, by pinning the patella firmly to the condyles of the femur by means of a steel screw the size of an ordi- nary gimlet. No danger need to be apprehended from such a procedure, as the soft and osseous structures are extremely tolerant of such a material. Of 164 cases of amputation at the knee-joint, tabulated in 1868 by Dr. John H. Brin- ton, 53 were fatal, the mortality being about 32 per cent., or, in other words, from one- fourth to one-sixth less than in amputation of the thigh in its continuity. Of these cases 117 occurred in America and 47 in Europe, with a remarkable similarity in regard to the death-rates. In 79 cases in which the condyles of the femur were left intact the percentage of mortality was 27.84, and in 32 cases in which they were removed 28.12. The loss at- tendant upon 59 primary operations for injury was 42.37 per cent., and 37.83 per cent, in 37 secondary cases. In 62 pathological operations, the mortality was only 22.58 per cent., thus showing a marked advantage over the traumatic. Of 794 cases of amputation at the knee and knee-joint in civil and army practice, tabulated by Professor Ashhurst, 379, or 47.7 per cent., died. The average death-rate of all cases of amputation at the knee-joint in the military practice of this country during the late war was about 50 per cent. Of 1597 cases of amputation of the thigh in its continuity performed during the same period, in the Army, 1029 terminated fatally, affording a death-rate of 64 per cent. Of 246 opera- tions for gunshot injury, analyzed by Dr. 8. W. Gross, 172, or 69 per cent., perished. AMPUTATION OF THE THIGH. The thigh may be removed in any portion of its length ; at its inferior third, at its middle, at its superior third, or at the hip-joint, according to the particular exigencies demanding the operation. The great general rule, mentioned elsewhere, of leaving as long a lever, in all cases, as possible, is still more applicable here than in the leg and arm; experience having shown that it is extremely difficult to adapt a short stump of the thigh to an artificial limb, especially when, as not unfrequently happens, it is at the same time very bulky. The operation which I have always performed, and which, in my judgment, is decidedly the best, is that by flaps, taken from the anterior and posterior parts of the thigh. I have seen enough of the circular method to satisfy me that it is, as a rule, even when well executed, very objectionable, on the ground that, as it seldom affords an ade- quate covering for the stump, it is so often followed by exfoliation of the bone, tedious suppuration, and ulceration of the integument. From these mishaps the flap amputa- tion is almost entirely exempt. It cannot be denied that admirable results are occasionally witnessed from the circular operation, but that it is more liable to be followed by acci- dents and by future inconvenience and suffering is unquestionable, and it is for these rea- sons, and not because it involves any particular difficulty or skill in its execution, that it should, as a rule, give place to the flap method. Although the operation by the antero-posterior flap usually furnishes the best result, from the circumstance that there is less liability to retraction, yet a very excellent stump 1120 SPECIAL AMPUTATIONS. may be made by taking the cov- ering from the sides of the limb, or even by dividing the parts ob- liquely. The fact is, the surgeon has often no choice in the matter, such being the nature of the dis- ease or injury demanding the ope- ration. In a case of horrible de- formity and ulceration of the leg, from the effects of a burn, fol- lowed by permanent ankylosis of the knee-joint, under my observa- tion, in 1852, in a boy live years of age. I was obliged to depend entirely upon one flap taken from the posterior surface of the thigh, with a result that could not pos- sibly have been more satisfactory. Whenever circumstances require a departure from the ordinary rules of procedure, the educated surgeon will have no difficulty in adapting his skill to the exigencies of the case. The lowest point at which amputation of the thigh can conveniently be performed is about four inches above the centre of the knee. The anterior flap should always be made first, as the posterior includes the femoral artery. The soft parts being forcibly raided with the thumb and fingers, applied to the opposite sides of the limb, the knife is entered about three inches above the superior extremity of the patella, and, transfixion being com- pleted, is drawn downwards close along the anterior surface of the femur, cutting its way out at the point just mentioned. The flap being now carefully retracted, the instrument is reintroduced into the wound at its upper edge, behind the bone, so as to fashion the posterior flap, which should be somewhat longer than the anterior, otherwise there will be danger of insufficiency of covering. This flap is now also held back, when, the knife being passed rapidly around the bone, on a level with the retracted structures, so as to divide any muscular fibres that may have escaped it in the previous stages of the operation, the bone is sawn off in the usual manner. The femoral artery with several of its branches will require ligation, and the principal nervous trunks should be retrenched before approximating the flaps. The stump left by the flap operation, as here detailed, is a very pretty one, and could not possi- bly be more serviceable. The drawing, fig. 914, is from life. The operation now described may occasionally be advantageously executed, according to Ver- male’s method, by lateral flaps, of which the outer one should always be formed first. The transfixion is effected at the same height of the limb as in the preceding case, that is, from three to four inches above the upper extremity of the patella, the knife being inserted at the centre of the thigh in front, and pushed out at a corre- sponding point in the ham, whence it is carried downwards and outwards nearly as far as the external condyle. The inner flap is formed in the same manner, except that the instrument is kept in closer contact with the bone, lest the fem- oral artery be split. In other respects, the opera- tion is to be conducted in the same manner as in the antero-posterior flap procedure. In the middle and upper third of the thigh, the method by anterior and posterior flaps de- CHAP. XXI. Fig. 913. Amputation of the Thigh. Fig. 914. stump after Amputation of the Thigh. AMPUTATION OF THE THIGH. 1121 CHAP. XXI. serves a decided preference over that by lateral flaps. The great advantages which it possesses over the latter are that the muscles are more evenly divided, and that, consequently, there is greater probability of obtaining a smooth and useful stump for sustaining the weight of the body upon an artificial limb. The different steps of the operation are similar to those which characterize amputation in the lower third of the thigh, and hence there is no necessity whatever for any formal description of it, as they will be readily comprehended by what precedes. The circular operation is easily performed by carrying an incision with a tolerably long knife through the integument about three inches and a half below the point where the limb is to be removed. The skin being carefully raised for twro inches from the aponeu- rosis, along with a thick layer of cellulo-fatty matter, the muscles are divided straight down to the bone, from which they are next separated for about eighteen lines, when the bone is sawn off' in the usual manner, the soft structures being carefully protected with a retractor. Some surgeons prefer, after the skin has been reflected for a short distance, to cut, first, through the superficial layer of muscles, and then through the deep, somewhat higher up, so as to give the parts a hollow, excavated appearance, the apex of which is represented by the extremity of the femur. I have myself no fancy for such a procedure, although there is no doubt that it may occasionally leave a good, serviceable stump. The edges of the wound, in either case, should be brought together vertically, in order to facilitate drainage, and the limb should be well bandaged from above downwards to pre- vent spasm and retraction of the muscles. The late Professor Davidge, of Baltimore, performed amputation of the thigh with two flaps, by making an incision on each side through the integument, so as to encircle the limb, with the exception of about an inch and a third in the centre, above and below. The two cuts were then connected at each of these points by a V_sliaPed incision, the apex of which extended upwards a distance of at least three inches from the horizontal cuts. The cutaneous flaps were reflected back until they equalled in length a little more than the semidiameter of the limb, when the muscles were divided circularly down to the bone, which was next separated from its attachments for about eighteen lines, and sawn off as in the common amputation. This operation is not only neater than the ordinary one, but, what is of no little moment, it prevents puckering of the integument at the angles of the wround, and at the same time greatly facilitates drainage. Amputation of the thigh by the rectangular method of Mr. Teale is described at p. 514 of the first volume, and, therefore, does not require any special notice here. Very valuable statistics of amputation of the thigh in its continuity, after gunshot injuries, were published by Dr. S. W. Gross, in the American Journal of the Medical Sciences for October, 1867. Of 4123 cases therein given, 977 were successful and 3146 fatal, thus affording a ratio of mortality of 76.30 per cent. He ascertained the period at which the operation was performed in 1448 instances, of which 695 were primary, with 381 deaths, the mortality being 54.82 per cent., and 753 secondary, with 572 deaths, the mortality being 75.96, or 21.14 per cent, greater than that of early amputation. In the Franco-Sardinian army of Italy, in 1859, and in'the French and British forces in the Crimea, removal of the limb was effected in its lower third in 236 cases, with 130, or 55.08 per cent, of deaths; in its middle third 268 times, with 175 deaths, or a mortality of 65.26 per cent.; and in its upper third in 225 cases, of which 177, or 78.66 per cent., died. The results of conservative treatment in gunshot fractures of the thigh, in the Franco-Sardinian army, the French army in the Crimea, and the United States army, as given by the same authority, were more encouraging than those of amputation. Thus, of 295 cases in the lower third, 150, or 50.84 per cent., were fatal; in the middle third, of 327 cases, 181, or 52.29 per cent., were fatal; and in the upper third, of 445 cases, 306, or 68.76 per cent., were fatal. If these results be compared with those of amputation in the different thirds of the thigh, they will be found to be very decidedly in favor of the former. The entire number of cases of gunshot fractures of the thigh treated by expec- tancy, collected by Dr. Gross, was 1450, of which 923, or 63.65 per cent., proved fatal; thus affording a better result than that of removal of the limb by 12.65 per cent., and of excision of the femur by 23.58 per cent. Much of this frightful mortality is, doubtless, justly attributable to the excessive shock sustained by the crushing effects of the injury necessitating the amputation, to the violence inflicted upon the patients during their«transportation from the field of battle, and to the influence of the vitiated air of military hospitals; all tending to produce a state of exhaus- tion incompatible with repair, and promotive of the occurrence of erysipelas, osteophle- bitis, pyemia, and typhoid fever. 1122 SPECIAL AMPUTATIONS. CHAP. XXI. AMPUTATION AT THE HIP-JOINT. To no operation that can be performed on the human body is the oft-repeated maxim, “ Ad extremos morbos extrema remedia,” more justly applicable than to amputation at the hip-joint. The operation may become necessary both on account of disease and acci- dent; but it is of so formidable a nature and so fraught with danger, that it should never be undertaken unless the patient has no other chance of escape. The great risk which attends it is chiefly due to shock, loss of blood, suppuration, erysipelas, and pyemia. The hemorrhage, however, will not, in any case, be likely to be profuse, if proper care be taken to compress the arteries during the formation of the flaps, and if the operation be per- formed, as it always should be, in twenty-five or thirty seconds, good and trustworthy assistants being at hand to anticipate the surgeon’s wishes and facilitate his movements. Under highly favorable circumstances, much of the enormous wound may unite by the first intention ; but, in general, more or less suppuration takes place, and in some instances the discharge is so copious as to lead to fatal exhaustion. The greatest danger of all, how- ever, is the occurrence of pyemia, or secondary abscess, especially in amputation at the hip-joint in consequence of injury, as a compound fracture or a gunshot wound. The shock of the operation must formerly have been very violent, and often of itself sufficient to cause death within a short time after its performance; now, however, that we can avail ourselves of the use of anaesthetic agents, no special risk is to be apprehended from that source. This operation, for a long time regarded as impracticable, and until lately alternately praised and condemned, was first performed, in 1748, by La Croix, of Orleans, upon a boy, fourteen years of age, the subject of gangrene of the lower extremities from the use of ergot. The operation, if so it deserves to be called, consisted chiefly in separating the devitalized structures with a pair of scissors, and proved fatal on the eleventh day. A similar, but successful case occurred to Perrault, of St. Maure, in 1773. It was one of traumatic gangrene, and is fully described by Sabatier in his Medecine Operatoire. In 1774 Kerr, of Northampton, performed the operation upon a girl, twelve years of age, on account of coxalgia complicated with lumbar abscess. Death occurred on the eighteenth day, apparently from tubercular disease of the lungs. Henry Thomson, surgeon to the London Hospital, came next in the order of time, only a fewr years later than Kerr. These cases were followed, near the close of the century, by those of Larrey, Blandin, and Perret, of the French army. The first successful example in military practice by a British surgeon occurred in 1811, in the hands of Mr. Brownrigg, in a soldier whose thigh bone had been broken at its upper extremity by a gunshot nearly twelve months previously. In this country amputation at the hip-joint was first done by Dr. Walter Brashear, of Kentucky, in 180G. The patient, a lad, seventeen years of age, the subject of a bad fracture of the femur, complicated with severe contusion and extensive suppura- tion, made an excellent recovery, and survived the operation many years. The next case, also a successful one, in the United States, was that of Dr. Mott, in 1824. Amputation at the hip-joint may be performed in a great variety of ways—upwards of thirty have been described in the books—with two of which in particular the surgeon should be familiar, as the circumstances of the case may leave him no opportunity for choice. These are the lateral and the antero-posterior flap methods, of which the first, as a general rule, deserves a decided preference, from the fact that it admits of more ready drainage during the healing of the stump. In the lateral amputation, the external incisions should always be made first, although this is not so important when there are skilful assistants, of whom there should be at least four ; one for administering the anesthetic, two for retracting the flaps and compressing the arteries, and one for holding the limb. If these matters be properly attended to, the operation is a comparatively easy one, and may often be executed in an almost incredibly short time, and with the loss of hardly a few ounces of blood. The buttock being brought well over the edge of the table, the thigh pretty widely separated and everted, and the femoral artery compressed over the brim of the pelvis, the knife, which should be upwards of a foot in length, is entered, supposing the operation is performed on the left limb, immediately below the tuberosity of the ischium, and made to issue at a point midway between the anterior superior spinous process of the ilium and the great trochanter. The external flap is now formed by cutting downwards and outwards, in close contact with the bone, for at least four inches, especially if the subject be at all muscular. An assistant is ready to seize and retract the flap the moment it is fashioned, as well as to compress the orifices of the bleeding vessels. Reinserting the knife into the upper angle CHAP. XXI. of the wound, it is rapidly pushed down, along the inner surface of the bone, so as to form a large flap in that direction, to compensate for the small one on the outside. The assistant having charge of the femoral artery in the groin now grasps the divided vessel, at the same time lifting up the flap. The next step of the operation is the disarticulation, which is readily effected by opening the upper and inner part of the joint, and then swiftly carrying the knife around the head of the bone, previously rendered prominent by de- pressing the knee. The arteries are now secured, first the femoral, and successively any other that may require the ligature, the assistants maintaining the compression until every vessel is tied. The antero-posterior amputation at the hip-joint, delineated in fig. 915, is conducted upon the same general principles as the lateral, the only difference being the manner in which the flaps are made. Great care must also be taken to hold the scrotum out of the way. It will be most con- venient to make the anterior flap first; this, when the operation is performed on the left side, is done by entering the knife on the outside of the hip, midway between the anterior superior spinous process of the ilium and the great trochanter, carrying it across the neck of the femur, and pushing it out at the centre of the thigh, immediately below the pelvis. The flap, which should be from four to six inches in length, is then formed in the usual manner; the joint is opened at its upper and inner part, as in the preced- ing case ; and, the disarticulation being effected, the posterior flap is fashioned by cutting along the back part of the bone. Although a long knife is generally recommended for performing these operations, and, indeed, is necessary when the flaps are formed by cutting from within outwards and from above downwards, a short knife, one not exceeding four or five inches in length, used in cutting from without inwards and from below upwards is far preferable, as it enables the surgeon to shape his flaps with greater accuracy, and to judge better what should be removed and what left. I have pursued this method in all my operations, and have had every reason to be pleased with it. It is well, as a rule, to map off the size and form of the flaps with ink, lead, or iodine, before the incisions are commenced. Great stress is very properly laid by surgeons upon the prevention of hemorrhage in this amputation. With this view one of three or four methods may be adopted; the ligation of the femoral artery as a preliminary step ; compression of the femoral artery as it passes over the pubic bone; the application of a tourniquet to the aorta, as $vas origi- nally practised by Professor Joseph Pancoast in June, 18G0, at the Pennsylvania Hos- pital ; or compression of the common iliac artery with the fist inserted into the bowel, as was originally suggested by Dr. Frank Woodbury, of this city; or, finally, by means of the rectal artery compressor devised by Richard Davy, of London. As to the first ot these procedures, it is generally entirely unnecessary, and is at the present day, so far as I know, never practised. Compression of the vessel as it passes beneath Poupart’s liga- ment can be rendered efficient only in very lean persons, but even then it is not wholly trustworthy unless it be combined with digital compression of the aorta, as in a case, in a very thin, emaciated girl, nine years of age, under my charge at the Philadelphia Hos- pital, in 1862, in which it answered most admirably, hardly one ounce and a half of blood being lost. The circulation was most effectually controlled with a thumb upon each vessel. The patient of Professor Pancoast was a man thirty-eight years of age, the sub- ject of a sarcomatous tumor of the thigh. This was the first case in which an aorta tourniquet was ever employed for such a purpose. The man breathed well under ether, and lost hardly any blood. Professor Lister, apparently without any knowledge of Pan- coast’s case, performed an amputation at the hip-joint soon afterwards with the aid of a similar instrument with equally gratifying results. I am not aware that Dr. Woodbury’s suggestion has ever been carried into effect upon the living subject, but it seems to me to AMPUTATION AT THE HIP-JOINT. Fig. 915. Amputation at the Hip-joint. 1124 SPECIAL AMPUTATIONS. CH a p. xxi. be a safer plan than that of Mr. Davy, who uses a polished ebony rod, about twenty inches in length, and from six to nine lines in diameter, surmounted by an elongated ivory knob. The rod is graduated in such a manner that one may easily judge of the length to which it has been passed, which, as a rule, should not exceed four inches. Oil being previously injected into the bowel, the rod is gently inserted toward the side to be operated upon, and the artery compressed by raising the handle, the knob resting upon the vessel in the depression between the sacrum and the ileo-pectineal line. Mr. Davy’s compressor fulfils the object of its inventor most admirably, and has been successfully employed in a number of instances. Decently, however, a case occurred in which, in his own hands, it caused rupture of the bowel, followed by death. The case was one of compression of the right iliac artery, and serious doubts, therefore, arise whether it should ever, from the distance of the vessel from the rectum, be again applied to that side, while, so far as can be determined, it may safely be applied to the left iliac artery. The late Professor Spence, of Edinburgh, who performed amputation of the hip-joint at least a dozen times, relied solely, as a means of preventing hemorrhage, upon the use of a broad, thick compress, fashioned like a pin-cushion, placed directly over the aorta, and confined by an elastic strap furnished with a buckle. Esmarch uses an elastic tourniquet. In the case of a girl, nine years of age, whose thigh I removed at the hip-joint in January, 1862, at the Philadelphia Hospital, on account of injuries sustained by a burn fifteen months previously, the circulation of the limb was effectually controlled by the pressure of the thumbs upon the abdominal aorta and femoral artery. The operation, in which I was kindly aided by my colleagues, Drs. Agnew, Levis, and Kenderdine, was performed in less than twenty seconds, with a loss hardly of an ounce and a half of blood. The patient, although exceedingly anemic and exhausted at the time, recovered without an untoward symptom, but died of valvular disease of the heart five years and a half after- wards. The case is detailed at length in the American Journal of the Medical Sciences for January, 1864. The most efficient tourniquet for compressing the aorta is that of Skey, represented in fig. 916, and variously modified by modern surgeons. It is easy of application, and the pressure may be so regulated as to answer the purpose most perfectly. The pad should be screwed down on a level with the umbilicus, a little to the left of the middle line, otherwise there will be danger of interfering with the circulation of the vena cava. The Fig. 916. Fig. 917. Abdominal Tourniquet. Lister’s Aorta Tourniquet. bowels should be thoroughly evacuated the night before the operation, and every possible care taken not to injure any of the abdominal viscera. Professor Lister’s tourniquet is shown in fig. 917. It is very simple, easy of application, and well adapted to the object for which it has been employed. The value of this mode of compression for the prevention of hemorrhage in amputation of the hip-joint has been tested in numerous instances; and, as an additional proof of it, I may mention that in the remarkable case related by Mr. J. Sampson Gamgee, of Birm- ingham, it was so effectual that, although the limb weighed more than the rest of the body, hardly any blood was lost. Objection has been made to the use of the aorta tour- CHAP. XXI. AMPUTATION AT THE HIP-JOINT. 1125 niquet on the ground of its supposed interference with respiration and the production of shock from injury inflicted upon the solar plexus of nerves ; but no such effect can pos- sibly occur if the instrument be properly adjusted, and the vessels rapidly secured as soon as the flaps are formed. I have certainly never witnessed anything of the kind. The appearances of the stump and the line of cicatrice, in the antero-posterior opera- tion, are well displayed in the annexed sketch, fig. 918, from a photograph kindly sent to Fig. 918. Stump after Amputation at the Hip-joint. me by Professor J. F. May. His patient, a man forty years of age, bad been laboring under caries of the head, neck, and shaft of the thigh-bone, attended with great enlarge- ment of the limb. The operation was performed within thirty seconds, with a loss of blood hardly amounting to eight ounces. A rapid and complete recovery followed. The drawing here represented was taken nearly two years and a half after the operation. The stump in my first case, referred to above, is exhibited at fig. 919. The drawing was taken upwards of a year after the operation. The flaps, made with a narrow catlin, were anterior and posterior. After both of these operations, the flaps, during the first four or five hours, should be supported simply by a few adhesive strips, and kept con- stantly wet with iced water. At the end of this time, when all oozing will probably have ceased, they should be approximated by numerous points of the interrupted suture, plaster, and bandage, care being taken to interpose a drainage tube at the inferior angle of the wound for the purpose of carry- ing off the secretions, which must always necessarily be considerable after such an exten- sive mutilation. When the patient is very robust, it will greatly promote the healing of the wound, and prevent the risk of pyemia and other serious accidents, if, before the flaps are united, they are, in great measure, divested of their muscular substance. One of the great troubles, as well as dangers, after this amputation, especially in large persons, is the difficulty of keeping the surfaces of the flaps in even apposition with each other by any mode of dressing, however carefully applied. In order to meet this con- tingency, and thus promote union by the first intention, I employed with much advantage, in one case under my charge, long acupressure needles, passed through the flaps at different points, and retained by means of ligatures, as in the common harelip suture. The man did admirably well, the suppuration was comparatively slight, and the recovery was most rapid and perfect. Fig. 919.' Amputation at the Hip-joint. 1126 SPECIAL AMPUTATIONS. The arteries divided in these amputations are the superficial and deep femoral, the two circumflex, and the branch of the sciatic accompanying the sciatic nerve. The ligature round the femoral should not be placed too near Poupart’s ligament, lest, on its detach- ment, secondary hemorrhage should take place from the want of a sufficient plug due to the close proximity of the epigastric and circumflex arteries. The main vessels having been tied, any muscular and cutaneous branches that may be disposed to bleed are carefully sought, and secured one after another until all danger from this source is over. It is very awkward in a wound so large as this to be obliged to undo the dressing and search for vessels. Any venous hemorrhage, especially that furnished by the femoral vein, should be controlled with the ligature, which is far more effective than compression, and equally harmless, so far as secondary consequences are concerned. The nerves should be cut off as high as possible; for, if any considerable branches be left in the flaps, more or less neuralgic trouble will almost be sure to arise at some period or other of the patient’s life. During the after-treatment incessant vigilance must be exercised in regard to cleanli- ness and the use of disinfectants, as carbolic acid, the chlorides, or permanganates, weak solutions of which should be freely injected into the wound at least from three to six times in the four-and-twenty hours. Accumulation of secretions must be most carefully guarded against; the stump must be maintained in an easy, elevated position ; the sutures must not be too soon removed; and the adhesive strips must be applied with a certain degree of tightness in order to insure due contact of the opposed surfaces of the flaps. A small tent or drainage-tube should always, as above stated, be inserted at the inferior angle of the wound at the first dressing, as complete union by the first intention is not to be expected under any circumstance after so formidable an operation. In my last amputation, performed in 1879, the stump was treated, in great measure, by the open method ; and the patient, a man, forty years of age, although greatly ex- hausted by his protracted suffering, made an excellent recovery. In a wound so large as this must necessarily be in every operation in this situation, I am satisfied that the open dressing, simple or modified, is, as a rule, entitled to the preference. The statistics of amputations of the hip-joint abundantly show that the results are much more favorable when the operation is performed for the removal of disease than for the relief of accident; depending, unquestionably, upon the fact that, in the former case, the system is more enured to suffering, and, consequently, more tolerant of the effects of the operation, while, in the other, the change is too sudden and severe to enable it to bear up under its exhausting influence. The most elaborate statistics of amputation at the hip-joint are those recently prepared by Dr. F. C. Sheppai’d for Professor Ashhurst, comprising, as they do, 633 cases, in 613 of which the results are known. Of these 237 occurred in army practice, of which 30 recovered, and 207, or 87.3 per cent., died ; 71 were performed in civil life for injury, with the result of 47 deaths, or a mortality of 66.1 per cent.; 261 were practised for disease, with 105 deaths, or a mortality rate of 40.2 per cent.; and of 44 amputations for unknown causes, 34, or 77.2 per cent, were fatal. The mortality of primary operations was 89.77 per cent., of intermediate 88 per cent.; and of secondary 60.52 per cent. From these statistics the great advantage of deferring exarticulation is sufficiently obvious, since sec- ondary operations afford rather more than one recovery in every three cases, whereas primary ones show a mortality of 98.68 per cent. All experience shows that amputation at this joint, if performed immediately after a severe injury, whether gunshot, compound fracture, compound dislocation, or wound of any kind, proves almost invariably fatal. Hence the rule is always to postpone the opera- tion to the latest possible period ; certainly, if practicable, until suppuration has taken place, and the system has had time to become enured to its new condition. In compound fractures of the thigh, involving the head or neck of that bone and the integrity of the femoral vessels, the case, of course, does not admit of much, if any, delay, and the patient must, therefore, run his chance. If the vessels are intact, resection of the upper part of the femur should take the place of ablation of the limb at the joint. If the soft parts are extensively injured and the bone violently shattered, but its head remain sound, the most judicious practice is to amputate the limb at or near the trochanters, leaving the ex- tremity of the bone in the acetabulum. The happy results of consecutive amputation at the hip-joint in gunshot lesions are well exemplified in the practice of Dr. Roux, of Toulon, who performed the operation six times upon soldiers wounded during the war in Italy, with four recoveries and two deaths. CHAP. XXI . CHAP. XXI. AMPUTATION AT THE HIP-JOINT. 1127 Amputation at the hip-joint, after previous amputation of the thigh in its continuity, or of the limb at the knee, was first performed by Mr. Guthrie in 1812, and has since been repeated in numerous instances. The first case in this country occurred in 1850, in the hands of Professor Van Buren, with a successful termination. The principal American opei’ators have been Mott, Bradbury, Buck, Packard, Blackman, Morton, Whitcomb, Fauntleroy, and Otis. In 21 cases, analyzed by the latter, the amputation was performed in 12 for chronic osteomyelitis ; in 6 for recurrent malignant disease, neuroma, or scrofulous degeneration; and in 3 for hemorrhage or gangrene. Of these cases 14, or 66 per cent., were successful. Of two intermediate operations of this kind, performed by Sir J. Fayrer, one was successful, and the other was fatal. A singular case of amputation at the hip-joint complicated by complete ankylosis has been reported by Professor Eve. After the flaps had been formed by the antero-posterior method, the bone was sawn at the trochanters, and the head removed with the chisel, gouge, and hammer. The patient, a man, thirty-six years of age, greatly exhausted by protracted suffering, died twenty-five hours after the operation. INDEX. ABDOMEN, abscesses of, ii. 637, 653 buffer, accidents from.ii. 605 contusions of, ii. 605 cystic tumor of, ii. 642 dermoid cysts of, ii 926 diseases of, geneial diagnosis of, ii. 652 dropsy of, ii 643 fatty tumors of, ii. 641 fistule of, ii. 647 floating tumor of, ii. 654 gunshot injuries of, ii. 615 phantom tumor of, ii 654 sarcomatous tumor of, ii. 642 tapping of, ii. 645 tumors of, ii. 641 wounds of, ii. 605 Abdominal aorta, aneurism of, i. 765, 767 ligation of, i. 770, 798 hysterectomy, ii. 897 organs, injuries, and diseases of, ii. 608 section, ii. 624 tourniquet, ii. 1124 Abortion from syphilis, i. 333 Abscess, i. 116, 121 alveolar, ii. 388 ano rectal, ii. 572 biliary, ii. 639 chronic, i. 132 cold, i. 132 communicating with blood- vessels, ii. 345 congestive, i. 132 diff used, i. 130 embolic, i. 122, 143 hepatic, ii. 632, 639 ilio-pelvic, ii. 641 lumbar, ii. 120 metastatic, i. 122, 143, 146 multiple, i. 122 of abdomen, ii. 637 of antrum of Highmore, ii. 387 of anus, ii. 592 of axilla, ii. 1024 of bladder, ii 675 of bone, i. 844 of brain, ii. 50 of cornea, ii. 168 of fingers, ii. 1014 of frontal sinus, ii. 269 of gall-bladder, ii. 639 of groin, ii. 1065 of ham, ii. 1059 of hand, ii. 1014 of hip-joint, i. 1074 Abscess— of jaw, lower, ii. 402 upper, ii. 387 of joints, i. 1041, 1047 of kidney, ii. 657 of lachrymal sac, ii. 220 of larynx, ii. 301 of liver, ii. 632, 639 of lung, ii. 379 of mammary gland, ii. 963, 964, 985 of membrane of the tympa- num, ii. 253 of nasal septum, ii. 283 of nates, ii. 988, 1060 of neck, ii. 364 of orbit, ii. 233 of palate, ii. 466 of parotid gland, ii. 457 of penis, ii. 831 of pharynx, ii. 486 of prostate glaud, ii. 789 of scalp, ii. 21 of spermatic cord, ii. 825 of spleen, ii. 640 of strangulated hernia, ii. 534 of testicle, ii. 802 of thigh, ii. 1058 of thyroid gland, ii. 350 of tonsils, ii. 477, 478 of urethra, ii. 785 of uterus, ii 875 of vagina, ii. 927 of vertebrae, ii. 120 of vulva, ii. 933 parietal, of abdomen, ii. 637 pelvic, ii. 959 perinephritic, ii. 658 perityphlitic, ii. 639 phlegmonous, i. 122 psoas, ii. 120 pulmonary, ii. 379 recurrent, i. 122 renal, ii 657 residual, i. 122 scrofulous, i. 122 spinal, ii. 120 splenic, ii. 640 stercoraceous, ii. 639 syphilitic, of bone, i. 321 treatment of, i. 126 tubercular, i. 132 urinary, ii. 785 Absorption, interstitial, of neck of femur, ii. 1059 ulcerative, i. 168 Accommodation of eye, diseases of, ii. 144 Acephalocysts, i. 208 in the orbit, ii. 234 Acetahulum, fracture of, i. 960 Acetate of lead as an antiphlo- gistic, i. 98 Acid, acetic, in treatment of car- cinoma, i. 257 carbolic surgical uses of. See Carbolic acid. chromic,-as an escharotic, i. 471 nitrate of mercury as an escharotic. i. 471 Acids, mineral, as escharotics, i. 470 Aconite as an antiphlogistic, i. 86 Acromion process, fracture of, i. 950 Acupressure, i. 665 in aneurism, i. 719 methods of, i. 666 substitutes for, i. 667 Acupuncturation as a counter- irritant, i. 463 for the cure of aneurism, i. 723 of hernia, ii. 508 Acupuncture, i. 463, 723 Adams’s operation for synostosis, i. 1095 Adenitis, acute, i. 649 chronic, i. 650 lymphatic, i. 306 suppurative, i. 649 syphilitic, i. 306 of the neck, i. 306 Adenoma, i. 237 of the lip, ii. 435 of the mammary gland, ii, 973 of the palate, ii. 468 of the pharynx, ii. 492 polypoid, of rectum, ii. 591 Adhesion, primary, i. 350 secondary, i. 351 Adhesions, congenital, i. 198 of lids, ii. 227 of tongue, ii. 453 Adhesive inflammation, i. 350 plaster, i. 339 in fractures, i. 909 | Adipose tumors, i. 210. See Fatty tumors. | iEtal changes of teeth, ii. 419 Age, sympathetic relations of, i. | 43 j Agnew’s operation for hernia, ii. 1 511 1130 INDEX Air, collections of, in the uterus, ii. 881 escape of, into the pleural cavity, ii. 368 introduction of, into veins, i. 820 cause of death in, i. 821 treatment of, i. 822 Air-passages. See Larynx, Tra- chea, etc. cauterization of, ii. 296 congenital defects of, ii. 298 diseases and injuries of, ii. 295 examination of, ii. 295 foreign bodies in, ii. 318 medication of, ii. 295 Albugo, ii. 170 Albuminoid degeneration, i. 189 Allarton’s operation of lithotomy, ii. 756 Alopecia, syphilitic, i. 305 Alveolar abscess, ii. 388 Amaurosis, ii. 201 Amblyopia, ii. 202 . Ametropia, ii 145 Ammoniaco-magnesian calculus, ii. 719 Ammonium, chloride of, as an an- tiphlogistic, i. 98 Amputations, i. 504 above the shoulder-joint, ii. 1106 after-treatment of, i 519 at the ankle, ii. 1111 Pirogoff’s, ii. 1112 Syme’s, ii. 1111 at the elbow-joint, ii, 1103 at the hip-joint, ii. 1122 at the knee-joint, ii. 1116 Carden’s operation, ii. 1117 Gritti’s operation, ii. 1117 at the shoulder-joint, ii. 1104 at the tarso-metntarsal ar- ticulation, ii. 1109 at the wrist, ii. 1 102 caries after, i. 528 circular, i. 510 circumstances demanding, i. 505 congestion of lungs from, i. 533 considerations in regard to, i. 504 constitutional effects of, i. 531 cutaneous, i. 515 dressings after, i. 519 flap, i. 512 hectic irritation from, i. 533 hemorrhage after, i. 527 in acute mortification, i. 156, 508 affections of the bones, i. 509 affections of the joints, i. 509 aneurism, i 509 articular wounds, i. 1042 caries, i. 853 chronic mortification, i. 162, 508 dislocations, i. 506, 1116 fractures, i. 506, 923 Amputations— in gangrene, 508 gunshot wounds, i. 383, 505, 537 injuries, i. 505 malformations, i. 510 morbid growths, i. 508 mortification, i. 508 tetanus, i. 510, 633 traumatic mortification, i. 157 ulcers, i. 509 wounds, i. 383, 505 intermediary, i. 507 knifes for, i. 518 Larrey’s, ii, 1105 Ligernolles’s, ii. 1113 manner of dividing the bone in, i. 511 methods of, i. 510 mortality after, i. 536 natural, in acute mortifica- tion, i. 154 necrosis after, i. 527 of the arm, ii. 1104 of the fingers, ii. 1099 of the foot, ii. 1107 Chopart’s, ii. 1110 Iley’s, ii. 1109 Syme’s, ii. 1109 of the forearm, ii. 1102 of the great toe, ii. 1108 of the hand, ii. 1099 of the index finger, ii. 1099 of the inferior extremity, ii. 1107 of the leg, ii. 1113 Sddillot’s operation, ii. 1116 of the little finger, ii. 1101 of the metacarpal bones, ii. 1101 of the metatarsal bone of great toe, ii. 11 OS of the penis, ii 835 of the scrotum, ii. 824 of the superior extremity, ii. 1099 of the thigh, ii. 1119 Davidge’s method, ii. 1121 Vermale’s method, ii. 1120 of the thumb, ii. 1101 of the toes, ii. 1108 open method of, i. 521 oval, i> 514 primary, i. 507 affections of the stump after, i. 524 pyemia from, i. 532 rectangular, i. 514 retention of urine from, i. 632 secondary,i. 507 affections of the stump after, i. 527 shock from, i. 531 spontaneous, i. 524 statistics of, i. 539 subastragaloid, ii. 1113 synchronous, i. 522 tetauus from, i. 533 time for, i. 507 traumatic fever from, i. 532 Amussat’s operation for artificial anus, ii. 626 Amyloid degeneration, i. 189 of arteries, i. 686 Anaesthesia, local, i. 560 ether spray for, i. 561 rhigolene for, i. 561 Anaesthetics, i, 547 bichloride of methylene, i. 558 chloroform, i. 550 chloromethyl, i, 558 ether, i. 556 ethyl bromide, i. 557 hydrobromic ether, i. 557 inadmissibility of, in certain cases, i. 550 laughing gas, i 558 mortality from, i. 549 nitrous oxide, i. 558 protoxide of nitrogen, i. 558 rapid breathing, i. 559 Anaplasty, i. 497 Anastomotic aneurism, i. 231, 690, 823 of bone, i. 890 of the face, ii. 136 of the orbit, ii. 234 Anchylosis. See Ankylosis. Anel’s probe, ii. 218 syringe, ii. 218 Aneurism, i. 689 after gunshot wounds, i. 374 amputation in, i. 509 anastomotic, i. 231, 690, 823 of the face, ii. 136 Antyllus, operation of, for, i. 724 arterio-venous, i. 727 of the aorta, i. 765 of the axillary, i. 763 of the brachial, i. 764 of the common iliac, i. 768 of the external carotid, i. 749 of the external iliac, i. 768 of the internal carotid, i. 750 of the palate, ii. 468 of the popliteal nerve, i. 628 of the posterior auricu- lar, i. 749 of the subclavian, i. 759 of the temporal artery, i. 749 Brasdor’s operation for, i. 711 by anastomosis, i. 823 of the face, ii. 136 of the skull, ii. 28 causes of, i. 691, 692 circumscribed, i. 690 cirsoid, i. 687 climatic causes of, i. 691 cylindroid, i. 690 death from, by inflammation of sac, i. 705 by injurious compres- sion, i. 705 by sudden rupture of sac, i. 705 from mortification,i. 706 from suppuration of sac, i. 706 INDEX 1131 Aneurism— diagnosis of, i. 700 diffused, i. 690, 698 dissecting, i. 687, 690 effects of, i. 702 erosion of bones from, i. 702 external, i. 690 false, i. 690, 727 varieties of, i. 727 fibrinous concretions of, i. 696 fusiform, i. 690 Hunterian operation for, i. 706 after-treatment of, i. 709 causes of failure in, i. 710 statistics of, i. 711 internal, i. 690 medical treatment of, i. 726 Valsalva’s treatment of, i. 725 intracranial, i. 750 intrathoracic, i. 730 needle, i. 661 nomenclature of, i. 690 of bone, i. 890 of the abdominal aorta, i. 765, 767 of the arteries of the leg, i. 779 of the foot, i. 779 of the hand, i. 765 of the axillary artery, i. 759 of the brachial artery, i. 764 of the coeliac axis, i. 767 of the common carotid, i. 742 of the common iliac, i. 767 ligation of abdominal aorta for, i. 770 of the deep femoral, i. 775 of the dorsal artery of foot, i. 779 of the external carotid, i. 748 of the external iliac, i. 768 of the facial artery, i. 749 of the femoral artery, i. 772 of the fingers, ii. 1013 of the frontal artery, i. 750 of the gastro-epiploic artery, i. 767 of the gluteal artery, i. 769; ii. 1060 of the hepatic artery, i. 767 of the innominate artery, i. 736, 744 treatment of, i. 739 by ligation of carotid and subclavian, i. 740 carotid alone, i. 741 subclavian alone, i. 740 of the intercostal arteries, i. 751 of the internal carotid, i. 749 of the internal iliac, i 769 of the ischiatic artery, ii. 1060 of the lower jaw, ii. 410 of the mesenteric artery, i. 767 of the middle meningeal ar- tery, i. 749 Aneurism — of the nates, ii. 1060 of the ophthalmic artery, i. 750 of the orbit, ii. 234 of the palate, ii. 468 of the penis, ii. 835 of the popliteal artery, i. 775 of the posterior tibial, i. 779 of the profunda femoris, i. 775 of the radial artery, i. 764 of the renal artery, i. 767 of the sciatic artery, i. 769 of the splenic artery, i. 767 of the subclavian artery, i. 751 of the subscapular artery, i. 759 of the superior mesenteric artery, i. 767 of the supraorbital artery, i. 750 of the temporal artery, i. 749 of the thoracic aorta, i. 730 of the transverse cervical, i. 759 of the ulnar artery, i. 764 of the vertebral artery, i. 751 sacciform, i. 690, 694 sacculated, i. 690, 694 spontaneous, i 690 spontaneous cure of, i. 703 symptoms of, i. 698 terminations of, i. 702 thoracic, i 730 traumatic, i. 690 treatment of, i. 706 by acupressure, i. 719 acupuncture, i. 723 Brasdor’s operation, i. 711 compression, i. 713 direct, of denud- ed artery, i. 718 with elastic band- age, i. 719 with finger, 717 with instruments, i. 713 deligation, i. 706, 711 forced flexion, i. 720 galvano - puncture, i. 720 Hunterian operation, i. 706 injection, i. 721 manipulation, i. 723 medical and surgical treatment of, i 726 opening the sac, i 724 operation of, Antyllus for, i 724 subcutaneous injec- tion of ergotine, i. 722 Valsalva’s method, i. 725 Wardrop’s operation, i. 712 true, i. 690, 694 causes of, i. 690 Aneurism, true— causes of greater fre- quency in certain ar- teries, i. 691 diagnosis of, i. 700 effects of, i. 702 influence of age in for- mation of, i. 692 of climate in for- mation of, i. 691 of sex in formation of, i. 693 symptoms of, i. 698 terminations of, i. 702 varieties of, i. 694 tubular, i. 696 varicose, i. 690, 727 varieties of, i. 694 Wardrop’s operation for, i. 712 Aneurismal concretions, i. 696 diathesis, i. 693 tumors of bone, i. 890 varix, i. 729 of common carotid, i. 748 of common iliac, i. 768 of femoral, i. 775 of foot, ii. 1049 of hand, i. 778 of leg, ii. 1049 of stumps, i. 530 Angeioleucitis, i 646 after venesection, i. 455 Angioma, i. 230 arterial, i. 231, 823 capillary, i. 230, 823 cavernous, i. 231 of bone, i. 890 of groin, ii. 1065 of vulva, ii. 936 venous, i. 231, 829 Angular curvature of the spine, ii. 112 Animal ligatures, i. 657 Anisometropia, ii. 150 Ankle-joint, amputation at, ii. 1111 caries of, ii. 1088 dislocation of, i. 1166 excision of, ii. 1088 gunshot wounds of, ii. 1089 tuberculosis of, i. 1069 Ankylosis, i. 1091 extra-articular, i. 1098 treatment of, i 1099 intra-articular, i. 1091 Adams’s operation for, i. 1095 apparatus for, i. 1093 Barton’s operation for, i. 1094 Brainard’s operation for i. 1096 Buck’s operation for, i. 1096 Gross’s operation for, i. 1097 osteotomy for, i. 1094 Pancoast’s operation for, i. 1096 Rodgers’s operation for, i. 1094, 1096 Sayre’s operation for, i. 1094 1132 INDEX Ankylosis, intra-articular— treatment of, i. 1092 of elbow, ii. 1020 of fingers, ii. 1018 of hip, ii. 1067 of knee, i. 1095 ; ii. 1051 of lower jaw, ii. 405 of shoulder, ii 1021 osseous, i. 1094 osteotomy for, i 1094 spurious, i. 1098 true, i. 1091 Yolkmann’s operation for, i. 1094, 1095 Anodynes as antiphlogistics, i. 88 in the treatment of strangu- lated hernia, ii. 524 Anterior curvature of the spine, ii. 110 Anteversion of the uterus, ii. 868 Anthrax, i. 578 Antimonio-saline mixture, i. 91 Antiperiodics in the treatment of inflammation, i. 91 Antiphlogistic, acetate of lead as, i. 98 aconite as, i. 86 anodynes ns, i. 88 blisters as local, i. 102 cataplasms as, i. 97 cathartics as, i. 80 chloride of ammonium as, i. 98 cold aud warm applications as local, i. 95 compression as local, i. 100 counterirritants as local, i. 101 depressants as, i. 85 diaphoretics as. i. 86 diet as, i. 91, 105 digitalis as, i. 86 diuretics as, i. 88 emetics as, i. 84 escharotics as, i. 101 fomentations as, i. 96 gelsemium as, i. 86 general bleeding as, i. 77 hydrochlorate of ammonia as, i. 98 iodine as a local, i 99 ipecacuanha as, i. 86 ligation of arteries as, i. 95 local bleeding as, i. 94 mercury as, i. 82 nauseants as, i. 84 necrotics as local, i. 100 nitrate of silver as, i. 98 poultices as local, i. 97 regimen, i. 91 rest and position as local, i. 93 sedatives as, i. 85 suppurants as local, i. 102 tartar emetic as, i. 85 veratrum viride as, i. 86 vesicants as, i. 101 Antiseptic treatment of abscesses, i. 135 of amputations, i. 521 of fractures, i. 918 of wounds, i. 346 Antiseptics, i. 135, 346, 467 Antrum of Highmore. See Jaw, upper abscess of, ii. 387 affections of, ii. 386 cystic tumor of, ii. 390 dropsy of, ii 390 effusions of blood in, ii. 388 encephaloid of, ii. 3 6 fistule of, ii. 389 inflammation of, ii. 387 polyp of, ii. 391 tumors of, ii. 390 wounds of, ii. 386 Antyllus, operation of, for aneu- rism, i 724 Anus, abscess of, ii. 592 abnormal, ii. 648. See also Rectum. artificial, ii. 625, 648 . enterotomy for, it. 650 formation of, ii. 625 statistics of, ii. 627 carciuoma of, ii. 595 diseases of. ii. 565 eczema of, ii. 601 epithelioma of, ii. 595 examination of, ii. 565 excision of, ii. 597 fissure of. ii. 577 fistule of, ii. 572. See Fistule. hemorrhage from, ii. 568,569 imperforate, ii. 603 injuries of, ii. 568 laceration of, ii. 568 malformations of, ii. 602 neuralgia of, ii. 599 phantom stricture of, ii. 594 prolapse of, ii. 579 pruritus of, ii. 601 sacciform disease of, ii. 578 spasm of sphincter of, ii. 600 stricture of, ii 592 syphilitic stricture of, ii. 593 trichiasis of, ii. 602 tumors of, ii. 591, 595 ulceration of, ii. 576 wounds of, ii. 568 Aorta, abdominal, aneurism of, i. 765, 767 ligation of, i. 770, 798 for iliac aneurism, i. 770 varicose aneurism of, i. 767 wounds of, ii. 383 thoracic, aneurism of, i. 730 tourniquet, ii. 1124 Aphakia, ii. 147 Apucea, ii. 334. See Asphyxia. Aponeuroses, affections of, i. 624 Aponeurosis, palmar, contraction of, ii. 1005 plantar, section of, ii. 1039 Aponeurositis, i. 624 Apoplexy of the mammary gland, ii. 968 Arm, amputation of, ii. 1104 artificial, i. 535 bandages for, ii. 1025 gunshot fractures of, ii. 999 Arm-pit. See Axilla and Shoulder. Arinsby’s operation for hernia, ii. 511 Arrow wounds, i. 365 of the skull, ii. 75 Arrows, caustic, i. 471 Arsenic as an escharotic, i. 470 Arterial compressor, i. 517 hemorrhage, i. 652 secondary, i. 676 transfusion, i. 457 tumors, i. 823 varix, i. 687 Arteries, acute inflammation of, i. 683 acupressure of, i. 665 albuminoid degeneration of, i. 686 amyloid degeneration of, i. 686 aneurism of, i. 689. See Aneurism. atheromatous degeneration of, i. 686 calcareous degeneration of, i. 685 calcification of, i. 685 changes in, after division, i. 654 after ligation, i. 662 chronic affections of, i. 685 collateral circulation of, i. 655, 678 compression of, i. 668 deligation of. See Ligation. for aneurism, ii. 706,711 diaeases of, i. 652, 683 dissecting aneurism of, i. 687, 690 earthy degeneration of, i. 686 fatty degeneration of, i. 686 fibrous transformation of, i. 685 gangrene of, i. 684 gunshot wounds of, i. 656; ii. 994 hemorrhage of, i. 652, 677 inflammation of, i. 683 injuries of, i. 652 intraparietal separation of coats of, i. 687 ligation of, i. 657. See Li- gation. occlusion of, i. 688 of stump, varicose enlarge- ment of, i. 530 operations on, i. 780 softening of, i. 684 subcutaneous hemorrhage of, i 677 suppuration of, i. 684 torsion of, i. 673 ulceration of, i. 686 varicose enlargement of, i. 687, 690 wounds of, i. 652, 654 Arteriotomy, i. 456 Arterio-venous aneurism, i. 727 of the axillary arterv, i. 763 of the brachial, i. 764 of the external carotid, i. 749 of the internal carotid, i. 750 of the subclavian, i. 759 cyst of popliteal nerve, i. 628; ii. 1056 Arteritis, acute, i. 683 chronic, i. 684 INDEX 1133 Artery, anterior tibial, axillary, etc. See Tibial, axillary, etc. Artery constrictor, i. 667 forceps, i. 661. See Forceps. Arthritis, rheumatic, chronic, i. 1085 Artificial anus, formation of, ii. 625 drum for the ear, ii. 265 eye, ii. 216 limbs, i. 533 pupil, ii. 179. See Pupil, artificial. respiration, ii. 335 Arytenoid cartilages, wounds of, ii. 315 Ascarides in the rectum, ii. 570 Ascites, ii. 643 tapping for, ii. 645 Aspergilli in the auditory tube, ii. 247 Aspermatism, ii. 861 Asphyxia, ii 334 from drowning, ii. 334 artificial respiration in, ii. 335 from hanging, ii. 337 from noxious gases, ii. 337 Aspiration, i. 440, 521 in hydrothorax, ii. 377 in pyothorax, ii. 377 in strangulated hernia, ii. 533 of the bladder, ii. 704 of the chest, ii. 377 Aspirator, i 440, 52l ; ii. 377 Assistants in operations, duties of, i. 486 Astigmatism, ii. 145, 149 Green’s test objects for, ii. 149 Thomson’s optometer for, ii. 150 Astragalus, dislocations of, i. 1163 excision of, ii. 1086 fracture of, i. 986 Atheromatous degeneration of ar- teries, i. 686 Atlas, displacement of, i. 1065 Atlo-axoid articulation, disloca- tion of, i. 1065, 1131 tuberculosis of, i. 1064 Atony of bladder, ii. 686 of rectum, ii. 571 Atrophy, i. 190 from cessation of function, i. 191 deficiency of nutritive matter, i. 192 deficient supply of blood, i. 192 inflammation, i. 192 loss of nervous influence, i. 191 of the bones, i. 872 of the hairs, i. 613 of the mammary gland, ii. 968 of the muscles, i. 616 of the testicle, ii. 808 of the tongue, ii. 449 of the upper jaw, ii. 389 of young children, i. 191 senile of bone, i. 873 treatment of, i. 192 Attitude of patient, a means of general diagnosis, i. 425 Auditory tube, affections of. ii. 241 accumulations of wax in, ii. 244 aspergilli in, ii. 247 boils in, ii. 249 erysipelas of, ii. 249 foreign bodies in, ii. 242 fungous growths of, ii. 247 furuncles in, ii. 249 granulation tumor of, ii. 247 gunshot injuries of, ii. 242 hemorrhage of, ii. 251 herpetic affections of, ii. 250 inflammation of, ii. 249 of ceruminous glands, ii. 250 rpalformations of, ii, 241 malignant tumors of, ii. 248 molluscous tumor of, ii. 248 occlusion of, ii. 241 osseous growths of, ii. 247 parasitic growths of, ii. 247 polypous growths of, ii. 245, 247 sebaceous tumor of, ii. 248 syphilis of, ii. 249 Auricle, affections of, ii. 239 Auscultation, i. 434 Autoplasty, i. 497 Avulsion, i. 445 Axilla, abscess of, ii. 1023 affections of, ii. 1023 bandages for, ii. 1026 encephaloid of, ii. 1022 inflammation of, ii. 1023 tuberculosis of, ii. 1024 tumors of, ii. 1024 wounds of, ii. 1023 Axillary artery, aneurism of, i. 759 ligation of, i. 761, 795 of subclavian for wounds of i. 792 dislocation of the humerus, i. 1149 BACK, tumors of, ii. 127 Bacteria, i. 139 Balanitis, ii. 843 treatment of, ii. 852 Balano-postbitis, infecting, i. 289 Baldness, syphilitic, i. 305 Balls, windage of, i. 372 Bandage, as therapeutic agent, i. 477 chalk and gum, i. 913 dextrine, i. 913 egg paste, i. 914 elastic, i. 179, 489 Esmarch’s, i. 489 for fractures, i. 909 for the arm, ii. 1025 for the axilla, ii. 1026 for the breast, ii. 991 for the fingers, ii. 1025 for the forearm, ii. 1025 for the groin, ii. 1068 for the hand, ii. 1025 for the head, ii. 89 for the inferior extremity, ii. 1068 for the knee, ii. 1068 Bandage— for the superior extremity, ii. 1025 for the testicle, ii. 802 for wounds, i. 345 glue, i. 914 invaginated, i. 345 Martin’s, i. 179 of Scultetus, i. 478 paraffin, i. 914 perineal, ii. 958 plaster of l’aris, in the treat- ment of fractures, i. 913 silicate of potassium, i. 914 of sodium, i. 914 spica, ii. 1026 starch, in treatment of frac- tures, i. 913 Bandaging, i. 477 gangrene from, i. 480 Barbadoes, glandular disease of, i. 593 Barton’s fracture, i. 969 operation for ankylosis, i. 1094 Bathing in inflammation, i. 87 Baths, mercurial, i. 327 vapor, i. 327 Battey’s operation, ii. 922 Bavarian dressing for fractures, i. 913 Baynton’s method of treating ul- cers, i. 179 Bedsores, i. 582 ; ii. 97 Bee, wounds by, i. 387 Bellocq’s canula, ii. 282 Bending of the boues, i. 924 Bibron’s antidote to poison of rattlesnake, i. 392 Biceps tendon, dislocations of, i. 1161 Bichloride of methylene, inhala- tion of, i. 558 Bifid nose, ii. 271 spine, ii. 122 Bilateral operation of lithotomy, ii. 754 Biliary abscess, ii. 639 fistule, ii. 648 Bistouries, i. 437 Black tongue, i. 566 Bladder, abscess of, ii. 675 affections of, ii. 667 aspiration of, ii. 704 atony of, ii. 686 calculi in, ii. 711. 762 carcinoma of, ii. 690 catarrh of, ii. 678, 941 morbid alterations pro- duced by, ii. 679 chronic inflammation of, ii. 678 colfoid of, ii. 690 columniform, ii. 679 encephaloid of, ii. 690 epithelioma of, i