:.\\\\\ i! i" ll!Hill :: l,M«!i;-.. mmmmmmmmm mm A treatise PRACTICE OE SURGERY. BY HENRY H. SMITH, M. D., PROFESSOR OP THE PRINCIPLES AND PRACTICE OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA ; CONSULTING SURGEON TO THE ST. JOSEPH'S HOSPITAL, PHILADELPHIA AUTHOR OF A TREATISE ON OPERATIVE SURGERY, * ETC., ETC. illustrator bg Warn funto too Statj-ta tfnpftings on »ob. Mitt. I ^'••^K. „ circumscribed mass of Lymph effused as te 1" o»iTr TJl THE ^ central portion represents the cavity of the abscess The LrinhpL the natural tendency of the sore being to heal by the process of granulation and cicatrization. All that is necessary therefore is for the dresser to avoid officious interference with the process of nature; thus, in cleansing the sore, let him abstain from washing the pus from off the granulations, though he may thoroughly cleanse the skin adjacent to them. Let him also, when the ulcer is so situated as to be kept in constant motion by the action of the part, resort to such means as will insure rest, as a splint, or confinement to bed, or the use of a sling, &c, or the approximation of the edges by adhesive plaster. In order to favor the organization of the lymph, and the formation of granulations, it will generally prove useful to protect the surface of the sore from the action of the atmosphere by the use of the warm water dressing (see p. 64), or by means of lint spread with fresh simple cerate, or calamine ointment, or mucilage. These articles may be advantageously fast- ened on the limb by means of a handkerchief folded like a cravat, and then carried obliquely around the part. Formerly heat and moisture were very generally applied to ulcers by means of poultices made of various substances, some of which were medicinally useful as stimulants, but the majority mere recipi- ents of moisture and heat. When the application of heat and moisture is desired, the warm water dressing, just alluded to, will prove the most useful, the decomposition, and rancidity, created by the chemical changes in the substance of many poultices, rendering them rather a source of irritation than of relief. Instances in which the adjacent sound skin has exhibited evidences of Eczema simplex and Eczema rubrum after the application of the poultice UNHEALTHY ULCERS. 115 are sufficiently common, and it will therefore be found most useful to substitute as far as possible the warm water dressing; the addition of opiates or astringents to the water making this dressing far superior to the old one of poultices. When in the treatment of the acute or healthy ulcer the reparative process begins to flag, that is, when, the granulations become paler, the pus less thick, and the cicatrization does not evidently advance, it will prove useful to stimulate the surface by touching the margin of the sore very lightly with the stick of the nitrate of silver, so as to ,form a white deposit, and this stimulus may be repeated every 24 or 48 hours until the reparative action again advances. It is also sometimes useful to paint the granulations near the edges of the ulcer with a camel's hair pencil, wet with a solution of nitrate of silver, 5 or 10 grains to the ounce of water, or to pour over it a solution of sulphate of zinc of the same strength. In some cases, the application of a piece of lint, moistened with the zinc solution, and lightly bandaged with a handkerchief, will prove serviceable by keeping the action up to the proper point for the organization of the effused lymph, from which the process of cicatrization re- sults. Throughout the treatment of this ulcer, attention should be given to the state of the digestive organs, so as to guard against constipation, as well as to the amount and character of the food, lest it prove too much for the powers of the system, and develop irritation. ■•§ 2.—OF THE UNHEALTHY OR CHRONIC ULCERS. Under this head, I would group all ulcers in which may be traced the ordinary evidences of unhealthy or chronic inflammatory action; that is, ulcers in which the color, heat, pain, and swelling are highly developed, as well as those in which one or more of these signs of inflammation are deficient, or only present in a modified degree. Of those in which the heat, pain, and swelling are marked symptoms, we have the "Irritable," the "Sloughing" and the "Phagedenic," as well as the "Fungous" ulcers of the older sur- geons, whilst the "Indolent" variety exhibits all the evidences of chronic inflammatory action, with the failure of the reparative pro- cess of acute inflammation to heal the chasm developed by the original source of the ulceration. 116 PRACTICE OF SURGERY. Fig. 25. In the class of unhealthy or chronic ulcers, I therefore place two varieties, the one being marked by excessive inflammatory action, the other by a deficiency of vital force:— 1. Ulcers due to active unhealthy inflammation, or those known as the Irritable and Sloughing ulcers, present marked characteristics, which will readily enable the observer to distin- guish them from those of the acute and healthy class. The edges of the skin near the tfrritable Ulcer are usually shining, red, hot, painful, and swollen, giving evidence of high inflammatory action, whilst its margin is serrated, indented, under- mined, or irregularly destroyed in consequence of the burrowing of the pus, and the absence of the layer of lymph which checks the destructive process in healthy inflammation. (Fig. 25.) The granu- lations are either very deficient, owing to the degeneration of the lymph layer which forms their basis, or give evidence of over-action, being of a deep red co- lor, raised above the level of the skin, spongy, very painful, and bleeding on the slightest touch, or even simply from the dependent position of the part, or the action of the neighboring muscles. The pus, or rather ichor from this va- riety of ulcers, is thin, acrid, and irritat- ing, of a pinkish-yellow from the admix- ture of blood, or of a light brown, like pus, blood, and water when mixed toge- ther. Wherever the discharge remains, it is disposed to evaporate, and form crusts or scabs, sometimes drying in patches on the surface of the sore. Seat.—The irritable ulcer is chiefly seen on the leg above the ankle, or be- tween it and the knee. The whole adja- cent structures, particularly when the ulcer is on the leg, are heated and swollen, and the pain, especially at night, is very severe and burn- ing, the patient being restless, feverish, and exhibiting the other constitutional evidences of inflammation. " The patient is most commonly one of irregular habits, a high A view of the Irritable Ulcer, showing the irregular serrated character of its edges, and the spongy bleeding granulations. (After Nature.) I unhealthy ulcers. 117 liver, or drunkard, or of a cachectic or bad constitution, and with an especial derangement of the digestive organs. The causes are varied. Sometimes a healthy ulcer degenerates in consequence of a want of attention to the sore; errors of diet; too much exercise, or the frequent application of sources of irritation, as repeated blows, friction of the part by clothing, &c. In the intemperate, or those with disordered digestion, a scratch of the skin will some- times suffice to establish the irritable ulcer, the tendency of which is constantly to spread. When its tendency is to slough, and the edges lose their vitality rapidly, it constitutes the variety known as the " Phagedenic Sore," this being a higher, or more marked grade of the " Sloughing Ulcer." Treatment.—All this class of unhealthy ulcers being evidences of excessive inflammatory action in the part, in consequence of which the reparative material degenerates more or less rapidly instead of continuing to be productive in its tendency, the indications in the treatment are, 1st, to allay the local irritability and vascular action; and 2d, to improve the general condition of the patient's system. Local Treatment.—As the local irritation causes the patient con- siderable suffering, attention should be first given to the dressing, and this should generally be of the mildest possible character. Few articles are better adapted to the unhealthy and irritable ulcer, as a primary dressing, than that of warm water, applied as before directed; the patient being placed in bed, and the limb elevated so as to drain the blood from it and diminish the local congestion. Should the pain be very marked, it will prove useful to add 5j of the Extract of Opium to a half pint of the warm water, and renew it by wetting the lint in this solution every hour or two, the solution being kept warm by placing it in a vessel of hot water, or by means of a spirit-lamp underneath the cup which holds it. Sometimes, and especially when the whole limb is swollen and painful, lint wet with cold anodyne water, so as to envelop it entirely, or the dressing by irrigation (page 63), affords the greatest relief. When the unhealthy or irritable ulcer takes on the sloughing or phagedenic character, its progress may be arrested by the appli- cation of lint wet with very dilute nitric ,acid, of the strength of one drop of the officinal' acid to the ounce of water, or 50 drops to the quart, as advised by Sir Astley Cooper; a piece of oiled silk being placed over the lint, and the dressing retained by a turn or 118 practice of surgery. two of a roller, or of a light handkerchief, these ulcers being often very intolerant of pressure. Cooper's anodyne wash is also sometimes very useful in this class' of sores. It is composed as follows:— R.—Ext. opii 3ij ; Pul. gum. acac. ^ij ; Aquae calcis f^ij; Aquae fontan. ^iv. When the ulcer has lost its irritability, and is disposed to take on the characters of a healthy sore, moderately stimulating applica- tions will often prove useful, as the Aromatic Wine of the French Hospitals,1 and water, in the proportion of half and half; this pro- portion being increased or diminished according to its stimulating effects, these being shown by the patient's sensibility. The healing of this ulcer after it has ceased to be irritable will often be expe- dited by the application of lint soaked in mucilage, as that of flax- seed, gum Arabic, or pith of sassafras; ointments having a marked tendency to irritate this class of ulcers, even when prepared with care and apparently free from rancidity, the heat of the body soon tending even with fresh ointments to the production of oleic and margaric acids, and thus stimulating the parts to a renewal of the unhealthy condition. Constitutional Treatment.—From the very first visit and local application, the surgeon must, however, remember the importance in the treatment of this as well as every uloer, of giving attention to the condition of the patient's general health, and especially to his digestive organs. When he presents a heavily furred tongue, with a yellow and bloated skin, and gives other evidences of hepatic disorder, nothing is better than an emetic of 9j or 5ss of powdered Ipecacuanha, followed after the nausea has passed away by a purge of Calomel and Jalap, each grs. x; or nine grains of Blue Mass may be given at night, and followed by a saline cathartic the next morn- 1 R.—Mentha piperita, Origanum vulgare, Rosmarinus officinalis, Salvia officinalis, Thymus vulgaris, Flores lavandula vera, aa gij ; Vini rubri (olaret) Oij. Mix, and let it stand 15 days. unhealthy ulcers. 119 ing. After freely evacuating the alimentary canal, diaphoretics and sedatives often prove useful, and may be continued for several days, or until the pain, sleeplessness and irritability have passed off. A good prescription that may be continued for two or three days after free purging, is as follows:— R.—Pul. Doveri &j ; Hydrargyri chlorid. mite grs. x ; Syr. q. s.—M. et ft. pil. xx. S. Take one pill every four hours. The additional dose of ten grains of Dover's powder at bedtime is also sometimes necessary to secure sleep. The action of opiates and diaphoretics having been already explained in connection with the constitutional treatment of inflammation, it is unnecessary to do more at present than state, that throughout the entire course of this class of ulcers the constitutional treatment of inflammation is essential to their cure; but bloodletting, either locally or generally, is badly borne by those who suffer from the irritable ulcer. 2. Ulcers Due to Chronic Inflammatory Action.—When the process of repair has been arrested in the simple healthy ulcer, or in one of the irritable, sloughing, or phagedenic class, the sore may continue in the same open unhealed condition for a period which may vary from thirty days to as many years. Hence this kind of sore is often designated as the Chronic or Indolent Ulcer, and is the second species of the unhealthy class. The Indolent Ulcer constitutes the greatest number of the ulcers found in the laboring classes, among soldiers and sailors, as well as in the wards of hospitals and almshouses. Its causes are neglect of the simple sore, repeated attaeks of ulceration, constant exposure to irritating agents, or the cessation of active inflammatory action in the irritable sore. Its seat is most commonly on the lower portion of the leg just above the ankle, especially towards the malleoli, and in preference the inner one, its seat on this side being probably influenced to some extent by the position of the great saphena vein. Its edges are elevated, protuberant, rounded, smooth, and often whiter than the adjacent skin; whilst the surface of the sore looks as if much deeper than usual, though in reality nearly on the level of the adjacent skin, the apparent depth being due to the elevation of its margins. (Fig. 26.) 120 PRACTICE OF SURGERY. The granulations are so badly developed that they are often not recognizable, the surface being formed of a gray, pultaceous-looking Fig. 26. A representation of the Edges, Seat, &c, of the Indolent Ulcer. (After Nature.) structure; or if distinct granulations are visible, they are pale, flabby, and jelly-like, do not bleed even when somewhat roughly touched, and are often so insensible as to sustain for an instant, without feeling it, the direct contact of a hot iron. This insensibility is, however, sometimes due to a crust of dirt which has collected on their sur- faces. When the granulations of the indolent ulcer are very exube- rant, and rise above the skin, they constitute the " fungoid ulcer" of some authors. The pus is viscid, gluey, thick, or muco-purulent, disposed to dry and form thick hard scabs, and is often very deficient, the amount of the discharge being trifling. The odor of the indolent sore is peculiarly offensive and permanent, a room being often scented for hours after a visit from one of these old sore lees. The limb often gives evidence of long-continued irritation, is swollen, and has the skin apparently hypertrophied; the veins are often also more or less enlarged and varicose; and the skin imme- diately around the sore, as well as in other points where former ulcers Tiave existed is livid, mottled, brown or dark-red, being not unfrequently accompanied by Chronic Eczema Rubrum. The pain is trifling; the chief inconvenience being the enlarged INDOLENT ULCERS. 121 heavy state of the limb. The general health is fair, or such as is usually seen in the laboring classes, especially if moderate drinkers. Treatment.—From an examination of the characters of the Indo- lent or Chronic Ulcer, it is evident that the reparative process consequent on the first production of ulceration in the part has been arrested; hence the thickened everted edges, which show tbe efforts of nature to check the progress of the disorder by the effu- sion of lymph; and hence the flabby granulations and permanently congested capillaries, the formation of the granulations proving that the primary condition of healthy inflammatory action had existed. The indications in the treatment are, therefore, to get rid of these useless materials, and excite active healthy inflammation, so that a new reparative substance may be produced in the part. The means of fulfilling the first indication, or the removal of the useless materials, are varied; thus the .thickened edges may be pared away with the knife, or absorbed by nature under pressure, or the vas- cular action excited in them and in the granulations by stimulants, as by pouring on the sore hot beeswax and turpentine, as advised by Stafford, the two being mixed and applied as hereafter stated. In paring off the callous edges of the indolent ulcer it is neces- sary to apply the scalpel flatwise to the limb, and, starting from the sound side on a line with the sound skin, shave off all that inter- venes between this point and the sore. The hemorrhage that ensues is trifling, as the thickened edges which are in this manner removed possess but little vascularity. The surface of the sore being then covered with dry lint, as a stimulant, or painted with the nitrate of silver, a new inflammatory action will be set up, and the part take on more of the character of the simple healthy ulcer, and require to be treated on the general principles of inflammation. A better plan for removing the edges, and stimulating the sur- face of this sore, is, however, to be found in the application of pres- sure. The advantages of pressure in the treatment of indolent or callous ulcers appears to have been suggested by Wiseman, who was surgeon to Charles II. of England in 1762, and who recom- mended the use of the laced stocking for this purpose. Whately, in 1799, revived this practice, covering the sore with a plaster com- posed as follows:— R.—Emplast. plumbi ^iv ; Aceti f Jj; Axunge porcina gxij. M. et ft. ungt. S. To be spread evenly on kid. 122 PRACTICE OF SURGERY. And then applying very accurately a soft flannel bandage previously well shrunken by washing it in very hot water. In several instances this treatment has proved in my hands an excellent dressing. Baynton, about the same period, also treated ulcers by approxi- mating their edges by means of strips of adhesive plaster, covering them with compresses, and then bandaging the limb from the toes to the knee; wetting the bandages each morning whilst on the limb with cold water, so as to promote evaporation from the limb. These plans, with some trifling modifications, are the means most employed at the present time, a combination of all of them being often the best plan of treatment. When, for example, an indolent ulcer of two or more years' standing enters a hospital, the treatment should be as follows:— Apply at night a hot poultice of powdered white-oak bark; have the limb thoroughly washed and shaved next morning; and then, as advised by Stafford, mix four parts" of beeswax and one of Venice turpentine, melt them together by a moderate heat, and when it .is on the point of cooling, cleanse and dry the ulcer by wiping its surface with dry lint; dip a brush into the wax, and drop it on the sore, so that the whole excavation may be filled with it, or pour it from the vessel into the ulcer until it covers the edges as a cake. After the wax has become solid, fasten it in its place by a strip or two of adhesive plaster. On the third day this dressing may be renewed, and, if granulations have appeared.it may be reapplied; or the limb, after its cleansing, may be dress- ed as follows, as advised by Mr. Cri- chet. , Cut a number of strips of adhesive plaster about a half inch wide, and long enough to extend a little over two-thirds of the circumference of the limb. Then, warming a strip by holding it on a can of boiling water, commence an inch or two below the ulcer by fastening one end to one side of the leg, and, drawing firmly Fig. 27,. A REPRESENTATION OF THE APPLI- CATION op the Adhesive Strips, as DIRECTED BY Mr. CRICHET, TO AN Indolent Ulcer on the Malleolus and lower part of the leg, accom- PANIED by a Varicose Condition of the Veins of the Foot.—The strips were first applied from the ankle up- wards, and then those around the foot were placed as in the cut, the free ends on each side of the limb being fastened by a vertical strip. (After Nature.) BANDAGING. 123 on the strip, cause it to pass around and adhere to the limb. Then apply a new strip, so that it will cover about one-third of the preceding strip, and continue to apply them until they reach at least an inch above the upper edge of the ulcer, fastening the ends by a vertical strip so as to prevent their curling up. (Fig. 27.) Over this apply the spiral bandage of the lower extremity, and let the dressing remain for three days, the patient using the limb moderately in the mean time. On the tbird day remove the band- age, and, if the plaster is yet firm, cleanse its outer surface of the pus, which often escapes through the strips, by wiping it carefully with a damp sponge, and reapply the bandage as before. On the sixth or ninth day the plaster should be removed and the surface thoroughly cleansed, when the ulcer will generally show a marked improvement; the dressing may then be renewed as before, until the sore assumes more of the characters of the healthy ulcer, when it should be treated accordingly. Pressure, under these circumstances, often acts most admirably, causing the removal of the lymph which formed the thickened edge of the ulcer, and stimulating the circulation in the part to the pro- duction of granulations. § 3.—BANDAGING. As the treatment of ulcers as well as many other surgical dis- orders requires the application of the Bandage or Poller, the student should give some attention to the manufacture and application of this powerful agent, the good effects of which will be very apparent in the treatment of ulcers, as without it the dressing would be but imperfectly made, and the reparative action often defective. Bandages are generally made of coarse, open, unglazed muslin, of the quality which commonly sells for six or eight cents a yard. That which is finer is not so well adapted to the surgeon's use. Bandages should be made of strips torn from the sheet, as follows: For the head, five yards long and two inches wide. For the chest or abdo- men, ten yards long and four inches wide. For a thigh or arm, eight yards long and three inches wide. For a leg or forearm, seven yards long and two and a quarter or two and a half inches wide, though the latter size also often suffices for the entire limb of either the upper or lower extremity. After tearing it from the sheet, roll the strip up into a cylinder, and then pull off all the loose 124 PRACTICE OF SURGERY. threads from each end. When the ravellings are removed before the strip is rolled it runs to waste. A bandage may be rolled either by means of a machine or by hand. Tig. 28. A view of a Machine for rolling Bandages.—Whilst the fingers of the left hand are spread out so as to direct the course of the strip upon the spindle, the latter is turned by the right hand until all is rolled up and the "cylinder" or "roller" fully formed, when the left hand holds the roller firmly whilst the right reverses the spindle and draws it out of the roller. (After Nature.) .' \" The bandage machine (Fig. 28) explains itself. The strip being placed upon the spindle and wound into a cylinder, reverse the spindle for a few turns, and, drawing it out, the roller will be ready for use. Where it is desired to prepare a number of rollers at one time, such a machine will prove very useful, and is an essen- tial implement in the surgeon's office. But there are many occa- sions where the surgeon finds it necessary to prepare or re-roll a bandage on the instant. To do this let him proceed as follows: Fold up twelve or eighteen inches of the strip, and roll it on the thigh or on a table into a small cylindrical mass, by placing the palmar surface of the ends of all the fingers flatly upon it, and pushing the hand directly forwards until the roll reaches the front of the wrist. Then, after repeating these movements four or five times, or until the cylinder is about as thick as the thumb, seize its two ends between the thumb and first three fingers of the left hand, Fig. 39; let the loose strip of muslin run over the forefinger of the right hand, where it is to be firmly held by the pressure of BANDAGING. 125 the right thumb, whilst the remaining three fingers of this hand pass around the cylinder, so as to hold it against the palm. Fig. 29. Rolling a Bandage by Hand. (After Nature.) The fingers and thumb of this hand, if rightly placed, will resemble in position that seen in the hand of the sign-post l^gf, the cylinder being held in the hand by the doubled fingers, which press it against the ball of the thumb. Whilst thus held rotate the cylinder from right to left with the left hand (Fig. 29), whilst the opposite passes round it from left to right, drawing tightly on the strip, which passes over the right forefinger, by pressing on it with the thumb, and by thus rapidly pronating and supinating each hand, the bandage may be quickly and firmly rolled to the shape of a cylinder and fitted for immediate use. In applying a bandage to the limbs place the outer face of the cylinder next to the skin, holding the roller so that it may unroll into the palm of the hand, and thus be prevented from being jerked upon the floor or accidentally dropped. As all the limbs of a well-formed subject are conical, and every bandage requires to be applied from the apex of the cone towards its base (as from the ankle to the knee), it must be evident that if the upper edge pressed on the skin, the lower would not touch it. To obviate this, and make equable pressure on all the portions that are to be covered, it is necessary to give the bandage a half turn, 126 PRACTICE OF SURGERY. so that it may fold over on itself, or be " reversed." The making of " reverses" embraces the most difficult part of the art of band- aging, but may be easily accomplished by a little attention. To make a smooth and proper reverse which shall not create un- necessary pressure on the part, proceed as follows1: 1. Be careful to apply the bandage in a line which is spiral or moderately oblique to the axis of the limb holding the cylinder, so that the fingers shall not encroach on the loose, or unrolled portion of the bandage. Fig. 30. A view of. the Application of the Spiral Reversed Bandage of the Leg— showing the patient's heel resting on the point of the surgeon's knee-Mhe turns around the heel and.the hands of ijhe surgeon in the act of making the reverse. (After Nature.) 2. Draw it firmly enough to cause the bandage to lay smoothly on the limb, but not too tight, or so as to cause pain, and fasten the J;urn just made by the perpendicular pressure of the forefinger (Fig. 30), or thumb of the opposite hand, so as to prevent this portion from becoming loose, as seen in the same figure. 3. Hold the cylinder in the proper degree of obliquity to the axis and slightly above the level of the limb. 1. Make no traction on the bandage whilst doing this, so that the portion of the bandage between the two hands may be perfectly slack. 5. Turn the hand holding the cylinder from semi-supination into simple pronation, and the reverse will be smoothly made by the turn of the upper edge of the loose portion of the bandage. 6. Pass the cylinder around the limb to the left hand and draw it moderately tight. BANDAGING. 127 7. Then passing it from the left to the right hand again, proceed to make another reverse, taking care to cover in only one-third of the width of the preceding turn, and making the edge of each re- versed turn perfectly parallel with that which, preceded it. In order to apply the "spiral reversed bandage" to the Leg, as in the treatment of the indolent ulcer, proceed as follows :— Apply the external face of the free end of the cylinder to the surface of the right leg, just above the ankle, and pass once or twice circularly around the limb so as to fasten this end of the bandage. On coming to the fibular side of the limb in the second turn, pass from the external malleolus very obliquely across the top of the foot to near the inner side of the ball of the great toe. Pass around the joints of the toes and then around the upper ends of the meta- tarsal bones or instep of the foot, and then directly around the point of the heel from the inside to its outer side, the limb of the patient resting on the^surgeon's knee, as represented in Fig. 30. Then come in front of the ankle-joint to the inside of the instep, under the sole, and obliquely behind the heel to the lower edge of the internal malleolus; thence around the front of the ankle, under the foot, and obliquely around the heel on its inner side, or from the internal malleolus around the tendo-Achillis to a little above the external malleolus. Then ascend the limb by passing over its inner side; to the outer side, giving the bandage the proper spiral course, and fixing it by the forefinger and making the reverse as before directed. Continue these reverses until the bandage reaches the head of the tibia, and terminate it at this point by one or two circular turns; after which apply one pin at the knee and one at each of the turns on the side of the heel, and the bandage will be completed. In re- moving this or any other bandage gather its folds loosely in one hand, and pass them rapidly from this to the other hand as the bandage is unrolled, taking care, on reaching the heel, to reverse the turns of the figure of 8 made in its application around the ankle. In bandaging the Upper Extremity, commence above but near the wrist, by one or two circular turns, in order to fasten the free end of the bandage. Then pass obliquely across the back of the wrist over the metacarpal joint of the forefinger, and make one two, or three oblique turns, so as to cover in all the fingers. On reaching the interdigital space between the thumb and forefinger, pass obliquely across the front of the wrist to its ulnar side; then across its back to the interdigital space, so as to form a figure of 128 PRACTICE OF SURGERY. 8, then around the palmar surface of the wrist to the ulnar side; and, having thus covered in the wrist, proceed by spiral reversed turns up the limb to the elbow, precisely as in the leg; terminating the bandage by a pin at the upper end of the radius, and also by Fig. 31. A representation of the Spiral Reversed Bandage of the Upper Extremity, showing the figure-of-8 turns to cover the' wrist, arid the position of the reverses. (After Nature.) one on the back of the wrist, to keep it from slipping. When it is requisite to bandage the arm or thigh in addition to the forearm or leg, cover in either the elbow or knee-joints by figure of 8 turns, and then proceed with spiral reversed turns as before, and as shown in Fig. 31. By a little practice upon the patient, it is in the power of any student soon to acquire a proper knowledge of this important and often required duty of the surgeon in the treatment of many of the surgical affections of the limb beside those of ulcers. § 4.—SPECIFIC ULCERS. , Under the head of Specific Ulcers may be placed all such as are due to special causes, as the Varicose Ulcers, or those induced and kept up by a varicose condition of the veins; the Toe-Nail Ulcer, as well as those due to constitutional disorders, as Scrofula, Cancer, and Syphilis. As the consideration of the latter will be reserved for the detailed account of the disorders which originate them, we shall examine first the peculiar characteristics of those due to vari- cose veins. 1. Varicose Ulcers.—Varicose ulcers may present the charac- teristics either of the Irritable or of the Indolent species; the obstruction of the capillary circulation, caused by the enlarged veins, resulting in either of the conditions of tissue alluded to under each of these varieties of ulcers. Most frequently, however, TOE-NAIL ULCERS. 129 Fig. 32. Varicose Ulcers present all the signs of the Indolent Ulcer. In either case they require no other treatment than that already advised for the relief of these ulcers, except that such a degree of pressure as will afford support to the veins, or otherwise diminish their calibre—as by the constant use of a laced stocking—is essential to the permanency of their cure. The treatment required by the enlarged veins by which this class of ulcers are developed, will be given hereafter, in connection witLt the disorders of these vessels. 2. The Toe-Nail Ulcer.—The Toe-Nail Ulcer is a form> of the irritable ulcer, which is found on the inner, and sometimes also the outer side of the flesh adjoining the nail of the great toe (Fig. 32). This ulcer is the result of inflammatory action, developed in the part either by the great toe being compressed against the second toe by a narrow and short boot, or by a stocking which is too short in the foot, or by " stumping the toe," or some- times in consequence of blows, or heavy weights falling upon the top of the toe. In consequence of the inflammation deve- loped by any of these causes the skin swells and rises over the side or end of the nail, in consequence of whieh the lat- ter appears to be buried in or "to grow into the flesh." The latter, however, is seldom the case, the origin of the ulcer from the incurving of the nail being rare, as compared with the uprising of the skin consequent on the development of inflammation. When inflammatory action distends the soft tissues, the continu- ance of the irritation soon produces an abrasion or bursting of the cuticle, which rapidly creates an ulcer, of the inflamed and irri- table variety, which is accompanied by considerable suffering as compared with its size, owing to the continued irritation of the edge of the nail. Sometimes the inflammation travels around the nail and involves its matrix, so as to create a form of onychia, and sometimes exuberant granulations surround one or more sides of the nail, according to the extent of the ulceration. When the inflammation extends to the bone, caries and the destruction of the phalanx of the toe, similar to that seen in the whitlow of the fingers, are very apt to ensue. 9 130 practice of surgery. Diagnosis.—The seat and history of the disease render its diag- nosis easy. Prognosis.—The prognosis should be guarded, as a cure without the removal of the nail is somewhat uncertain,, and it is unpleasant to a surgeon to find his opinion of such an apparently trifling com- plaint proved to be incorrect by the return of the disorder. Treatment.—The indication in the treatment of the toe-nail ulcer is to remove the cause, and this may be accomplished either by a palliative and temporary plan, or by one that will thoroughly . eradicate the disorder. The Palliative Treatment consists in directing the patient to wear a loose and very square-toed shoe, so as to prevent the great toe from being pressed against the second by the lateral pressure of the boot, or to wear stockings or boots which are not so short as to force up the end of the toe against the nail. When a tendency to inflammation of the skin becomes apparent, and irritation is induced, relief may be had by soaking the foot in warm water, scraping the top of the nail tolerably thin, and then lightly packing a little charpie, or soft thread, under the edge of the nail, so as to elevate it above the sore, as advised by Sir A. Cooper; or by placing a very small compress over the swollen flesh, and fastening it dofrn by a little strip of adhesive plaster carried around the toe and over the sidej so as to force the flesh off the nail, as advised by Dr. Meigs, of Philadelphia. At the same time the irritability of the ulcer, especially if accompanied by exuberant granulations, may be re- lieved by touching it lightly with the nitrate of silver every forty- eight hours, or by keeping a piece of lint spread with Turner's cerate on the ulcer before applying the compress, or by powdering it every day or two with arsenious acid, which is then to be covered with a compress of lint. As the nail grows in length it should be but lightly trimmed, and that only at the end, caution being given to prevent the patient from trimming it at the corners. The Radical Cure of this disorder can only be accomplished by the removal of the nail, an operation which was formerly one of the most painful in surgery, but which may now be performed without the consciousness of the patient, as follows: After creating perfect anaesthesia, by causicg him to inhale one part of chloroform, well mixed with three of ether—each by weight—run one blade of'a sharp-pointed pair of scissors under the nail from its point to the base, so as to divide it in the middle. Then pass a spatula or seal- SEQUELS OF ULCERS. 131 pel handle around the fold of the skin at the root of the nail, and, seizing the two halves in a pair of forceps', turn them out. After checking the slight bleeding by the pressure of a piece of lint, pass a sharp pointed stick of nitrate of silver entirely around and within the matrix, so as to thoroughly cauterize thesurface from which the nail grows, and introduce with a probe a morsel of lint into the matrix, so as to prevent its closing up. Then cover the whole toe with the warm water dressing, and let the patient be roused from the anaes- thetic state by such means as will stimulate his brain. The water dressing should now be dontinued until free suppuration is estab- lishedj eare being taken throughout the first week to keep the matrix from closing up, or contracting adhesions with the surface which was below the nail. Subsequently dress the sore as a simple ulcer, and in about three weeks it will be healed, and the patient radically cured. Without the separation of the fold of the skin from the nail previous to the evulsion of the latter, and unless the cauteriza- tion of the matrix after the evulsion of the nail be thoroughly done, a new nail will be liable to reproduce the disorder. The tender state of the toe for some weeks subsequently will require a loose boot, and the absence of all pressure on the top or sides of the toe. § 5.—OF THE SEQUELAE OF ULCERS. ' Ulcers having bepn shown to be the result of inflammatory action, and their reparation to be due to the organization of lymph through the process of granulation and cicatrization (as will be again alluded to in connection with wounds), it might be thought that a thorough cure could, in most instances, be readily and certainly obtained. Experience, however, proves the reverse, and that an ulcer once established is very liable to heal up to a certain point and then have its progress arrested, or, if healed, to open again at or near the original seat of the complaint.' The cause of much of this diffi- culty may, it is thought, be made apparent by a brief allusion to the state of parts seen in many limbs anterior to, during, and after the occurrence of an ulcer. One of the most common causes of the arrest of the reparative or healing process in many ulcers is the neglect of rest, or of the employment of such means as will prevent the stretching of the newly formed skin, such, for example, as that which ensues on 132 PRACTICE OF SURGERY. muscular action in the part. When the tender character of the newly formed skin and the vessels beneath it is recalled, it must be evident that this newly formed tissue cannot sustain much ten- sion without giving way, and that even a slight rupture of crack in it will be sufficient to develop enough inflammation to start anew the ulcerative action: Hence the importance of quiet as ob- tained by the use of splints, rest in bed, &c, as well as by the use of strips of adhesive plaster applied over the cicatrix and then car- ried partly around the limb-, or at least on to the adjacent sound skin, so as to support that which is recently formed. In a certain class of cases, as the indolent ulcers, motion in the part has been shown to be sometimes useful, and to aid the reparative process; but it only does so by exciting the very action in the indolent structures which is so injurious in those which are more delicate and newly formed. Attention to the condition of the newly formed skin for a few weeks, is then essential to the preservation of its soundness in a limb which has been ulcerated. Another point demanding attention is the tendency of the con- gestion of tissue left by the healing of an ulcer, and constantly seen during its existence, to result in an effusion of serum beneath the cuticle, and the production of Eczema Rubrum, or the pustules of Impetigo,. Ecthyma, or even of Rupia. These affections of the skin," even when consequent on ulcers, have been so long regarded in the United States as peculiarly appropriate to treatises on Dermatology, that it is rare to find even an allusion to them in works which are purely surgical. As they are of very Common occurrence, and frequently the origin of ulcers, as well as a great obstacle to their cure, they deserve the special consideration of every one investigating this subject, being as truly surgical complaints as the ulcers with which they are more or less directly connected. § 6.—OF SKIN DISEASES AS CONNECTED WITH ULCERS. Eczema Simplex is a vesicular complaint of the skin, which shows itself frequently upon the legs, either in consequence of vas- cular congestion or repeated though slight irritations; or as the result of the application of poultices or their long-continued use in the treatment of ulcers. SEQUEL.fi OF ULCERS. 133 Symptoms.—Soon after the application of any irritant, the patient complains of itching, heat, and fulness of the part, the skin becomes of a bright red color, which is more or less diffused, and sometimes occupies the entire front of the leg for an extent of four or six inches. When closely examined, minute vesicles or small and fine blistered points may be seen, of about the size of a pin's head, seated directly in the inflamed skin.- These vesicles, being soon ruptured, leave the skin moistened, or as if varnished, and, by expos- ing the true skin to the action of the atmosphere, increase the burning and itching wnich previously existed. As the serum of the discharge dries, it forms thin white scales on the skin, which are similar in appearance to those created by a dried solution of gum Arabic or starch, and give to the whole surface of the part a white scaly and cracked appearance. A continuance of the disorder, leading to new vesicles and increased flow of serum, soon thickens these scales and makes them more brownish, though they continue soft and comparatively thin; that is, not so thick as the scab seen in a dried vaccine pustule. If this acute attack passes off, the skin is left covered with a delicate cuticle, which wrinkles superficially on motion, and is accompanied by a dark red color of the tissues below it, which ultimately becomes brown, and leaves the peculiar discoloration so often seen after the healing of any ulcer. Eczema Rubrum.—When eczema simplex has existed for a few days and developed this redness, it is designated as Eczema Rubrum, a condition that is common in connection with the indolent as well as the irritable variety of ulcers. When eczema rubrum affects several inches of the limb, and the latter becomes slightly swollen under its irritation, it is not unfrequently spoken of as "Chronic Erysipelas," though very rnuch misnamed, erysipelas generally pro- ducing large bullae or blebs, and not the fine vesicles of eczema. When this condition has lasted a few weeks it is called Chronic Eczema Rubrum, and leaves the skin cracked, excoriated, and pre- senting' a red, soft, swollen surface, which continues for months. This is one of the most frequent sequelae of ulcers. Sometimes chronic eczema rubrum results in scales of considerable thickness, which have been mistaken for Psoriasis inveterata, from whicjh it may be told by picking off the scales and carefully examining the part, a moist surface or a few vesicles being always found in 134 PRACTICE OF SURGERY. Eczema underneath the scales, whilst Psoriasis does not at any period of its course give evidence of the presence of moisture. Treatment—The indications in the treatment of Eczema Ru- brum are the same as those given under the codstitutional treat- ment of Inflammation, as purging, cooling drinks, mild diet, and the removal of all sources of irritation. When connected with ulcers, it will generally yield to the use of a foot-bath, night and morning, of warm water slightly thickened with wheat bran, or to the appli- cation of mucilages; or, if there is much discharge and excoriation, to the anointing of the surface or the application of linen spread with the following ointment:— $.—Hydrarg. chlorid. mite 3J; Pul. plumbi acet. grs. vj ; Axunge ^ss. M., et ft. Unguentum. attention being given, at the same time, to the substitution of the warm water dressing for all poultices. In the irritable ulcers, and in patients with marked disorder of the digestive organs, or in those much annoyed by the itching (in consequence of which the skin is irritated by scratching), the administration of the Liquor Pbtassse in the dose of 15 drops, increased to 30 or 50, three times a day, and given in a little sweetened water, will prove highly useful. Impetigo Figurata.—This cutaneous disorder is also often seen on the legs, either as preceding or following the development of ulcers. Symptoms.—Impetigo figurata appears in the form of slightly raised red patches, which are soon covered by small pustules which, by becoming confluent, originate ulcers. These pustules differ in their results from the vesicles of Eczema, being soon covered by thick greenish-yellow scabs; the skin around them becoming much thickened in consequence of thev inflammatory action which accompanies their development. Treatment.—Impetigo figurata requires the application of the warm water dressing, or, if the scabs do not readily separate, the addition of the Carb. Sodse in the proportion of grs, xij or xv to the ounce of water, or the soda may be applied as an ointment in the same proportion to the ounce of Unguentum Aquas Rosas, though the wash is preferable when the discharge is free and the surface of the skin remains superficially ulcerated. After the removal of mortification. 135 t]ae scabs, the application of a wash of Acetate of Lead or Sulphate of Zinc, in the proportion of 6 or 12 grains to the ounce, will some- times be necessary. Ecthyma and Rupia.—The pustules of Ecthyma and Riipia are not so common in connection with the presence of ulcers as eczema and impetigo, though they are frequently the starting-point of the ulceration. Being both due to inflammatory action, general prin- ciples suffice ftrf the direction of their treatment. Summary.—In summing up the consideration of the treatment of ulcers, it will now be seen that the origin, duration, and cure of these very troublesome and often chronic surgical disorders re- quire that the surgeon should examine carefully the condition of the parts, both in the Ulcer and in the surrounding tissues; that he should subdue or excite the inflammatory action until he brings it to that degree which is essential to the effusion and organization of the lymph or plasma, which is the blastema of tissues generally; and that, whilst the reparative process is proceeding, he should guard the patient from any source of local or constitutional derangement which can interrupt it. The best test of a proper degree of inflam- matory action, as connected with the healing of ulcers, is the pre- sence of healthy granulations. If the granulations are pale and flabby, stimulate them; if not sufficiently formed, favor the circu- lation through the part by heat and moisture; and when new skin is forming, or the cicatrization is completed, protect the new tissue from being strained, by means of an equable support, either as applied through adhesive strips, or by the use of a bandage. CHAPTER VII. OF mortification. By mortification {mors, death; and fiq, I become) is understood the loss of the vital functions of a part, or the destruction of its organic texture, either in consequence of the action of some direct cause, as heat, cold, &c, or from the application of such means as produce immediate disorganization of the tissues, or from the effects of indirect causes, as the degeneration and destruction which 136 practice of surgery. ensue when tissues are deprived of that which is essential to their nutrition. As the mortification which results from heat and cold will be again alluded to under the heads of Burns and Frost-bite, attention may now be given to that which is due to the destruction of the powers of nutrition,by general causes. In the definition of inflammation it was shown that the inflam- matory process created a change in the natural preservative action of the part affected; and it may, therefore, be readily understood that, when this process goes too far, it may end in mortification. Inflammation is, therefore, often elosely associated both with the creation of mortification as well as with the efforts of nature to check the progress of death, and repair the loss which it has occa- sioned. Mortification is, in fact, one end (death) of the chain of the inflammatory process, whilst resolution (health) is the other. . By surgical writers two distinct conditions of parts are recog- nized tinder the general term of Mortification: one, in which the superficial tissues are mainly involved, being named Gangrene; whilst that which also involves the deep-seated parts, and thus creates the entire death of the part, is called Sphacelus. The term mortification shouldr therefore, be regarded as the generic expression character- izing in a general way the death of structure, whilst gangrene and sphacelus indicate the specific extent or degree to which it extends. In gangrene, there is usually noted the death of the skin, fascia, and muscles; whilst the additional death of the bloodvessels, nerves, tendons, ligaments, and bones, constitutes sphacelus. The dead portion resulting from a circumscribed gangrene is usually spoken of as a " slough," whilst the process which creates it is designated as " sloughing." By the term slough is also understood the yellowish, soft, pulta- ceous, irregular mass, cast off by nature from the adjacent vital tissues. The symptoms of mortification are both local and constitutional, both being modifications of such symptoms as have been alluded to under the characters of inflammation. 1. Local Symptoms of Mortification.—In. the local symptoms of mortification, as well as in those of inflammation, there may be noted change of color, heat, and sensation in the part, together with a modification of secretory action in it, as well as in the organs of the general system. When mortifioation has commenced, the color of the inflammation MORTIFICATION. 137 which generally precedes it is changed from the red of acute, and the more purple tint of chronic inflammation: to a hue which is of a darker character, being first brown and then black. The tem- perature, also, either rises to that of the highest grade of inflam- mation, or else, as is more usual, • falls' much below the natural standard, till ultimately it reaches the cold of death. The natural sensation, of the part is also much modified on the occurrence of mortification, being sometimes very much increased, and at others diminished, until, as in-death, the part becomes entirely devoid of sensibility. The effusions resulting from the process of mortification are also of a peculiar character, differing materially from those seen in ordinary inflammatory action; the effusion of lymph or of pus, so constantly seen in the different degrees of inflammation, being entirely absent in the mortified, structure, though it may be pre- sent in the adjacent parts where nature is endeavoring to check the progress of the disorder. The effusion of serum in mortification'is, however, greater than that which accompanies healthy inflamma- tion, and usually shows itself more or less throughout the tissues which are involved; the cuticle being first elevated'in patches, so as to form blisters or " phlyctenae," -and the subjacent parts being subsequently so infiltrated as to render them sodden, or as if lique- fied. The local disorder of secretion is also very evident; tjie degenera- tion and disorganization of tissue resulting in chemical changes, by which gases are formed, and particularly that of the sulphuretted' hydrogen or sulphydric acid. In consequence of the presence of this gas, the cellular tissue soon becomes so infiltrated and distended as to crackle under the pressure of tlm finger, whilst, as the gas escapes into the atmosphere, it creates an odor which is highly characteristic of the presence of the disorder. Sphacelus.—When the complaint goes still further, and that condition is produced which has been alluded to as Sphacelus, all these symptoms are increased. The color is now no longer brown, as it was in gangrene, but becomes of a dark, livid purple, or even black. The odor also is changed, becoming either more heavy, or perhaps less offensive, especially if the liquid products of the dis-' order are rapidly evaporated, and as these liquids escape, there is usually more or less shrinking of the mass; the mortified parts becoming smaller and more shrivelled than they were before. If nature now endeavors to get rid of the decomposing mass, it 133 PRACTICE OF SURGERY. Fig. 33. accomplishes it by the development of healthy inflammatory action in the surrounding parts, which, leading to an effusion of lymph, results in a gluing together or adhesion of the neighboring, tissues, as well as in the subsequent formation of the granulations of repair; whilst the same action (adhesion) in the bloodvessels closes the arte- ries for some distance from the dead structure, and thus prepares the part for the separation which is about to ensue. When the re- parative inflammatory action has progressed still further on to the sound tissues in the neighborhood of those which are mortified, ulcerative action is established in those which directly join the dead parts; and it is by the continuation of the ordiuary processes of ulcerative inflammation that these parts are finally separated from those which retain their vitality. The progress of ulceration in separating the dead from the living structures presents two stages; in the first a red color of a linear shape, is produced by the inflammatory action in the skin, which resem- bles the red tint of acute healthy inflammation ; and,, as this soon separates the dead from the living tissues, it is known as the " line of demarcation." As the ulcerative action goes still further, the parts evidently begin to separate; a deep fissure or trench being formed, which becomes deeper and deeper, till the mass is finally thrown off. This furrow, or deep ulceration, is known- as the " line of sepa- ration." When this line of separation progresses to such an extent as to divide the muscles- nerves, bloodvessels, and bones, and leave a stump, we are again presented with the ordinary characters of a simple granulating surface, these granu- lations being formed by the organization of that lymph which was the result of the inflammatory action in the sound parts, A REPRESENTATION OF SPHA- -i , . , . , r > celus of the Foot and Ankle, an& wmcn; in the earlier stages prevented SHOWING. THE SLOPING LINE OP Umn».l,„„„ -L„ „• •■, . , ■■ , separation, with the Granu- aemorrnage by circumscribing the ulcera- AtLTvER0FiT^TpAScET.-TEhDe f6 Process' whilst it; also closed the separation is nearly completed, divided ends of the bloodvessels. the bones alone remaining un- t t • divided. (After Miller.) ia studying the process of separation, MORTIFICATION. 139 it will be noticed that the different tissues resist it in various degrees, and preserVe their powers for a greater or less length of time, in accordance with the degree of vitality or the amount of blood circulating in them; thus, as a general rule, the arteries and the nerves are the last to mortify, although sometimes the bones resist the process of mortification the longest, in consequence of the denser character of their texture, and the amount of lime which enters into their composition. 2. Constitutional Symptoms.—The constitutional symptoms which present themselves in cases of mortification may be described in almost one word as those of depression. Being generally the result of irritation and inflammatory action, the symptoms of de- pression which accompany extended mortification exhibit chiefly the disorder of the nervous system, as reacting on the circulation. There is, therefore, usually a quick, irritable pulse, not unlike that of inflammatory fever, and which it is sometimes difficult to dis- tinguish from the pulse due to inflammatory action, and which demands the abstraction of blood. Indeed, the surgeon will often have to experiment somewhat in order to distinguish it, as may be done very safely by placing the patient for twelve hours on a full diet. If the pulse diminishes in frequency under this, treat- ment, it may be safely asserted that it is one due to nervous irritation, and not to inflammatory action; and that, consequently, bleeding would be highly injurious. Besides the derangement of the circulatory system, there is. also disorder of the digestive apparatus, as shown in a dry, furred tongue, loss of appetite, with the other evidences of a typhoid dis- order, such as diarrhoea, colliquative sweat, cold skin, &c. &c. As the typhoid symptoms are developed, the disorder of the nervous system becomes highly marked, and is shown in the anxiety of countenance, restlessness, insomnia, hiccough, floccitation, stupor, and death. Varieties.—The varieties of mortification may be noted either in reference to the duration of the disorder, as acute or chronic; or in reference to the condition of the affected tissue, being sometimes spoken of either as Humid or Dry. Tt is also designated as Trau- matic when it results from a wound. Humid Mortification, or Gangrene, is so called from the fact that a certain amount of humidity is preserved in the dead tissues by means of the liquid effusions which ensue upon its development, 140 PRACTICE OF SURGERY. and are the result of the inflammatory action which usually pre- cedes it. Dry Gangrene is also often the result of inflammatory action, though usually of a lower grade than that seen in the Humid variety, the inflammation being sometimes so slight as to be al- most imperceptible. The effu- sions in this variety either form very slowly, or are much more limited in quantity, or escape more rapidly, though the first is most frequently the case, and hence its dry shrivelled charac- ter. SECTION I. OF HUMID OR MOIST GANGRENE. Causes.—The cause of Humid Gangrene may be either inflam- matory action or mechanical or chemical agents, or it may be the result of the obstruction of the venous or of the arterial system. It may-also be pro- duced by injuries to the nerves. The manner in which inflamma- tory action results in gangrene has been already alluded to. Under the head of mechanical causes may be placed gunshot wounds and fractures, which not unfrequently result in gan- grene, as well, as badly applied bandages, the tightness of which have sometimes created it. Un- der, the head of chemical agents Humid Gangrene from the Strangulation of are to be found the application an Injured Limb by a badly applied Bandage. „ "" ^"*uwu (After Jno. Bell.) of the mineral acids, as well as MOIST GANGRENE. 141 that form of gangrene which results from the escape of certain secretions into sound tissues, as.in the infiltration of urine into the cellular tissue of the perineum and scrotum from rupture of the urethra. Under the head of gangrene from injuries to the nerves may be classed cases of sloughing of the cornea from injuries to the fifth pair of nerves, and bed sores, or even mortification of the feet seen after injuries to the spinal marrow, whilst.it is seen as produced by obstructions to the circulation in cases of arteritis, ossification of the arteries, etc. etc. Diagnosis.—Humid gangrene may be confounded by an inex- perienced observer with a very simple and perfectly healthy condi- tion of parts, as in a stump which has been closed with adhesive plaster, and in which the whole surface has become of a dark brownish or blackish color, simply in consequence of the action of the sulphuretted hydrogen liberated from the mortified structures upon the lead of the adhesive plaster, forming a sulphuret of lead. The true character of this discoloration will, however, be at once revealed by the fact that a sponge and a little warm water will readily remove it. A severe bruise may also be mistaken for gangrene; but a bruise, in a day or two, will show its true character; for, besides the absence of the constitutional symptoms which usually accom- pany gangrene, a bruise which is black at first, soon becomes blue, and then yellow, or green, as is familiarly seen in the case of the ordinary black eye; it is also seldom accompanied by phlyctense or the serous effusions, which elevate the cuticle. Prognosis.—The prognosis of humid gangrene will depend upon the cause, upon the age of the patient, and upon the condition of his general health, as well as upon the circumstances in which he is placedj the prognosis of a case in private practice being generally more favorable than it would be in the camp, on board ship, or in a hospital. Treatment.—The indications for the treatment are— First. To remove the cause, and when this is accomplished to remove the inflammatory action as far as possible. Second. To favor the separation of the dead from the living tissue. Third. To support the strength of the patient. In the selection of the means of accomplishing these indications, much will depend on the particular case which is under treatment. Thus, in carrying out that portion of the first indication, which 142 PRACTICE OF SURGERY. relates to the allaying of inflammation, there are cases in which local bloodletting may be of great service, although, as a general rule, it would be badly borne, and should be practised with great caution. In carrying out the same indication, there may also be occasion to employ counter-irritants, and these are much more generally serviceable. The counter-irritants useful in the treat- ment of humid gangrene may consist of stimulating poultices, stimulating washes, or blisters, the latter being applied either close to the parts affected or removed some little distance from them, and placed on the perfectly sound tissues, as suggested by Dr. Physick, of Philadelphia. Stimulating ointments are-sometimes usefui; such, for instance, as the Kentish ointment, as it is gene- rally called, though properly a liniment, which is formed of resin cerate and turpentine mixed together in the proportion of one part of oil of turpentine to four parts of the resin cerate. With the same object, and also to remove the fetor, such washes may be used as are not only stimulating, but antiseptic in their character, as Labarraque's solution, or a solution of chloride of lime. Or, if these cannot be"obtained, a stimulating poultice made of raw carrots grated fine; or the fermented poultice, as made of porter or yeast mixed with corn-meal, and kept in a warm place until fermentation is established, may be substituted. Few plans of checking the progress of mortification, and favor- ing the formation of the " line of separation" have, however, proved more useful in my hands than that recommended by Dr. Physick, to wit: the creation of healthy inflammatory action beyond the diseased structure, by placing a strip of blistering plaster around the limb just above the seat of the mortification. If it is in a finger, place it on the hand; and, if in the hand, place it around the wrist or forearm. The application of the Nitrate of Silver, or of the Tincture of Iodine, are both of much less value than the blister, their action being generally more superficial, whilst the object of the treatment is the development of a sufficient amount of healthy inflammatory action to excite a decided effusion of lymph and the commencement of reparative action in the adjacent parts. The constitutional treatment of Humid Gangrene, or the fulfilment of the third indication, consists in supporting the powers of life by the use of tonics and stimulants, and especially by the preparations of Bark, such as the Compound Tincture of Bark, or the Sulphate of DRY GANGRENE. 143 Quinia, or the Bark itself in substance. The preparation of Iron, especially that of the protocarbonate generally known as Vallet's mass, with a full diet, should also be directed, accompanied by the use of malt liquors, or, if much depression supervenes, by the free use of brandy. Opium is often of great service in the treatment of this disorder, as it acts in two ways: first, by allaying pain and checking the nervous irritation, thus diminishing the in- flammatory action; and second, by checking all other secretions, and yet acting on the skin so as to induce perspiration. When gangrene has progressed so far as to result in Sphacelus, and when, by the process of separation, the dead portion has been almost completely detached from the living, or is held only by a very limited attachment, the dead portion should be separated at once from the living by the use of the scissors or knife, in order to free the system from contact with the putrefying mass. It will also be useful to operate surgically where the liquid effusions take place to such an extent as to threaten to do- mischief, either by being absorbed or by burrowing into the adjacent cellular tissue. In such a case, several free incisions should be made through the skin and cellular tissue, in order to facilitate the evacuation of these fluids. SECTION II. OF DRY GANGRENE. When gangrene comes on slowly, or depends upon a very low grade of inflammatory action, the part becomes dry, shrivelled, and mummy-like, and it is then spoken of under the specific term of Dry Gangrene. Causes.—The causes of dry gangrene may be obstructed circu- lation, old age, improper diet, diseases of the arteries—such, for example, as ossification, or arteritis—the former, when combined with old age, being very apt to produce it. Class of Patients.—This kind of gangrene is most frequently seen in hard drinkers, in men who are exhausted by gout, in old worn-out constitutions, in which the vital powers are below the normal standard. In Europe it is said to be found not unfre- quently among those classes of the population, particularly in 144 PRACTICE OF SURGERY. Germany, who are compelled to eat the miserable brown bread of the country, which is made chiefly from rye, that is more or less spurred. Symptoms.—The symptoms of dry gangrene, when it has been developed from any one of the causes just named, are local tingling and coldness of the limb, with a change in the local circulation, as indicated by the modification of the color from its natural tint to that of a deep red, or brownish hue. Phlyctenae, or the little, blad- ders filled with brownish serum, as already described, also fre- quently form, and soon burst, allowing the serum to escape, through they are also often absent, the parts becoming gradually darker in color, and at last are dried up and shrivelled, until a mere shell remains as a covering to the bone. Fig. 35. A representation of Dry Gangrene of the Arm, consequent on general debility in a patient aged seventy-five years. The line of separation of the dead from the living parts is well seen. (After Liston.) When dry gangrene results from the use of bread that contains ergot in greater or less quantities, that condition of things results which is designated by many writers as Ergotism. This disorder is often described by European surgeons, though rarely seen in the United States. It may, therefore, be reasonably doubted whe- ther ergot alone is the cause of its appearance, spurred rye being sufficiently common in certain sections of this country. Experi- ments have also shown that too much stress has probably been laid upon ergot as a cause of dry gangrene; many surgeons having considerable doubts of its power to produce this disorder, when not aided by the additional circumstances of ossification of the arteries, want of cleanliness, want of ventilation and of exercise, circum- stances which are generally found combined among the peasantry of Europe, where ergotism is most common, and which, without the aid of ergot, would be quite sufficient for its production. The effects of ergot in creating gangrene have, however, been positively main- MORTIFICATION. 145 tained by Thompson, in his work on Inflammation, and by some others, though post-mortem examinations were not made in many of these supposed cases. In one of a similar character reported by Elliotson, of London, the examination showed the conjoined exist- ence of ossification of the arteries. In connection with these opinions, it may be instructive and interesting to present a brief account of the experiments of Block upon the subject, made in 1811, which show that ergot does not readily produce dry gangrene in the lower order of animals. " Block fed twenty sheep upon nine pounds of spurred rye a day, and kept them upon this treatment for four weeks, without finding' that any injurious results were the consequence. In another in- stance, twenty sheep consumed thirteen pounds and a half daity for two months, without injury. Thirty cows also took twenty- seven pounds for three months, with impunity; and two fat cows took in addition nine pounds of ergot daily, with no other obvious effect than their milk giving a bad caseous cream, which did not yield good butter."1 Chickens have also been fed upon the ergot with like results, and in many instances it has been eaten by indi- viduals in large quantities, either by accident .or from necessity, without any injurious results. Medicinally, it is frequently given quite extensively in hemorrhages from the uterus; yet the cases in which it has produced any such effects as have been generally attri- buted to it are quite rare; and in all those recorded there has been the possibility of the existence of ossified arteries. I have, therefore, but little faith in its efficiency as a cause of dry gangrene, and am far from being disposed to admit that it possesses the potency ascribed to it by many European writers. Among certain classes of people in the United States rye is largely used, and spurred wheat is not unfrequently seen—yet I have never met with a case of dry gangrene which could be attributed to it—those supposed to be so having in two instances exhibited on post-mortem examination well-marked evidences of ossified arteries. Where ergot is aided by any of the causes which have been already detailed, such as old age, debilitated constitution, &c, it may have some influence in expediting the occurrence of the disorder; but that it will produce dry gangrene in a healthy patient, may, it is thought, be justly regarded as doubtful. 1 Cheliusls Surgery, by South, vol. i. p. 75, Philad. edit. 10 146 PRACTICE OF SURGERY. Seat,—Dry Gangrene usually attacks first those parts in whieh the grade of vitality is lowest, and shows itself in the tips of the ears, at theend of the nose, in the fingers and in the toes, especially the latter. Having been once established, it will be found that its progress is very slow as compared with the humid form; but the prognosis is generally bad. A patient may recover from a very limited dry gangrene with the toes of a limb, but by far the greater number of cases will terminate fatally. Treatment of Dry Gangrene.—In the treatment of dry gangrene, the indications are very much the same as those stated under the humid variety; thus it is necessary to keep up the tempera- ture of the limb, to support the patients strength, to favor the sepa-. ration of the dead parts, and to watch the proper time" for the performance of amputation. The question of the propriety of amputation in any case of gangrene, whether humid or dry, is one which has been much dis- cussed. It is, however, generally regarded as the safest practice to await the formation of the " line of separation" before amputating, as the operation has often been followed by the reproduction of the complaint in the stump, when it has been performed before this has taken place, even though the amputation was made at some distance from the gangrenous parts. SECTION III. OF SENILE GANGRENE. Another variety of Dry Gangrene is that to which professional attention was at one time called by Mr. Percival Pott, and to which he< applied the term of " Senile Gangrene? because usually found in old men. In consequence of his paper oh this subject, the com- plaint is now often designated as " Potis Gangrene? Symptoms.—The symptoms of Senile Gangrene are as follows: An old man, in a debilitated condition, or after some injury to the bloodvessels of a limb, such, for instance, as is sometimes caused by the fragments in a fracture, or after a fall which has created a strain, or after exposure to cold, or sometimes without any appre- ciable cause, wakes up in the night with excruciating pain in one of his feet, which he generally finds hot and swollen, and which he MORTIFICATION. 147 supposes to be attacked with gout or rheumatism, according as the pain presents itself in the ankles or toes. At the same time he will complain greatly of numbness, of cold, of a dead feeling, and of the other varied degrees of disordered sensation consequent on obstruction to the circulation in the part, all the various anodynes and narcotics failing to alleviate it or produce the slightest impres- sion upon the suffering. After these symptoms have existed from one to five days, the surgeon's attention will be called to a small reddish or brownish spot upon one of the toes, which soon becomes vesicated, loses its cuticle, is surrounded by an inflammatory areola, and rapidly runs on to mortification, presenting all the symptoms which have been detailed under the head of dry gangrene. The points upon the foot at which this kind of mortification is most apt to show itself are the smaller toes or the top of the instep; Fig. 36. A representation of Dry Gangrene in the Feet, with the line of separation well advanced. In this case the exciting cause appeared to be cold. (After Liston.) whence it gradually progresses up the limb, resulting in the ap- pearances shown in Fig. 36, and causing horrible suffering, till death ends his torment. Diagnosis.—This disorder, from its insidious commencement, is very liable to mislead the inexperienced; but the age of the patient, the seat of the disorder, the violence of the pain without any appre- ciable cause, all tend to establish its existence. It has been and is most correctly ascribed to arteritis, to ossification of the valves of the heart, to obstructions in the local circulation, the disorder being nearly always fatal, no matter what treatment is resorted to. Anodynes, internally and externally, afford the greatest relief, 148 PRACTICE OF SURGERY. whilst warm and stimulating applications are the most rational means of carrying out the local treatment. SECTION IV. OF HOSPITAL GANGRENE. Another form of gangrene, to which attention should be given, is that known as Hospital or Epidemic Gangrene—a condition of things which generally indicates an impure atmosphere, or some neglect respecting the patient's strength. Sometimes, however, it appears in hospitals in spite of the greatest precautions, assuming an epidemic form, and causing the destruction of every part which it attacks. When such a condition of affairs occurs in the wards of a hospital, every sore begins to sloughy the slightest as well as the most severe wounds sharing the same fate, and presenting more or less of the following symptoms :— Symptoms.—First a change in the character of the wound, which loses its healthy florid appearance, a white film-like membrane overspreading the granulating surfaces, and indicating an arrest of the healthy processes. The pus, also, is either entirely dried up, or much changed in its characters, becoming ichorous and un- healthy; the parts slough with extreme rapidity, whilst typhous symptoms, or those of extreme prostration, rapidly precede the fatal issue. When epidemic gangrene has been established in the wards of a hospital, there is but one thing to be done; let in plenty of fresh. air, clear out the wards, turn the patients into the street, if nothing better can be done, or place them in tents; do anything but allow them to remain in the building. Ventilate the wards, fumigate, paint, scrub, whitewash; and then, perhaps, when after two weeks they are reopened, the surgeon will have the satisfaction of seeing that the tendency to this form of gangrene has fortunately been arrested. Still, in spite of every means that can be adopted, this disease will sometimes progress; and many instances are known to surgeons in which patients have lost their lives from the sloughing of ulcers which originally were not larger in size than a twenty-five cent piece. I have also known more than one instance in which am- SPECIFIC FORMS OF INFLAMMATION. 149 putation has been required in stumps that were so nearly healed that a mere spot, no larger than a sixpence, alone remained to be cicatrized. Treatment.—The only additional treatment demanded by Hos- pital Gangrene over the general sanitary plan just alluded to, as well as that advised under the head of Humid Gangrene, is the use of the strong nitric acid, applied to the dead part on cloths wet with it, poured over the surface, or painted on it with the camel's hair pencil. Whilst the action of the pure acid is limited to the parts already dead, and the removal Of which it hastens, the structures immediately adjacent, which retain some/ vitality, may be occasionally wet with a diluted acid, the strength of the solution being fifty drops of the acid to a quart of pure water, as suggested by Sir A. Cooper, though sometimes the patient will bear it less diluted. This application should create some little sensibility in the part if it is to prove useful. CHAPTEE VIII. OF THE SPECIFIC FORMS OF INFLAMMATION.. After the detailed account of the ordinary forms of inflamma- tory action that has been presented, attention may next be given to such modifications of inflammation as are seen when the dis- order is developed under peculiar circumstances, to wit, when it is seated in the cellular tissue, as in Furuncle—or excited by un- healthy causes, as Erysipelas—or by poison, as the Malignant Pus- tule. In all these affections certain peculiarities may be noticed which require special consideration. SECTION I. OF THE FURUNCLE, OR BOIL. The word Furuncle (furiare, to make mad), or boil of common language, is employed to designate a circumscribed inflammation of the derm, or of the cellular tissue, which is usually followed by 150 PRACTICE OF SURGERY. the death of the circumscribed portion of the skin which is over it, and by the separation of the central portion from the adjacent parts in the form of a slough or "core," as it is usually termed. Seat.—The furuncle, or boil, may show itself on any part of the body, but especially on parts where the skin is liable to friction or irritation, or where it is thickest, as about the deltoid or gluteal muscles, on the thigh, or on the neck, near the head of per- sons who are in the enjoyment of good health, and who have been exposed to some slight exciting cause, as the chafing of a pimple or of an obstructed sebaceous follicle, or to some irritation about the root of a hair. Symptoms.—The earliest sign of its presence will be found in a circumscribed redness, attended wit^ considerable burning and a violent throbbing, pulsatile pain, after which swelling occurs, the part being raised more or less above the level of the sur- rounding parts, as a conical eminence, with a firm, hardened base. The summit of this cone soon presents a softened point, in which pus is quickly apparent. On the occurrence of the suppuration the pain and irritation diminish, though the swelling continues, and is soon followed by the bursting of the skin, the escape of a thick, yellow, and healthy pus, and the creation of a rugged circumscribed ulceration, which leaves apparent in the sore a soft, pultaceous, yellowish slough, which is generally spoken of as the "core." After a few hours or days, this core escapes, and the skin usually heals rapidly, though it is left tender and often redder than usual. After the lapse of a few days or weeks, another boil is apt to be located in the immediate neighborhood of the first. This also runs its course, and may be followed by various others, either near it or at some other portion of the skin, it being very commonly re- marked " that one boil makes many." Diagnosis and Prognosis.—The superficial and limited character of the inflammation, and the robust health of most of those who suffer from furuncle, generally suffice to distinguish boils from any other complaint, whilst the prognosis as to the ultimate result is favorable, barring the tendency to a reproduction of the dis- order. Treatment.—As boils are usually found in those who are free livers, and whose digestion and secretions are somewhat dis- ordered, the best plan of treatment is to administer a full dose of blue pill at night, and follow it next morning by a saline cathartic; SPECIFIC FORMS OF INFLAMMATION. 151 repeating the cathartic in twelve hours if its action is not quite free. The local treatment should consist in the application of heat and moisture by means of the warm water dressing, or by means of hot emollient poultices; or the popular stimulating salve of brown sugar and soap may be employed to hasten the suppuration. When pus is certainly formed, but not before this, the skin should be punctured and the matter evacuated, but without disturbing the core, the latter being left to be thrown off by nature, aided by the subsequent application of heat and moisture. Much unnecessary pain is often caused by puncturing a furuncle before the pus is fully formed, and this practice should therefore be carefully avoided. ,A little calamine cerate, or the cold cream of the shops, or the tallow of domestic use, generally suffices for the dressing of the ulcer, the healing of which is not usually a matter of difficulty. To prevent a reproduction of the complaint close attention should be given to the diet, which should be chiefly vegetable, whilst frequent purging with saline cathartics, and the removal of all local sources of irri- tation, will generally prove useful. SECTION II. OF ANTHRAX, OR CARBUNCLE. The Anthrax, or Carbuncle, or furunculus malignus (cw&pat, a coal, earbo, a burning coal), a malignant form of the boil, which deeply involves the subcutaneous areolar tissue, is a truly gangrenous form of inflammation, and has an especial predilection for the back of the head, neck, and shoulders, as well as the thigh, buttock, and arm of the middle-aged, or those advanced in life, who have been addicted to eating and drinking, especially the latter, though sometimes it is also found in the most abstemious. When a car- buncle is once developed, it generally terminates in the death of the integuments at the point affected, and though comparatively rare, this affection also occasionally prevails epidemically to a limited extent. Local Symptoms.—After a short period of uneasiness, fulness, and irritation in the part, which is followed by great. heat and an intense aching pain, vesication of the cuticle is seen, accompanied 152 PRACTICE OF SURGERY. by great itching. On examination of the seat of the disorder, a circumscribed, firm, and hard swelling, which is evidently deep- seated, is apparent. This soon assumes a dark purple or livid color in its centre; immediately after which numerous vesicated points appear and give exit to a brownish sanies. Shortly after this, a little brown or black slough shows itself, which seems, from its color, and from its resemblance to the condition created by the application of a burning coal, to have given rise to the name of the complaint. As the disorder progresses, the various vesicated points become the seats of numerous small ulcers through which the dead cellular tissue protrudes as a soft pultaceous mass, which is ulti- mately thrown off, if the patient sustains the irritation, and leaves a wide but superficial ulcer, which shows but little disposition to heal. Constitutional Symptoms.—Soon after the first appearance of the local disorder there is a chill, followed by fever, and the pulse exhibits signs of irritation. This is soon succeeded by many of the symptoms of a typhoid condition, as nausea, loss of appetite, costive- ness, or diarrhoea, with a furred tongue, inability to sleep, great restlessness, headache, or even delirium. There is also often diffi- culty of breathing, colliquative sweat, fainting, subsultus tendinum, and hiccup, all which may terminate in a return to health, but which in old persons, and especially when the disorder is seated near the head, frequently ends in death. Diagnosis.—The age and constitution of the patient, the pain and gangrenous tendency of the inflammation, with the peculiar seat of the disorder generally, suffice to render the diagnosis of carbuncle from the furuncle or common boil sufficiently easy. Prognosis.—The prognosis is dependent on the size and seat of the affection, the age and character of the patient, and the early period at which the surgeon is called in. From the serious consti- tutional disturbance which carbuncle often creates, the prognosis should always be guarded. Treatment—-The indications in the treatment of carbuncle are, first, to excite healthy inflammation in the skin; second, to favor the exit of the gangrenous cellular tissue; third, to create healthy inflammatory action; and fourth, to support the general powers of life. In the milder forms of the disease, where it is apparently threatening an invasion, that is, whilst the skin is only discolored but not livid, and before ulceration is established, it is sometimes useful to apply a blister upon the part, so as to excite healthy SPECIFIC FORMS OF INFLAMMATION. 153 action, this application being followed by the use of the warm water dressing. But, unless seen at an early period, this mode of treating carbuncle will not prove of much service, and sometimes greatly augments the patient's suffering. In more severe cases, it is all- important that attention should be first given to the entire destruc- tion of the skin which is involved in the disorder, and to the evacuation of the slough. The treatment suggested by the late Dr. Physick, of Philadelphia, and specially applicable to those cases in which there is an evident mortification of the subcutaneous cellular tissue, consists in making a sufficiently long crucial incision entirely through the skin into the sloughing cellular tissue, after which a stick of caustic potassa (Kali purum) should be rubbed throughout the line of the cut and all over the surface of the livid skin, until it becomes black and is converted into an eschar. After this free application of the caustic, for about one minute the part should be thoroughly wet Fig. 37. A view of the Sling of Four Tails, as applied to the Back of the Neck.— In its preparation, cut a square piece of muslin of the proper size for the part, and divide it nearly to its middle. Then attaching four tapes to its ends, carry two of them round the throat, and tie them on the front of the neck. After which the othertwo should be carried over the ears and around the forehead. (After Nature.) with sweet oil or vinegar in order to neutralize the caustic, whilst the surrounding sound skin, especially that over which the dis- charge will flow, should be also painted with sweet oil, or well greased with cerate in order to protect it. This application of the 154 '•..■■ PRACTICE OF SURGERY. caustic, if thoroughly made, destroys entirely the extreme pain of # the disease, and gives the patient prompt and efficient relief. When the carbuncle has been thus cauterized, it should be covered with a fermenting or yeast and corn meal poultice, which should be spread on oiled silk, and renewed every four hours. As soon as the parts show a disposition to throw off the dead mass, the flaxseed poultice or the warm water dressing may be substituted, this, like the fer- menting poultice, being also changed three times a day, in order to get rid of the irritating and fetid discharge which escapes from the sore. When the carbuncle is seated on the upper part of the neck, these dressings can be best retained in position by means of the four-tailed sling, as represented in Fig. 37. But when it is - seated on the back of the shoulders, there is no dressing which is neater or more thorough in its application to this part of the body, than the Scapulo-dorsal handkerchief of Mayor. (Fig. 38.) Fig. 38. A representation of the "Scapulo-dorsal Handkerchief" of Mayor, formed by tying a cravat around the waist, and applying a second handkerchief in the shape of a triangle, so that one angle can be fastened to the circular cravat on the back, whilst the other two ends are pinned to the same cravat on the front of the chest (After Nature.) After the separation of the slough, the ulcer should be treated on the general principles of healthy ulcers by means of the warm water dressing, to which may be added a little of the aromatic wine of the Burns. loo French pharmacopoeia if the granulations seem to require stimula- tion. A half ounce of the wine to two ounces of water applied by means of Jint wet with it is sufficiently strong, though sometimes the anodyne wash of Cooper, as advised in the treatment of the irritable ulcer, answers admirably. Mild ointments, as the calamine or red precipitate or Basilicon cerates are also useful as a change of dressing when the cicatrization appears to be tardy. But it is not unusual for a bad carbuncle to require six or eight weeks before it heals, even under favorable circumstances. Constitutional Treatment.—Throughout the entire period of the local treatment, attention should be given to the constitutional symptoms caused by carbuncle. If the patient is seen early, and the digestive organs are loaded, an emetic followed by a mercurial cathartic is generally useful, after which the nervous irritation should be allayed by the free use of opiates and diaphoretics, es- pecially the Dover's powder. Owing to the severity of the pain, large doses of opiates, as from two to four grains of opium in twen- ty-four hours, may be demanded. At the same time the patient's strength should be supported by quinine in doses of twelve to twenty grains a day, combined with a nutritious diet, and when prostration becomes evident, the stimulants should be augmented by the free use of alcoholic drinks, the previous habits of the pa- tients as well as their age not unfrequently rendering such articles essential to the maintenance of the powers of life. In fact, the constitutional treatment should be conducted on the plan already mentioned under the head of mortification. CHAPTER IX. OF BURNS. To the student who is possessed of a correct knowledge of the various changes produced by inflammatory action, the investigation of that condition which ensues upon the application of powerful irritants, requires only a specification of the peculiarities created by such a modification of the ordinary process of repair as is in- duced by these agents. Thus heat, cold, and chemical substances, 156 PRACTICE OF SURGERY. when applied to the body, develop only such inflammatory action as has been previously studied, though the special effects of their application are generally described as a distinct class of surgical disorders, under the name of Burns and Frost-bite. Burns, or that variety of injuries created by the application of an unnatural degree of heat, or one greater than the highest tem- perature of the blood, present a series of changes in the action of the tissues which are correctly included under one general head, though the special designation of Scalds is given to those produced by hot liquids. The effect of a high degree of heat upon the animal tissues is usually dangerous in proportion to the extent and depth of the portion injured, it being received as a sound surgical aphorism that a severe burn of more than one-third of the superficies of the body is generally fatal. As a general" rule, it may also be stated that burns or the injuries created by heated solids produce a more se- rious class of injuries, in reference to their duration, than heated liquids, though the former are often the most circumscribed, the depth of the burn being generally greatest in the case of solids, and the reparative effort required for their cure correspondingly tedious. Thus, if the skin be touched with a red-hot iron, or if a child's clothes take fire, the source of heat, particularly in the latter in- stance, remains some time in contact with the tissue burned; whereas a liquid substance, as hot water, flows off quickly, and does not become so glued to the part as solids are apt to be. In those cases of scalds in which the clothes become saturated with the heated liquid, the depth of the burn may, however, be fully as great as that produced by solid bodies when heated. The dangers arising from severe burns may be classified under four distinct heads. 1. The shock, or dangers arising from the primary depression. 2. Dangers from the subsequent reaction. 3. Dangers from the effects produced upon the internal organs. 4. Dangers arising from the efforts of nature to repair the damage, and shown in the repair of the ulceration which is left behind. Varieties.—Bum* have been variously divided, for purposes of study, by different authors, but the most useful is that of Dupuy- tren, as it accurately indicates the extent of the injury. I. All burns which produce merely superficial redness or inflam- BURNS. 157 mation, but without vesication. Here a simple erythema, or a turgescence of the vessels, is the ordinary result. II. Those in which the inflammation goes still further, and re- sults in the effusion of serum, the cuticle being elevated into blisters, constituting the condition ordinarily known as vesication. III. Those in which the heat is applied in a still higher degree, or for a greater length of time, thus producing not only redness and vesication, but also the destruction of the derm or true skin. IV. Burns in which not only the cuticle and skin, but the sub- cutaneous cellular tissue is converted into an eschar. V. Burns which are attended by the destruction of the subjacent tissues, muscles, etc. VI. Those in which the entire structure is carbonized, or burned to a coal. In the first class we have simply the symptoms of inflammation in its first stage, or that of congestion, which have been already de- scribed. In the second, we have the effusion of serum and a super- ficial raw surface resulting from the rupture of the bullae, this super- ficial sore or abrasion being similar to that produced by a fly blister. In the third may be noted instances of limited gangrene, the dead parts being separated by the process of sloughing. In the fourth class the vital structures are encroached upon to a greater depth; and the fifth and sixth furnish examples of true sphacelus, which, when limited in extent, is usually spoken of as an "eschar." Seat.—Burns may be found in any situation, but they are very often seen upon the back, especially in females, as in consequence of the skirt of the dress coming in contact with the fire, the flames rise, and, before they can be extinguished, produce a burn of an ex- tensive character. The same accident happens at times to children, though in these little patients, it is usually the front of the dress that is set on fire, there being a corresponding change in the locality of the burn, which is thus apt to reach the front of the neck and the face. Although Dupuytren's classification of burns is very useful for the purposes of study, it must not be expected that a similarly exact division will be ever seen in nature, the simple redness of one part, the vesication of a second, and the entire carbonization of a third being often apparent in the same patient. Symptoms.—The local and constitutional symptoms of burns differ according to their extent. The most marked of the local symptoms 158 PRACTICE OF SURGERY. is usually pain, unless the skin is entirely destroyed, and then there is little or none, until the inflammatory action is induced in the sur- rounding parts to a sufficient extent to produce it, whilst the most serious of the constitutional symptoms are those due to the shock, these being generally shown in a chill followed by reaction and fever, with the modifications of pulse and of secretion which have been already described under the head of Irritative or Inflamma- tory Fever. Diagnosis.—The diagnosis of burns sometimes becomes of great importance in a legal point of view, as the surgeon may be called upon to say whether the injury has been the result of a scald or a burn, as where a woman has sworn that she has been pushed into the fire by her husband, but where the character of the injury proves that it was not due to a burn but to a scald. The esta- blishing of this fact would, in most cases, be sufficient to vitiate the action; and it becomes therefore a matter of consequence to recog- nize positively the difference between them. As a general rule, a burn may be told from a scald by its limited character and by its depth, though the latter difference is not always marked. A very good rule, and one which will apply to most doubtful cases is this: if the hair is singed we may 'pretty safely assert that the injury in question was a burn; as in scalds the hair is most generally left, or is not removed unless the cuticle has been removed with it; but even then, the hair of adjacent parts will indicate the character of the injury. Great caution should, however, be observed by every surgeon in giving an opinion under such circumstances. Prognosis.—The prognosis of burns will be governed by the extent, by the degree, and by the character of the portion burned: thus a burn near the eye or near the mouth would be much more serious in its consequences than a burn upon one of the extremi- ties. The age and habits of the patient will also materially affect the prognosis, as a young person will bear a serious burn better than one enfeebled by years, and a temperate person will be less likely to succumb than one of intemperate habits. Certain circum- stances will, however, materially influence the prognosis even under these conditions, as the fact of the patient being under the influ- ence of alcohol at the time of the injury, by which the sensibilities were blunted, as was once presented to me in the case of a man who, having sat down whilst drunk near a stove, fell with his knees BURNS. 159 against it, and did not awake till they were literally roasted through. This man, however, recovered after an amputation of both limbs, having apparently been unaffected by the excitement and suffering on the reception of the burn, which would otherwise probably have been sufficient to destroy his life. With regard to a special prognosis, it may be stated that, as a -general rule, the experience of all surgeons agrees with that of Dupuytren, " that a burn of the first or second class covering one- half the body will be likely to prove fatal; that one of the third class occupying one-fourth of the body will most likely terminate in the same manner, whilst the fourth, fifth, and sixth classes will be apt to produce death if only one square foot of the body be affected." Treatment.— The local and constitutional treatment of burns varies with the extent of the injury. In superficial burns, where there is simply redness, and the ordinary signs of commencing in- flammation, the indication is first to diminish the sensibility, and check the vascular action of the parts. No application is likely to prove of greater service in carrying out these indications than that of cold water, applied to the part by means of irrigation. It is, indeed, the most natural thing in the world after burning a finger to put it into cold water with a view of allaying the pain, and,, as both cold and moisture have a sedative effect, no better plan of treatment can be pursued. If the burn is of a very limited extent, a bladder may be filled with cold water or pounded ice, and laid upon the parts; but it should not be filled too full, or its weight will make it painful, but only half filled, so that it may lay over the surface and keep up a moderate degree of coldness; or lint may be wet and applied to the burn, as in irrigation. To the cold and moisture of the water dressing we may also add some sedative article, as the watery extract of opium. Ink, and the domestic appli- cations of scraped potatoes, &c, are chiefly useful as means of ap- plying cold. The sugar of lead, Goulard's extract, or some other mild astringent, may often be advantageously added to the water dressing. In the case of burns of the second class, or" those in which the cuticle has been more or less vesicated, it will sometimes prove useful, with a view of shielding the skinj and doing away with the irritation likely to be produced by the contact with the atmosphere, to resort to raw cotton, carded and laid on the part; or to the Linimentum Aq. Calcis of the United States Pharmaco- 160 PRACTICE OF SURGERY. pceia, Or Carron oil, as it has been called, because originally exten- sively used and kept constantly on hand at the Carron Iron Works, in England. This liniment consists of equal parts of linseed oil and lime-water, and should be spread upon rags and laid over the parts. It has, however, one objection, and that is its very disagreeable smell, which, to most persons, is exceedingly offensive. Glycerine has also been recommended, and is to be used in the same way. As it is a very mild, unirritating substance, it will, in many cases of superficial burn, prove useful. With the same view—that of excluding the atmospheric air—it has been recommended to dust flour over the parts, and this is sometimes highly serviceable, although it is not applicable to that large class of burns which result in suppuration, as in these cases the pus mixing with the flour, cakes it, and the whole drying, more or less sharp irregular masses are produced, which lacerate the in- jured surface upon every movement of the limb, and develop a very considerable amount of inflammation. It is therefore an ap- plication which is specially applicable only to very superficial burns. Other articles of a similar character have been recom- mended at different times, and may be noticed, in order to present a list of such as may be obtained when others cannot. Thus, chalk finely powdered and dusted like flour over the part, is sometimes useful. White lead ground with linseed oil, as in the ordinary white paint, has also been highly recommended by Barry, in England, and by Dr. Gross, of Louisville, Ky.; the lead being ground in the oil and spread thinly over the surface, so as to give it a complete coat of paint. If the burn is of a very limited extent, the surface may sometimes be very advantageously painted with collodion or the ethereal solution of gun cotton. This is at first painful, from the stimulus of the ether which it contains'; but, as the latter soon eva- porates, the collodion shields the parts from contact with the atmo- sphere, produces contraction of the tissues, and thus promotes the healing of the ulcer whilst obviating external sources of irritation. In the more severe forms of burns, where there is a disposition towards sloughing, as it is always desirable to favor the early sepa- ration of the slough, there is nothing better than the warm water dressing, applied from the very first moment, and continued through- out the treatment as long as heat and moisture can be beneficial. One great recommendation of this dressing is its cleanliness the constant flow of water washing away the pus before it can be de- BURNS. 1£1 composed, thus securing the purity of the air of the chamber, and removing one great source of annoyance in these accidents. The old method of burying the patient in poultices is objectionable, because they are heavy, liable to become rancid, to interfere with cleanliness, to adhere to the diseased surface, and to act as recep- tacles for the very free discharge of pus, which generally ensues upon a burn, and which soon becomes offensive from its decompo- sition. Spongio-pileine, or patent lint, kept saturated with warm water, as in the warm water dressing already described, gives moisture and heat in a much neater form, and does not oppress the patient. As soon as the slough seems disposed to separate, it will be useful to stimulate the action of the parts so as to favor the cicatrization, evidences of a want of action being generally present in the granulations of the ulcer which remains after a burn. A very good application for this purpose is the ointment of Mr. Kentish, made, as already mentioned, of turpentine and basilicon ointment. This ointment was applied by Mr. Kentish, of England, to all classes of burns, but is especially useful in those which are deeply burned, as it stimulates the local circulation and resuscitates the vital pow- ers of the part. When it cannot be obtained, its place may be temporarily supplied with the fermenting poultices or similar stimulating applications. A very important part of the treatment of burns is the manage- ment of the ulcer, which is left after the separation of the eschar or slough. This is often very difficult to heal, and presents the cha- racters of the ordinary irritable ulcer. In order to favor its cica- trization, sedatives will often prove useful, such as the cold water dressing, which is very soothing, and, by washing away the pus from suppurating burns, keeps off one source of irritation. Some- times, in the ulcerated stage of burns, stimulating applications are demanded, in order to excite reparative efforts and overcome the local depression consequent on the injury, such as touching the, edges of the ulcer with a stick of nitrate of silver, stimulating the parts and inviting the scabbing process, by dusting the surface of the ulcer with finely pulverized calamine or prepared chalk, and then covering it with a piece of spread cerate and oiled silk, so as to exclude the air. The Cicatrix from burns is often a source of serious difficulty, as it has a greater tendency to contract than any other cicatrix or inodular tissue resulting from injury. So marked is this tendency 11 162 PRACTICE OF SURGERY. in some cases, that the motion of limbs is lost, and surrounding parts are drawn out of their line, so as to create great and striking deformities. Generally this contraction shows itself by the in- fluence which it exercises in the traction made upon surrounding tissues, rather than in the substance of the inodular tissue itself, Fig. 39. A representation of the Deformity caused by the Contraction of the Cicatrix of a Burn on the Neck. (After Liston.) ' the adjacent skin being very much puckered, and presenting ridges, furrows, seams, and all other varieties of disfiguration. (Fig. 39.) Sometimes, also, the cicatrix presents such a low degree of vitality that ulceration is constantly taking place in it. The relief afforded by the division of any of these cicatrices is exceed- ingly doubtful, and, as a general rule, it may be said that it is useless to cut through any adhesions which result from burns, unless a plas- tic operation is also performed in order to replace the tissue that has been destroyed. Thus, for instance, in an adhesion of the arm to the side resulting from a burn, it is worse than folly to cut through the cicatrized portion in order to free the limb. If the arm be tied up over the head, so as to prevent the possibility of any contraction, the ulcer will not heal; and if we let it down to heal the ulcer, the contraction will be reproduced. The same is true of adhesions be- EFFECTS OF COLD. 163 tween the fingers; unless we can introduce a portion of new skin by a plastic operation, it is useless simply to divide the cicatrix. It is necessary therefore to watch burns when first healing, in order to prevent these adhesions as much as possible, and particularly in the case of those situated near orifices, such as the mouth, the nos- tril, the anus, or the vagina, where it is particularly desirable that the patulous condition of the part should be maintained. The same precautions will be required in burns near joints on the fingers and toes. CHAPTER X. EFFECTS OF COLD. When cold is first applied to the body in a moderate degree, its effects are those of a gentle and pleasant stimulant. Carry it a little further and the stimulation becomes painful, producing an aching, tingling paim Carry it still further, and the depression which always ensues upon superexcitement is developed in the part, which now becomes numb and devoid of sensibility. Carry it still further, and there will be a depression of the vital powers both in the heart and nervous system, from which the patient generally cannot recover. When the sedation produced by cold, as applied to the entire body, is carried to such a degree as to impair materially the power of the nervous centres, we have all the constitutional symptoms which result from congestion of the brain. Thus the. patient will have a marked disposition to sleep, or at times exhibits tetanic spasms, as was the case in some of those exposed to Polar cold in the late expedition of Dr. Kane, after the loss of their vessels. More frequently, however, stupefaction and coma supervene on the exposure, the patient sinking quietly and unconsciously into the sleep of death. The effects of cold upon a limited portion of the surface of the body may be classified under two distinct heads. To the first, the name of Pernio or Chilblain is given, which indicates a condition resulting from the stimulus of cold creating and resulting only in irritation or inflammation of the skin ; whilst the second or more 164: PRACTICE OF SURGERY. marked degree, or that of the depression supervening on stimulus, and which results in the production of gangrene, is designated as Frost-bite. . Those portions of the body which possess the least vitality are most apt to suffer from the depressing effects of severe cold, and accordingly we find chilblains and frost-bite first appear in the tips of the nose or ears, or of the fingers and toes. SECTION I. OF PERNIO OR CHILBLAIN. In Pernio or Chilblain, or that superficial irritation which is developed in parts exposed to cold, we have the following symp- toms :— Symptoms.—-In the first place, there is a tingling or benumbing sensation which is much augmented, and gives rise to the burning sensation, with which most persons are familiar when the extremi- ties after exposure to cold are brought near to a fire. The part, then, also assumes a violet or livid color, which, depends for its intensity upon the degree of cold which has been applied. After this a reaction shows itself as the result of the depression produced by the cold, and this reaction results in inflammatory action, pro- ducing vesication and ulceration, the latter of which may show itself either as a simple fissure of the skin or acquire a more extended form. Patients.—Chilblains are most common among women and children, as might be expected from the greater delicacy of their skin. Treatment.—The treatment of chilblains may be classified as prophylactic and curative; the former being the most important. It consists in protecting the part in the first instance from the application of cold and moisture; and next, when that cannot be done, in avoiding sudden changes of temperature, as by keeping away from the fire after exposure to low temperatures. The curative treatment of chilblain is to be carried out by such means as will regulate the vascular action in the parts. As the first effect of the cold is depression, resort should be had as a general rule to local stinfulants, a elass of applications many of which are in domestic suspended animation from cold. 165 use. Thus it is very common for the old women to recommend any one suffering from frosted feet to put them every night into a bucket of hot mustard and water, and it is not a bad application. Washes of spirits of turpentine, of the solution of the sulphate of copper, or of sulphate of iron, or of a solution of the nitrate of silver, are often employed, of a strength sufficient to create a feeling of warmth, and are very useful in aiding the restoration of the local circulation, and relieving the nervous sensibility. In the fissured form, or in limited ulcerations, collodion is an excellent application, but each returning winter will often develop neuralgic pains in the tender skin left after the primary attack. SECTION II. OF FROST-BITE. Frost-bite presents us, in a slightly modified form, with all the symptoms which have been detailed under the head of Gangrene. It is, in truth, a term only expressive of the fact that the gan- grenous condition has been induced by exposure to cold. The portions of the body which suffer from frost-bite are very much the same as those alluded to in chilblains. Treatment.—With regard to the indications in the treatment of frost-bite, it is a repetition of the principles laid down, when speak- ing of mortification, that is, to favor the formation of the line of separation and ulceration, that the dead parts may be thrown off, and afterwards promote the processes of granulation and cicatrization, that the ulcers may be made to heal, which it is sometimes difficult to accomplish, owing to their unhealthy and irritable character. SECTION III. OF SUSPENDED ANIMATION FROM COLD. Another point connected with the effects of cold requires here brief reference, and that is, the suspended animation resulting from exposure to cold for a considerable length of time. When called to a person under these conditions, the surgeon should proceed as 166 PRACTICE OF SURGERY. follows, in order to restore a healthy condition of parts without creating a violent reaetion: Strip the patient, carry him into a cold room, or out into the open air, if a room sufficiently cold is not con- venient, and there rub him with ice, snow, or cold water, till an improvement in the condition of the circulation is perceptible. Then place him in a room the temperature of which is a little higher, and give him warm drinks, such, for example, as balm tea, elder tea, black or green tea; then apply heat very gradually, whilst at the same time injections of warm water may be advan- tageously introduced into the rectum. As the respiration gradually becomes more easy, the temperature should be slowly raised, till the patient finally regains his natural healthy condition, any catarrhal or pneumonic symptoms that may be subsequently developed being treated on the general principles of such disorders when due to other causes. The prophylactic treatment in a case of suspended animation, as in most others, is infinitely better than the curative; thus persons exposed to cold should, under no circumstances, be allowed to give way to the feelings of torpor and drowsiness which are generally induced by it. Those who have read Captain Cook's Voyages must be perfectly familiar with the adventures of Dr. Banks and Dr. Solander, and the difficulty they experienced, when exposed to cold, in keeping each other awake. Throughout the treatment of the injuries resulting from cold, it should be remembered that patients suffer much more from changes of temperature, and from moisture and cold, than they do from mere exposure to a low degree of cold steadily maintained. In Baron Larrey's memoirs it is stated that in the Eussian campaign of Napoleon, the troops under his observation would frequently do very well whilst marching, even when exposed to a temperature of 15° below zero, and with comparatively few cases of injury from cold; but, when a soldier came near the bivouac fires, he was apt to suffer directly from severe frost-bite, losing fingers, toes, and even limbs. He also mentions one case in which a soldier having come from an exposure to this degree of cold went into a warm guard-room and immediately fell down asphyxiated and died.1 1 Larrey, op. citat. ERYSIPELAS. 167 CHAPTER XI. OF ERYSIPELAS. The next complaint to which attention may be given is a pecu- liar form of unhealthy inflammation which is designated as Erysi- pelas. The name of this complaint is derived from two Greek words, tpvw, I draw, and Htxas, near, and points out the marked tendency of the disease to spread itself and involve adjoining parts. It has been called " the Rose," from its color, and St. Anthony's fire from the burning character of the pain, and from the supposed power of the saint to cure it. If limited to the skin alone it is called Simple erysipelas, but if the subjacent cellular structure is involved it receives the appellation of Phlegmonous erysipelas. It also receives various names from accidental complications; thus it is called (Edematous when there is serous effusion into the surround- ing cellular tissue; Bilious, when complicated with disease of the portal circle; Erratic, when it frequently changes its seat, disap- pearing in one part and reappearing in another; Idiopathic, when it results from constitutional causes, and Traumatic when it follows upon some external injury. Erysipelas may be defined as " an inflammation of the skin and subjacent cellular tissue, characterized by the deep red color and swelling of the affected part, and by a marked tendency to spread." Seat.—It seldom exists, except under peculiar circumstances, in any other part than the skin and adjoining cellular tissue. Symptoms.—The symptoms of erysipelas are of two classes, constitutional and local; the former generally preceding the latter. Thus, when erysipelas is about to appear there is, in the first place, a severe chill, with pain in the back and limbs, nausea, loss of ap- petite, restlessness, frequent pulse, dry tongue, great anxiety and despondency, which is soon followed by defective secretions of all the glands and the symptoms formerly detailed under the head of inflammatory fever. At various periods of these constitutional 168 PRACTICE OF SURGERY. symptoms, local changes become apparent, the secretions of the wound are modified, and the character of its surface becomes changed, as is shown by the difference in its color, as well as in the character of its pus. The adjacent skin also becomes dry, bluish, and shining, and the surface of the wound or ulcer is covered by a green, thin, offensive, irritating pus or ichor. The edges of a wound also show unhealthy action, and have, in some instances, a marked tendency to slough. As the disorder progresses, the skin becomes irregularly vesicated and the color variegated, with an edge which is separated by a margin of a marked color from that of ttbe- healthy structure. After these changes in the condition of the wound, local affec- tions of the internal organs may complicate the disorder. Some- times the serous membranes become involved and create peritonitis, as after wounds of the abdomen; or there may be inflammation of the brain, as after those of the scalp. Sometimes also in both these instances the mucous membranes become involved and diarrhoea appears. Soon after the occurrence of the primary constitutional disturb- ance, a change becomes apparent in the skin in some cases, even when there is no wound, as after violent contusions followed by ecchymosis. The skin now becomes of a bright arterial red, or of a yellowish or brownish hue, and is elevated into blisters by the serous effusion under the cuticle, or it becomes hard, dense, and unyielding, from the lymph which accompanies the serous effu- sion. In bilious erysipelas there is also more or less of a jaundiced hue soon apparent, which renders the color browner than is usual in cases uncomplicated by deranged biliary secretions. The pain of erysipelas is characteristic of the disorder, and is described as of a burning, tingling, irritating kind, the approach of the attack under conditions favorable to it being indicated by this fact. Etiohgy.—The etiology of erysipelas is extremely doubtful; many causes having been assigned, but none so far as is positively known, which can be regarded as a constant source of the complaint. Thus, the disease has been said to originate in bilious and gastric disorder; from the presence of irritating ingqsta, and from acidity of the stomach. But occasionally it is found to exist independently of these conditions, as well as in cases where the slightest impru- dence could not be charged on either patient or surgeon. In ERYSIPELAS. 169 the latter it has been supposed to depend upon some peculiar condition of the atmosphere. As a source of local irritation many have thought that the em- ployment of adhesive plaster was especially injurious, as its removal in the dressing of wounds, irritated the cutaneous follicles by pulling out the hairs of the skin, but in many instances, even with a tendency to the disorder, it has not invariably followed the use of adhesive strips. The alternate compression and expansion of the capillaries, under the application and removal of a bandage, have also been regarded as exciting causes, whilst heat and moisture, cold, &c, have all been supposed to be equally powerful excitants of it. It is apparent, therefore, that but little is known respecting the etiology of the complaint. There is one singular fact which deserves mention in connection with, erysipelas, and that is the conjoined existence of puerperal fever and phlebitis during the same period. This singular coinci- dence has led to many discussions, and volumes have been writ- ten without adding very materially to our understanding of the matter. It is right, however, that this connection should be re- membered, even though unexplained, because whilst attending a case of erysipelas a surgeon ought not to attend one of midwifery, lest puerperal fever should be developed in the woman. The connection between these two complaints has frequently been exhibited in hospitals, and especially the Pennsylvania Hos- pital, of Philadelphia. In the latter institution, the long surgical ward is at one extremity of the building, and' the obstetric depart- ment at the other end of the grounds ; the buildings are therefore separated by several hundred feet of open space; the medical offi- cers and nurses are also different, and no connection exists between the two, yet frequently erysipelas has become epidemic in the surgical ward, whilst puerperal fever has prevailed in the lying-in department. So also, on the other hand, practitioners making post-mortems of puerperal peritonitis have not unfrequently had erysipelas deve- loped in their own persons. In explanation of these singular phe- nomena, it has been said that in both there is phlebitis, that there is a marked sympathy existing between serous membranes and the skin, etc. etc.; but nothing satisfactory has yet been suggested which is applicable as an explanation in the majority of cases. Diagnosis.—In studying the symptoms of erysipelas more in detail, it will be seen that its redness has some peculiarities which 170 PRACTICE OF SURGERY. Fig. 40. distinguish it from the redness of ordinary inflammation. At first, the erysipelatous redness spreads rapidly; but, after its primary violence is spent, it ceases to extend, or more frequently extends irregularly, giving to the margin a feathered edge, which is quite characteristic of the complaint. The creation of this edge is said to be due to the fact that the inflammation is of the unhealthy variety, in consequence of which there is no effusion of lymph to limit the progress of the inflammatory action; but when the effusion of serum takes place, as it generally contains more or less lymph, an imperfect limitation may be noted, and the color consequently spreads irregularly. In consequence of a certain similarity of symptoms, Ery- sipelas may be confounded with Ery- thema or Phlegmon, or with simple redness of the skin produced by irrita- tion, such as the chafing of the clothes or the action of the sun. A patient, for instance, may be brought into a hospital with redness or even vesication of the back of the neck and head, and at first erysipelas might be suspected, but the history will generally show that the some instances, and showing color is only the result of a very deli- HOW IT TENDS TO LIMIT THE EX- . i • -i , , „ tension op the disorder.—a cate slan having been exposed for ^d^SSS-^TUnSS some time to the direct ™J* ^ the sun. masses, which also fill the areolar Usually there is but little difficultv in tissue. The transparent nuclei of . . J ceils are seen at different points arriving at a correct diagnosis in ery- among the granules in the inter- „•„■!„„ ±t_ •>• . n ,1 .1 vascular deposit. (After Bennett.) sipelas, the history of the case, the symptoms, as the burning character of the pain, etc., and the absence in cases not erysipelatous of the con- stitutional symptoms generally present in the disease, will be quite sufficient to guide the surgeon in the formation of an opinion. Prognosis.—The character of the prognosis of Erysipelas will depend very much not only upon the extent of the disease, but also upon the nature of the parts affected. Thus, erysipelas in the scalp would be much more dangerous than erysipelas in the extremities, on account of the possibility of the first involving the membranes of the brain. The terminations of Erysipelas are two in number. 1. It may end by resolution. 2. It may terminate by suppuration. In most A view of the Effusion of Serum, explaining the cause of Erysipelatous Swelling in ERYSIPELAS. 171 instances, where there is a circumscribed Erysipelas which is limited to the skin, its tendency will be to resolution. If, however, it in- vades the cellular tissue, it will most probably end in suppuration. Among the constitutional symptoms, moreover, are certain which have an influence upon the prognosis. When the pain in the back is very severe, for example, we may, as a general rule, expect to have trouble. The habits of the patient also influence, in a very marked degree, the prognosis, erysipelas in an intemperate person being much more serious than in one of temperate habits. The previous history of the case should also have its weight in the formation of a prognosis, as an attack supervening in a patient who has been exhausted by a long suppuration would be much more serious than one occurring after a recent injury. When erysipelas assumes an epidemic character it is much more serious than when simply sporadic; and its repetition is materially influenced by the state of the weather, mild and dry weather being much more favorable than that which is cold and damp; hence erysipelas is especially pre- valent in February and March in this latitude. The prognosis, in some instances, will also be influenced by the circumstances of the patient, as whether he can have fresh air, good diet, and all those little comforts which are needed by the sick, or whether he is de- prived of these by his position ; whether the surgeon finds him in private practice or in the wards of the hospital, as erysipelas deve- loped in a hospital is much more apt to prove serious, and to cause sloughing, than the sporadic Cases which occur in private practice. Treatment.—The treatment of Erysipelas will depend upon circumstances. If it arises from a wound, the first indication is to allay irritation. In doing this, everything calculated to inflame the skin should be carefully removed, as bandages and adhesive plaster; the warm or cold water dressing being substituted, in accordance with the feelings of the patient. But generally the treatment of erysipelas should be directed almost entirely to the constitutional derangement, the local disturb- ance being only evidence, as a general rule, of constitutional derange- ment of an asthenic character. The treatment, therefore, should be based on this principle: Thus, in the first place, it is a good prac- tice to administer an emetic, as it empties the stomach, gets rid of indigestible articles, and affects favorably the portal circulation, or, as the celebrated Dr. Rush used to say, in homely language, " shakes the gall bladder ;" and, when followed by a dose of calomel 172 PRACTICE OF SURGERY. and jalap, " clears the ship fore and aft." After thus thoroughly clearing the alimentary canal, resort may be had to diaphoretics; and, among these, nothing is better than Dover's powder, the ipecacuanha modifying the action of the circulation in the skin by the perspiration it produces, while the opium serves to tranquillize the existing nervous excitement. When erysipelas, however, is of an epidemic character, and has a special tendency to assume the asthenic form, stimulants are required from the very commencement. Indeed, in the forms of traumatic erysipelas, and among patients suffering under the de- pressing influence of serious injury, as in complicated fractures, amputations, &c, no plan of treatment has proved more useful in my hands than that of stimulants both in food and drink, after the use of a thorough mercurial purge. In some instances, and espe- cially in those who have been high livers, I have administered over a pint and a half of the strong beef essence as made by Liebig's formula,1 together with twelve ounces of the best brandy, and fifteen grains of quinine; the pulse under this treatment sinking from 120 to 98 in the minute, whilst it lost its irritability. The tongue also became more moist and cleaner, and a free perspiration, accom- panied by sound sleep, proved of great comfort to the patient. When, however, such a plan of treatment increases tbe frequency of the pulse, so as to cause it to count 140 or 150, whilst the skin becomes dryer and hotter, and the tongue browner and drier, it will do harm, and should be superseded by saline cathartics, cremor tartar water, and gruel, until signs of debility become apparent. Great caution should always be employed in this as in other dis- eases, in deciding between the inflammatory or debilitated and irri- table pulse; and there is no better mode of settling its true character than by testing the effects of stimulants. If the frequency of the ' pulse diminishes, and the patient perspires freely under their use, stimulants will prove useful, but not otherwise. In the local treatment of erysipelas, little or no benefit need be expected from external applications, except in so far as they may add to the patient's comfort or protect the part from the action of 1 Beef, free from fat, and cut into small pieces, £ pound; muriatic acid, 4 drops; salt, one teaspooiiful; cold water, 12 ounces. Let it macerate for two hours—then pour it through a sieve, and pour the water a second time over what remains on the sieve. This beef essence, when well made, is almost as clear and free from color as water, and is entirely devoid of the empyreumatic odor of the older formula. ERYSIPELAS. 173 external irritants. The most comfortable of the local applications is lint wrung out of warm flaxseed or slippery elm mucilage, and covered after its application with a piece of oiled silk; or if there is a free discharge from a wound cover the part, especially if in a limb with a thick layer of wheat bran, which will absorb the matter and shield the skin from the atmosphere. Cloths, wet with a solution of the sulphate of iron, twenty or more grains to the ounce of water or stronger, was at one time highly lauded by Velpeau; but even in his own wards, as well as in those of Ameri- can hospitals, it has, according to my experience, not sustained the character which was at first demanded for it. It is also a dirty dressing, as it stains all clothes that it touches. The perchloride of iron, in the proportion of one part of the salt to three of water, is also highly spoken of by the French surgeons, but its results are similar to those of the sulphate. Frictions with mercurial ointment, washes of nitrate of silver, of the1 tincture of iodine, &c, have also disappointed many who have relied upon them, and in the vesicated form of erysipelas, often prove a source of additional suffering. Nor will the attempts to check the progress of the dis- order by drawing a circumscribing line between the sound and the diseased skin, prove of much service, as it has over and over again passed its boundary without even temporary delay, and the same is true of strips of blistering ointment. It is, therefore, judging from personal experience, injudicious to rely on a local treatment of erysipelas, except as a palliative; and of these, the mucilages are decidedly the most soothing, especially when combined with extracts of opium, aconite, or belladonna. In all cases the importance of the constitutional treatment cannot be too strongly impressed on the mind of the young surgeon, and especially the utility of invigorating the powers of life after the use of such purgation as will correct the condition of the abdomi- nal organs. y ■• PART III. PATHOLOGY OF ABNORMAL GROWTHS IN THE SOFT TISSUES. In the consideration of the inflammatory process, allusion has been frequently made to the action of the component parts of the body towards their own preservation, under the general name of "healthy nutrition;" and before proceeding to the investigation of such deviations as result in abnormal growths or deposits in the Soft Tissues, it will prove useful to the young student to state very briefly the general steps of healthy nutrition, as well as those of the development of normal structures. The first result noted in the effort of nature to develop structure is the formation of a plasma, nidus, or blastema. In this blastema or lymph, granules, nucleoli and nuclei soon appear, from which, by the formation of an invest- ing membrane, cells or cytoblasts are produced, which are the natural germs of all organic tissues. From the varied modifica- tions of these cytoblasts are formed all parts of the body, as muscle, tendon, bone, and bloodvessels, each of which is continually under- going destruction and repair, in accordance with the powers of life of the individual. This power of repairing its own losses by the action of the component cells of a part corresponds with the idea which was expressed by ancient writers under the general title of the "Vis Medicatrix Naturae." Were it continuous, life would never end, because, as fast as any structure was worn out, it would be replaced by a fresh one, and man would flourish in eternal youth. The failure of the system, as regulated by Divine laws, to accomplish this constant repair, creates in many instances such a modification of healthy action as gives rise to abnormal structures, which, in most cases, are readily distinguishable from the normal tissues either by their physical characters or by their subsequent 176 PRACTICE OF SURGERY. progress. When the tendency of these deposits is to form a struc- ture whose constant progress is to destruction, and in which no- thing avails to prevent its ultimate loss of vitality, they are designated as "Malignant" diseases or growths, in contradistinction to such as, though abnormal, are known as " Benignant," because more amenable to treatment even though causing inconvenience and suffering. CHAPTEE I. OF MALIGNANT DEPOSITS OR GROWTHS. The alteration of normal structure which is created by the deposit and growth of such a substance as has a malignant or de- structive tendency, has been designated under the generic term of "Carcinoma;" and the affections resulting from it are, therefore, known as " Carcinomatous disorders." In the progress of a Carci- nomatous growth various changes may be noticed; thus, at first, the deposit is imperceptible, but, when it attains even a moderate size, it is characterized by extreme hardness, as compared with that of the natural tissues, or by a soft and pulpy structure unlike the normal structures. The hardened state of these growths is usually designated as Scirrhus, whilst that condition in which their ulceration and the destruction of tissue become very evident is called " Cancer," or sometimes " True Cancer," or " Open Cancer," or the ulcerated stage of " Carcinoma Reticulare." When the deposit is pulpy and soft, and like the marrow or medulla of bones or the substance of the brain, it is designated as Soft, Medullary, or Encephaloid Carci- noma, the bleeding stage of which, when accompanied by exuberant granulations, is termed " Fungus Hsematodes." When the malig- nant deposit is highly colored, or contains a black pigment, it is known as "Carcinoma Nigra," or as "Melanosis;" and when its chief characteristic is that of cells filled with a jelly or glue-like matter, it is spoken of as "Colloid Cancer," or the "Carcinoma Alveolare of Muller." As the pathology of each of these requires special study, owing to the frequency of their occurrence, and the suffering which their development entails upon those who are affected by them, they will be described under distinct heads. CARCINOMA. 177 SECTION I. OF CARCINOMA. The origin of the common term "Cancer," which has been popu- larly applied to Carcinoma and Carcinomatous disorders, has been variously explained, some asserting that it is derived from the Ro- mans, who gave it the name of the Crab {Cancer), because the pain was of a gnawing character, as though caused by the pinching of the claws of the creature; or, as others assert, because the progress of the disease resembled the retrograde or irregular movements of this shell-fish. Other writers state that the name was given to it on account of some supposed connection between the origin of the disease and " Cancer? one of the signs of the Zodiac; whilst others entertain the opinion that it was named from some fancied resem- blance between the roots of the tumor and the claws of the crab. However derived, the general term cancer is applied by many to all carcinomatous affections, though it should be limited strictly to the ulcerated form of hard or reticulated cancer. Etiology.—The origin of Carcinomatous diseases, even with the minute investigation of microscopists, is yet, to some extent, un- known, and will doubtless remain so as long as the cause,of the resemblance of the child to the parent, the modifying influence of vaccination on smallpox, or the extension of syphilitic virus from the parent to the infant continues to be unexplained. In the first instance there is, doubtless, such an impress of the individual peculiarity of the cells of the parent as gives a specific character to the germ which constitutes the infant. So with vaccine and syphi- litic inoculation, in both of which there is probably some peculiar modification of the cell germs which continues till the end of a cer- tain period. But how this is accomplished is yet a mystery. That certain constitutions are predisposed to carcinomatous disorders, ancl that sisters and nieces, brothers and cousins, will all suffer from it whilst others escape, is well known to every surgeon. In one family from North Carolina, individual experience has shown me cancer of the breast in the third generation, though the second had escaped it. Without any explanation being presented, the fact must, therefore, be assumed that there is a condition of the blood 12 178 PRACTICE OF SURGERY. or a peculiar formative tendency in the germs of some patients that will lead to the production of carcinoma by any exciting cause; whilst in others not so predisposed these causes produce no such results. The question of the contagiousness of carcinomatous disorders has also excited much interest, as has that of the possibility of benignant growths degenerating into malignant disorders. That cancer is not contagious has been proved in various ways, whilst many arguments might be adduced in support of the opinion that under the action of such causes as impoverish the blood, cancerous matter, like tubercle, may be deposited in the tissues of those who were without hereditary taint, and whose previous health was once good. Waiving, therefore, any explanation of the ultimate source from which carcinomatous disorders originate,'I would express the opinion that they are, as a class, true blood disorders; that is to say, hereditary in many persons, developed by trifling excitements in others, and liable to impoverish the blood of all in whom they appear. Cancer, when once developed in any structure should, therefore, be treated as a disease liable to infect the whole system— to cause a marked degeneration of all the powers of life—and as always likely to be redeveloped in those who have once suffered from it. Every plan of treatment likely to obtain a successful result must therefore be based on the employment of such means as will tend to prevent its formation in constitutions which are hereditarily predisposed, as well as check its progress when once developed. The means most likely to accomplish this are such as improve the digestion and augment the quality of the red corpuscles circulating throughout the system. The exciting causes of carcinomatous disorders are blows, and such other injuries as develop local inflammatory action in a consti- tution suited to its formation; otherwise such causes will simply lead to hypertrophy of tissue, or to simple and benignant growths. Microscopical Characters of Carcinoma.—From the observations of pathologists and microscopists, surgeons have lately become very familiar with the appearance of carcinomatous deposits, though yet ignorant of the manner of their production. In its earliest development, a carcinomatous deposit exhibits under the microscope a simple modification of the normal cells of the part near which the disorder has shown itself, and presents characters which are sufficiently specific to enable us to designate them as the CARCINOMA. 179 carcinomatous cells. Of these there are two varieties, that of hard and soft canCer, though each preserves certain generic character- istics. The generic cell of Hard Cancer is usually larger than the normal exudation corpuscles, and is of an oval, caudate, round, an- gular or spindle shape, the majority being broadly oval, whilst others are fusiform, reniform, or nearly lanceolate, these various forms being probably due to the pressure made upon it by the fibres which sur- round and constitute the firmest portion of the hard carcinomatous growth. These cells appear to possess increased formative power, Fig. 41. A microscopic view of the Cells of Hard Cancer, showing their varied shape, with the numerous free Nuclei, as seen in Scirrhus of the Breast.—Magnified 500 diameters. (After Paget.) ' and to contain an unusual number of distinct nuclei, which in some cases are largely surrounded by granules, as in the Encephaloid variety, and sometimes by pigment cells, as in Melanosis. It is also not Uncommon to find some of each variety in all the deposits of a malignant character. It is evident that the reproductive power of these cells is greater than that seen in those of healthy tissue, as all malignant deposits extend themselves rapidly into the surrounding structures, and also attract to themselves a larger share of blood, in consequence of which they sometimes grow with great rapidity and attain considerable size. Though thus active at first, these car- cinomatous cells soon lose their vitality; much sooner, indeed, than those of the normal tissue; and hence, though carcinomatous de- posits grow rapidly, they also ulcerate, slough, and die under the action of caustics more rapidly than those of healthy or normal tissue. The interest shown in studying the peculiarities of the cancer cell soon led microscopists to express different opinions respect- ing its peculiarities. Thus, Miiller asserted that it was "impos- sible to distinguish the carcinomatous cell from the cells of other abnormal or even normal tissues, and Dr. Bennett agreed with him in the opinion that no single element could positively be said to 130 PRACTICE OF SURGERY. be characteristic of the cancer cell."1 Lebert, however, who is certainly high authority, and admitted as such by Dr. Bennett, positively asserts " that the cancer-cell may be distinguished from all others;" though he admits that, if an isolated cell were pre- sented, he could not by microscopical examination tell whether it belonged to a cancerous growth; but, that if "any morbid tissue was given to him, he could say from an examination of its cells whether it was cancerous or not."2 Cancer-cells appear to have an especial tendency to infiltrate glands and such tissues as contain a large amount of the fibrous element, the varied amount of the fibrous tissue, developed during the growth of the tumor, creating the varieties Of carcinoma above described. Thus, in Scirrhus and Cancer, the fibrous structure is in excess, and hence the firm, hard character of these tumors; in Encephaloid carcinoma it is less, and the tumors are consequently softer; whilst in Colloid carcinoma the fibrous element is expanded into cells and filled with a jelly-like substance. The microscopic characters of these varieties of carcinoma are also somewhat varied, differences being found in " both the corpus- cles and their basis, stroma or intercellular substance of the can- cers."3 There is, however, no mark by which the cells of encepha- loid may always be distinguished from the cells Of hard cancer, though the former may be softer, less exactly defined, more easily disintegrated by water, and flatter than those of scirrhous cancer. " The only constant difference is in the mode of compacting, Scir- rhous cells being closely packed in a spare, firm intermediate sub- stance, or tightly packed among the contracted structures of a mammary gland, whilst those of Encephaloid or Medullary cancers are more loosely held together in a more abundant and much softer or liquid intercellular substance."4 The carcinomatous cells are generally found in a matter of vary- ing density. In encephaloid, the most of it is of the consistence of brain, whilst in cancer they are mixed with a thick cream-like fluid, which can be squeezed out of the deposit, and is known as the cancer milk or juice. After thus briefly examining the microscopic characters of ma- • Miiller's Principles, Phila., 3d edit., by Sargent, p. 308. 2 Op. citat., by Sargent, of Phila., p. 308. 3 Paget, p. 537, Phila. edit. 4 Opus citat., ibid. SCIRRHUS. 181 lignant deposits, attention may be given to such peculiarities in the course of the disorder as have been shown by clinical observa- tion, and these are so.constant that they may be mentioned under special heads, as the laws which regulate these deposits generally. 1. Carcinomatous deposits of all varieties are disposed to trans- form and cause degeneration of the tissues in which they are deposited. 2. They tend to invade and destroy the adjacent tissues. 3. They are disposed to travel along the lymphatics and to attack the nearest lymphatic glands. 4. Though at first apparent in some one point, they soon invade several other parts, and cause or are attended by an impoverished condition of the blood. 5. When removed, the wound heals rapidly. 6. They tend to reappear in or near the cicatrix when removed by an operation. 7. They seem to prefer the glands as a nidus, though they may invade all the tissues of the body, as the muscles, skin, cellular tissue, bones, &c. As carcinomatous deposits, in whatever structure they may be seated, produce the same kinds of local and constitutional disturb- ance, the latter may be explained before taking up the special con- sideration of the seats of each deposit. § 1.—OF SCIRRHUS. General Appearance.—Scirrhus, wherever found, presents a hard- ened mass, varying in size from that of a pea or chestnut to that of a potato, or it may attain the size of the fist; but, as a general rule, hard carcinoma does not attain any very great bulk. As the tumor increases, it produces by pressure more or less con- gestion of the neighboring bloodvessels, particularly those of the skin. This, however, is true of any non-malignant tumor which causes an interruption to the superficial circulation, as was stated on page 24. As the disease progresses, the tumor forms' adhesions with the surrounding structures and becomes irregularly lobulated, whilst the part first deposited, and which is the most advanced begins to soften, to ulcerate, or even to slough. To the touch the scirrhous tumor is found to be hard, firm, and resisting, and is evi- 132 PRACTICE OF SURGERY. Fig. 42. dently heavy. When removed from the body and cut with a knife, it creaks under the edge of the instrument, or as the French express it, " Cries under the knife" like a raw potato. Its surface is also not unlike that of a potato, having a bluish, pearly aspect, and being frequently intersected by fibres or bands, which appear as if formed by the cellular structure of the part crowded together by the development of the abnormal growth. These bands often extend from the tumor itself into the adjacent cellular tissue, and consti- tuting what is popularly spoken of as the roots of the disease. They seem to have the power of influencing the neighboring parts to re- produce the disease after an operation, and serve probably as chan- nels of communication between the diseased and the healthy cells. They should therefore always be carefully removed in an opera- tion, lest they prove to be the extended nidus of cancer cells. The microscopic views of Scirrhus are said by Mr. Paget1 to ex- hibit the infiltration or insertion of the cancer substance into the interstices of the affected tissue. When deposited, the materials of cancer either expand these interstices by accumulating quickly— hence the rapid growth of cancerous tu- mors—or they shrivel and degenerate, and thus allow the affected tissues to shrivel and collapse, as is often seen in the breast. "The elementary structure of the cancer substance, as infiltrated in the breast, are chiefly two: 1. Certain cells and other corpuscles; and 2, a fluid or solid blastema, or nearly homogeneous substance, in which they lay imbedded. The blastema, or intercellular substance, presents no peculiar features." Local Symptoms.—As first developed, the Scirrhous tumor or deposit is movable and painless; but, after a time, it becomes im- movable by contracting adhesions with the surrounding parts, and begins to ulcerate, though sometimes it ulcerates before adhesions occur. A movable tumor is, therefore, usually less serious than one that is adherent. A microscopic view of the Cancer-cells filling the inter- stices among the bundles of the fibro-cellular tissue in the skin of the breast. Magnified about200 times. (After Paget.) 1 Lect. Surg. Pathol., Phila. edit., p. 495, ut supra. SCIRRHUS. 183 The pain from Scirrhus is usually dull and heavy; but, as the disease approaches the skin, it changes its characters and becomes more burning. When the lymphatics become involved, the pain takes on a shooting or lancinating character, which generally ex- tends towards the nearest lymphatic glands. Thus, in cancer of the breast, it shoots towards the axilla; in cancer of the testicle, it extends towards the groin; and, in'cancer of the lip, towards the lymphatic glands of the neck. As the nerves follow-very much the same course as the lymphatics, the direction of the pain corresponds with their line; thus, the lymphatics from the breast go to the axilla, whilst the origin of the nerves of the breast is also in the axilla; hence the pain is said to follow the course of the lymphatics, though they do not excite it. When ulceration ensues on the scirrhous condition, the variety known as "open cancer," or as ulcerated carcinoma, is produced. The cancerous ulcer presents edges of an inverted, irregular cha- racter, and is surrounded by a puckering of the skin. Or the edges may be everted, or elevated and covered with exuberant granulations. The pus from such an ulcer presents the character- istics of ichor or sanies, and possesses a smell which is at once peculiar, and, when accompanied by sloughing, horribly offensive. Constitutional Symptoms.—When scirrhus is once well developed, or when it progresses to ulceration, the constitutional symptoms become very marked; thus there is often, from an early period, loss of appetite, nausea, difficulty in obtaining sleep, and, if the disorder attacks the liver as well as shows itself externally, a peculiar sodden, leaden hue of the skin appears, which has been aptly compared to the appearance of " a cold buckwheat cake," as it is yellow in its tint, and wants the warmth of life. As the ca- chectic condition progresses hectic symptoms appear, and the patient sinks and dies from exhaustion and constant nervous irritation. Treatment.—The general treatment of carcinomatous disorders consists in fulfilling the following indications:— 1. As the disease is due to or accompanied by a perversion of nutrition, an effort should be made to remove any derangement in the nutritive organs, whilst the general health should be built up by the use of tonics and alteratives. 2. To remove or check the local irritation. 3. To continue the constitutional treatment through all stages of the disease. 184 PRACTICE OF SURGERY. 4. To operate early, if the disease presents such conditions as may be deemed sufficient to justify an operation. 5. To select such means for its removal as will be likely to pro- duce the least irritation. With regard to the tonics suitable in these cases, by far the greatest amount of good may be expected from the use of Chaly- beates. Justamond, of London, gave from sixty to one hundred and twenty grains of the ammonio-chloride per diem; and Car- michael, of Dublin, derived much benefit from washing ulcerated scirrhus with a solution of the sulphate of iron. The iodide of iron has also been used with advantage. Vallet's mass, in doses of from five to ten grains three times a day; the muriated tincture and the prepared carbonate have also been frequently given, and individual experience has shown me several instances in which these prepara- tions have retarded desperate cases. In one case in which I was consulted with a view to operation, I declined on account of the rapid progress of the disease, but suggested the use of Vallet's mass, conjoined with the application of the powdered carbonate to the sore, and the patient lived for eight years without the disease having made any very great progress. In regard to the fulfilment of the second indication, benefit will sometimes be derived from applying leeches around the tumor (not on it), especially in the early and inflammatory stage of the disorder. Narcotics of various kinds, both internally and as plasters, prove useful, such as opium or belladonna pills for internal exhibition, and the emplastrum saponis of the Pharmacopoeia, either alone or mingled with due proportions of stramonium, belladonna, aconite, opium, &c., may be employed externally. The administration of opiates requires, however, great caution, as they tend to weaken the digestive organs and check the secretions, producing loss of appetite, nausea, and constipation, all of which tend to impoverish the blood by impairing the source of its nutriment. The temporary relief afforded is, however, in hopeless cases a great object, and patients will often employ narcotics themselves, and conceal the fact from their surgeon. As the pain is excruciating, and from its duration leads to the frequent administration of opium, the amount that will ultimately be requisite to afford relief is incredible to those who have not seen it. An instance has come under my personal notice where from sixteen to twenty-four grains of sulphate of mor- CANCER OF THE SKIN. 185 phia, or about one hundred and twelve grains of opium were taken in the course of twenty-four hours. The external and internal use of the preparations of iodine was at one time strongly urged by Lugol, and facts cited in support of their utility; but though active in removing tubercular or scro- fulous deposits, and improving the general health, they have not, according to my observation, an equally beneficial effect in scirrhus. Externally, iodine stimulates the circulation, and is often positively injurious by causing an afflux of blood to a part from which every sound principle indicates it should, if possible, be abstracted. The constant use of the emplastrum saponis spread on kid, and kept constantly on the part, is often a source of comfort, as well as beneficial in promoting perspiration, and thus preventing local con- gestion. It also is often tranquillizing to the patient, and protects the part from friction, &c. In all cases the patient should be strictly cautioned against han- dling the tumor, or moving the adjacent parts, as this only adds to the irritation, and diposes the disease to ran its course more rapidly. If the removal of the tumor is to be attempted, it should be re- membered that it is worse than useless to operate while the local excitement is high; that cancer which is progressing rapidly will not be checked by an operation, and that it will, after such an operation, take on a more rapid career in the cicatrix or elsewhere. § 2.—CANCER OF THE SKIN. Cancer, as developed in the skin, is a true scirrhus, presenting a small, long, or oblong flattened swelling, similar in appearance to the common mole. Its seat is generally in the neighborhood of the ala of the nose, though sometimes it is found on the top of the lip, on the side of the cheek, or, indeed, anywhere. Symptoms.—The symptoms are as follows: At first there is a little-tumor in any of the above-named situations, painless in the beginning, but, by and by, more or less painful, giving rise to, a burning sensation. As the disorder progresses the skin cracks, and a little serum is effused, which dries and forms a scale or scab over the crack; when this comes off a superficial ulceration is left, which spreads, resists all ordinary treatment, and even grows worse under the applications usually employed for similar ulcers, and this in so 1S6 PRACTICE OF SURGERY. marked a degree that the sore may be designated as " Noli me tangere," or ^ouch-me-not. When it attacks the lips, the eyelids, the prepuce, or any place where it is likely to be much handled, it spreads rapidly, and the ulcer, which is usually superficial, assumes a thickened edge, that gives it an apparent depth, though really limited to the skin. Diagnosis.—Skin cancer may be confounded with lupus, or more frequently with chancre; but it may be readily distinguished from both, by characters which will be apparent after these diseases shall have been described. Prognosis.—The prognosis of cancer of the skin is favorable, more so, indeed, than that of any other form of malignant deposits. It seldom invades any other part than the skin, and generally yields to appropriate treatment. After an operation it will sometimes return, but, in the majority of cases, the patient will continue free from the complaint. Treatment.—For the removal of epithelial cancer resort may be had to the knife, to the ligature, or to caustics, the latter being especially useful in skin cancer. The whole class of caustics present us with a set of remedies which are very serviceable, not only in epithelial cancer, but also in other forms of the disease, especially where the patient is unwilling to submit to the knife, or where the tumor having been once extirpated by the knife returns in the cicatrix. Unfortunately, however, the removal of cancerous de- posits by caustics has latterly been very much cast aside by the profession in the United States; and they have fallen, therefore,1 into the hands of empirics, who do a great deal of mischief, because applying them to improper cases. As personal experience has shown me that some of the old formulae for caustics are very useful in certain cases, I think their employment may now be advocated with advantage, if only by recalling attention to this means of treatment, and keeping it within proper professional bounds. § 3.—TREATMENT OF CANCER BY CAUSTICS. In the application of caustics in the treatment of cancer, the vitality of the deposit is destroyed, inflammation is developed, and the malignant growth is thrown off as a slough. The pai'n is, therefore, very much greater than that felt from the operation of TREATMENT OF CANCER BY CAUSTICS. 187 excision; yet there are some patients who, whilst possessing an unconquerable dread of the knife, yet do not fear caustic. When caustic is applied to a cancer the part rapidly sloughs, because the morbid growth being a degenerated structure, possesses less vitality than the healthy tissue, and is hence acted upon by the caustic more readily than the surrounding parts. For this reason caustic, by its extended action, will in some instances remove the disease with much greater certainty than can be done by the knife, the operator being sometimes unable to recognize the degenerated tissues, whilst they are readily destroyed by the caustic. When the disease reap- pears in or near the cicatrix, the use of caustics will also be found preferable to the repetition of the operation of extirpation. In the formula for these caustics it will be seen that the chief ingredient in nearly all of them is arsenious acid, and at first sight it misdit be feared that the constitutional effects of arsenic would be induced by such an application. But the general rule that, in order to favor the absorption of any substance, it must be applied in such a manner as not to create irritation, holds good also here, the irrita- tion being so great in the application of these caustics that effu- sion occurs, not absorption; hence there is no risk of mischief from the poisonous effects of the arsenic. The first of the caustics, of which the formula will now be given, as collected from various sources, is that commonly called " Hel- mund's Powder," which is very similar in its composition to Frere Cosme's paste. It is as follows:— R.—Acid, arsenious Qij ; Cinnabar gij ; Pulv. carb. lig. grs. xij ; Sang, draconi grs. xvi. M. The purpose of the charcoal in this preparation is to correct the fcetor of the slough, whilst the dragon's blood is probably used merely to conceal the other constituents. It should be applied to the sore or tumor either by mixing it with one ounce of resin cerate, or with one ounce of the following ointment, which it may be per- ceived, from its name—the Narcotico-Balsamic Ointment—is a very ancient prescription:— R.—Balsam Peru, Ext. hyoscyam., iia ^ss ; Plumb, acet. ^iv; Tr. opii TT^xl; Ung. cetac. %iv. M. / 188 PRACTICE OF SURGERY. In its application to a cancerous growth this caustic should be spread upon a piece of lint of such a size as will cover the whole sore, and extend a little beyond its edges, when it should be fast- ened down by strips of adhesive plaster, and covered by a compress and bandage. During the first hour, perhaps, it will produce little irritation; but after four, six, or eight hours, the pain will become more severe, and subsequently so violent that it may be found neces- sary to give an anodyne to alleviate the suffering. After a lapse of forty-eight hours the caustic plaster may be removed and another put in its place, if the slough is not deep enough; but after obtaining a white, felt-like slough, of sufficient depth, it only remains to favor its separation by the use of poul- tices or the warm water dressing, repeating them until the slough comes away, when the ulcer that is left should be dressed with the narcotico-balsamic ointment, or with simple cerate, or basilicon, whioh answers the purpose quite as well. Sometimes it happens that while the slough is separating the odor of it is very offensive, and to counteract this the parts should be washed with the following lotion:— R.—Potassae sulph. 3J ; Aq. rosse f5;iv; Ext. hyoscyam. gj. M. the extract of hyoscyam. aiding in allaying the local pain. Another caustic, which was once quite celebrated, is "Justa- mond's powder." R.—Oxid. antimon. J; Arsenious acid §. To which equal parts, or three parts of opium are to be added. Justamond applied this powder by making it into a paste with the white of eggs, and smearing it over the sore with a spatula. A notorious and old cancer prescription, much used in Phila- delphia and New York, is the Red Ointment of certain unprincipled men who are designated as " cancer doctors," It is evidently the same as Dubois's paste, and is the basis of most of the quack pre- scriptions at present in use. R.—Hydrarg. sulphuret. §j ; Acid, arsenious 3 ss ; Sang, draconi gss; Ung. cetacei §j. M. TREATMENT OF CANCER BY CAUSTICS. 189 In the use of this paste the patient is directed to spread the oint- ment on a piece of rag, and apply it to the sore, changing the plasters from day to day till the cellular attachments of the tumor loosen and come away, or, as the quacks and the vulgar say, till " the cancer comes Out by the roots." They then apply the Brown ointment over the sOre thus left. This, also, is an old prescription, and is simply a mild, soothing ointment. R.—Litharge 9j; 01. lini fgiij; Cerat. resin, £j. M. There are several other articles in use, and one of them, which has become quite celebrated in the hands of Indian doctors, corre- sponds very much with "Plunket's caustic." R.—Pulv. rad. ranunculus bulbosus, Acid, arsenios., Sulphur, sublimat., equal parts. M. Any of the more powerful caustics will also answer the same purpose; thus, corrosive sublimate or caustic potash may be ser- viceably employed. Another popular caustic is made by burning any number of herbs, boiling their ashes so as to make a lye, evapo- rating it till it forms a true caustic potash, and then applying it on the part. One of the best caustics that can be employed in the treatment of such cases as demand caustic applications is the Chloride of Zinc, as suggested by Mr. Ure, of England. This substance, when used as a caustic, should be mixed with flour or calcined gypsum, in about the following proportions, and either made with water into a paste, or used as an ointment, as follows:— R.—Zinci chloridi Qj; Farina? ^j; Ext. aconiti gss; Cerate, simple ^j. M. It should be spread on kid or muslin, and applied to the ulcer- ated cancer, or the ulcer may be sprinkled with the zinc and flour, and then covered with the cerate; or, if it is intended to remove a distinct tumor beneath the skin, but over which the integuments are not ulcerated, the cuticle should be first taken off by means of 1Qq PRACTICE OF SURGERY. a blister, in order to expedite its action. After its application, the pain is sometimes very severe, but often the plaster-can be worn for twelve or twenty-four hours, especially if Dover's powder is given at the same time. On removing it, if the slough which it has made is not deep enough, it may be reapplied, after which the warm water dressing or warm mucilages or poultices should constitute the dressing, in order to favor its separation. Five or six days of this treatment sometimes suffice for the removal by caustic of tumors of some size, whilst those which are smaller and more superficial will slough out in less time. The ulcer usually heals promptly under the ordinary treatment of the -Healthy Ulcer, and the whole time occupied in this mode of treatment varies from one to six weeks, according to the depth and extent of the portion that is to be removed. | 4—CANCER OF THE EYEBALL. Hard carcinoma of the eyeball is an exceedingly rare disorder, the deposit of encephaloid matter being much more common. Can- cer of the eye usually commences in the anterior coats, and pro- gresses inwardly at first; whilst encephaloid cancer, commencing in the choroid or retina, extends forwards. Both impair and destroy the usefulness of the organ from the commencement of the disorder, and both are liable to be reproduced, though hard cancer is less so than encephaloid. Cancer of the eye usually occurs in the old and middle-aged, whilst encephaloid disease is seen in the young and at adult life, though sometimes, also, it is met with in those who are more advanced. Symptoms.—When cancer is developing itself in the conjunctiva, cornea, or sclerotic coats of the eyeball, the earliest symptom is an irritation of the eye, accompanied with redness and vascularity simi- lar to that seen in catarrhal ophthalmia, but the source of which is often not recognized at the moment. Then, after the continuance of these symptoms for a week or ten days, a small tuberculated spot is seen, which, if in the cornea, at once impairs the sight; but, if in the conjunctiva, is simply an increased source of lachrymation. The tumor increasing, there is shortly an ulcer seen, which gradu- ally assumes the everted edges of the cancerous class; the eyeball becomes prominent; the lids distended, oedematous, and ulcerated; CANCER OF THE LIP. 191 the pain becomes severe and deep-seated; the disorder extends to the lachrymal gland, leads to absorption of the bony walls of the orbit, and the patient dies exhausted by pain, or of the extension of. the irritation to the brain. The diagnosis will be given in connection with the symptoms of encephaloid growths in the eye. The prognosis is unfavorable as is that of cancer generally. Treatment.—In the treatment of cancer of the eye, but little is demanded in its earlier stages, the ophthalmic symptoms being treated in the manner that will be stated under the affections of the eye. But, when the presence of the cancerous tumor is established, extirpation of the' entire ball becomes the only rational plan of treatment, and this is useful rather as diminishing suffering, than as affording any hope of preventing the,return of the disorder. For a detailed account of the operative proceedings in extirpation of the eye, the reader is referred to the volumes on operative sur- gery1 by the author. § 5.—CANCER OF THE LIP. Cancer of the lip shows itself generally on the lower lip, and most frequently at its edge, as on the everted portion of the mucous membrane, though sometimes it commences lower down, between the margin of the lip and the edge of the chin. Symptoms.—The symptoms of this form of cancer are as follows: When the cancerous deposit is developed at the edge of the lip, it shows itself in two forms; in the first, it appears only as a slight scale, due to the degeneration of the epithelial structure of the part, which, separating, leaves a superficial ulceration or crack, from which a fungous granulation or two are very apt to spring; in the second, it is seen in the middle of the lip, and then the first thing, noticed is the presence of a little shot-like body beneath the skin, which is quite movable in the tissues of the lip. In this latter form, it is probable that the cancerous deposit has taken place in some of the labial glands. As this little tumor enlarges, it distends the skin, and the integuments take on ulcerative action, creating the everted edges and peculiar appearance of the cancerous ulcer. As the disease advances, irritation of the glands of the neck ap- 1 Operative Surgery, vol. i. p. 292, 2d edit., 1855. 192 PRACTICE OF SURGERY. pears; the tumor .spreads, and the patient at last sinks under the effects of hectic fever. Before this termination, however, the ulcer- ation may extend itself to a frightful degree, it having been known in some cases to remove the whole lower lip, lay bare the jaw, and produce a change in the countenance that it was terrible to look on. Etiology.—The exciting cause of this form of cancer is to be found in local irritation of any kind, the biting of the lip being sometimes sufficient to create it in those predisposed to the deposit. Smoking of a clay pipe has also been said to excite it; but it may be doubted whether this practice exerts any influence of a specific character, the use of the pipe being very common, and this form of cancer comparatively rare. Diagnosis.—The diagnosis is generally easy. Sometimes, how- ever, a simple ulcer of the lip, such as that which results from a chap or a fissure, and which it becomes difficult to.heal—in conse- quence of the flow of the saliva over it washing away the reparative lymph—might create a doubt of its true character; but the history of the case, and the absence of any very great amount of irritation in the lymphatic glands of the neck, will generally show the simple character of the latter, and distinguish it from cancer. So, again, difficulty may occur in the diagnosis of cancer of the lip from the syphilitic ulcer or chancre, although the occurrence of chancre on the tongue or lip is not so common in this country as it is in France. As the two present different appearances, the details of the diag- nosis will be given in the description of the character of chancre. Prognosis.—The prognosis of cancer of the lip is serious; and the opinion of a positive cure should be very cautiously given; the general belief that this seat of cancer, when unaided by surgical treatment, proves fatal in about three years, and that if excised it is apt to return in a few months, being quite in accordance with the most extended experience of surgeons. But the removal of cancer of the lip by an operation is much more desirable and justi- fiable than the operations of extirpation elsewhere, because, although the excision does not cure the disease, it removes a disgustinc source of irritation, prevents foul matters from passing into the stomach, and generally prolongs life. Treatment.—The operation that is required for the removal of cancer of the lip depends upon the extent of the disease. If the whole lip has been destroyed, and the surgeon ventures to excise the edges of the ulcer, a plastic operation will be required—the mode of, per- CANCER OF THE TONGUE. 198 forming which will be found in the volumes on Operative Surgery.1 Where, however, the deposit is smaller, it may be removed by excising a V-shaped piece containing the cancer, and also a broad margin of the healthy structures, the wound being subsequently closed with hare lip sutures. After the operation, though the pa- tient may be well for about two years, yet the disease will be very apt to return, § 6.—CANCER OF THE TONGUE. Cancer sometimes shows itself in the Tongue, where it is pre- sented in the form of a small tumor, which is first seen as a little flattened circumscribed swelling, situated generally opposite the first molar tooth. Or it may be a more extensive induration of tissue, accompanied by a superficial ulceration, from which fungous granulations sprout, and the pus of which being swallowed to a greater or less extent, soon aids in contaminating the system. Etiology.—Any local irritation may cause cancer of the tongue in those predisposed to it, as the contact of hot liquids when taken suddenly into the mouth, or the rough edge of a tooth, or frequent pinching of the tongue in convulsions, &c. Diagnosis.—The diagnosis is to be based on the characters already detailed in connection with Carcinoma generally. Prognosis.—The prognosis of Cancer of the Tongue is much more unfavorable than that of cancer of the lip, from the fact that the matters swallowed more certainly disorder the digestive apparatus, and thus aid the disease in breaking down the patient. Treatment.—The apparently radical treatment of cancer of the tongue consists in removing as far as possible all sources of irrita- tion, by filing off the rough edge of the teeth, and giving the patient a mouth wash of honey and alum, which also contains 5ss extract of cicuta to every six ounces of the wash. If the glands beneath the tongue enlarge and become painful they may be leeched, and the ulcer on the tongue be touched with a strong solution of muriatic acid or nitrate of silver. Mr. Earl, of England, has highly recom- mended touching this ulcer with a solution of arsenious acid. Where it is possible, however, it is much better to remove the tumor by the ligature, or preferably by the knife.2 1 See Op. Surg., by the Author, vol. i. p. 357. 2 See Operative Surgery, 2d edit., vol. i. p. 369. 13 194 PRACTICE OF SURGERY. If the knife is used, the organ should be steadied by transfixing it by a tenaculum, which an assistant may hold while the surgeon removes the diseased parts, ligates the arteries, and closes the wound by sutures. As the wound heals, the granulations, if dis- posed to be too luxuriant, may be touched with nitrate of silver. Ligature of the lingual artery has also been recommended as a curative measure; the mode in which it is performed being stated in the volumes just quoted. § 7 __CANCER OF THE PAROTID GLAND. Cancer of the parotid gland is a complaint occasionally seen. Generally, however, the cancerous deposit is at first made not in the gland itself, but in the lymphatic glands exterior to it; and this observation is equally applicable to all the salivary glands. As the lymphatic gland at first affected becomes enlarged, it soon invades the proper structure of the parotid, and the whole becomes one indistinguishable mass of disease, creating a tumor directly in the parotid region. This tumor is not very bulky, being generally not larger than the fist, and bound down by the dense fascia of the part. It, therefore, progresses inwardly to such an extent as to compress and sometimes completely obliterate the carotid artery; so that in operating in these cases it has occasionally been unneces- sary to tie the external carotid after it was cut, the hemorrhage from the operation of extirpation being much less than might under ordinary circumstances be expected. Prognosis.—The prognosis of this flisorder when left to itself is generally unfavorable, the disease being exceedingly apt to run its course within eighteen months. Treatment.—The palliative treatment is the same as that already detailed under the general head of Carcinoma. In regard to the curative treatment, it may be attempted by the ligation of the carotid, but generally the collateral circulation is so soon re-es- tablished that this affords only temporary benefit, and the extir- pation of the tumor is therefore more reliable. § 8.—CANCER OF THE SUBMAXILLARY AND SUBLINGUAL GLANDS. The primary deposit of cancer in the proper substance of the CANCER OF THE MAMMA. 195 submaxillary gland is rare, the lymphatic glands of the neighbor- hood being generally first involved. Neither of these glands, how- ever, present us with any features demanding special consideration. -CANCER OF THE MAMMA. Fig. 43. Cancer of the breast is most common in females, being very seldom seen in males. As a general rule, it shows itself more freqnently in the unmarried than in the married woman, and especially in those who are forty-five years of age and upwards; the disorder being rarely found in females younger than eighteen or twenty. Symptoms.—Cancer of the breast shows itself as a small tumor loosely connected with the gland, and movable in it at first. It is generally seated not far from the nipple. As it subsequently en- larges the skin over the tumor becomes congested from the distension of its' vessels, inflammation is developed, the tissue becomes fissured, and then gives out a thin serous discharge. The nipple soon be- comes retracted; ulceration is developed; a portion of the ulcerated structure sloughs, and there is thus created a most offensive and irri- tating discharge. The skin is now often puckered, around the sore, and the entire breast appears more or less flattened, especi- ally when it becomes adherent to the pectoral muscle. The tumor of cancer of the breast is always of a moderate size as compared with that of encephaloid. When the breast is ex- tirpated it resembles Fig. 43. Etiology.—The etiology of the disease is that of hard cancer elsewhere. Diagnosis.—The diagnosis of cancer of the breast is important, as there are various non- malignant tumors of this gland with which it may be confounded. These tumors have, therefore, been arranged in a tabular form so as to facilitate examination. The diagnosis of carcinoma of the breast from other tumors, as stated by Velpeau, may be made by the following comparison of it with— Cancer of the Breast after it has been removed and bisected; showing the flattening of the gland and the retraction of the nipple. (After Liston.) 196 PRACTICE OF SURGERY. I. Chronic •mammary tumor.—This occurs before thirty-five; in healthy constitutions; is. circumscribed; rounded; not painful; quite movable; and increases very slowly. II. Irritable mammary tumor.—This is mostly seen before middle age; in nervous habits; it is not large, nor well defined; is tender, painful, and often accompanied by general swelling of the bosom. III. The Adipose tumor has great size, elasticity, regular surface; mobility, freedom from pain, and generally occurs in healthy females. IV. Scrofulous tumor (or tuberculous tumour of Velpeau) is seen in early life in those of scrofulous habits. This tumor is large, irregular, indistinct, not painful, and varies in size at different times. V. Cancerous tumors are generally seen between forty and fifty, often in those whose relatives have likewise suffered from the com- plaint. They are painful, the pain being of a lancinating charaoter; are hard and irregular; move with the gland, but not in it like the chronic mammary tumor; contract adhesions; pucker the skin; depress the nipple; ulcerate and develop hectic fever. They are also often accompanied with the pallor or yellow hue of the skin spoken of in connection with the cancerous cachexia. VI. The Encephaloid tumor occurs in young patients; it is large and elastic; consists of two or more lobules; increases rapidlyr, ulcer- ates, bleeds, creates a fungus, and sloughs extensively, wearing out the patient's strength with great certainty through the renewed hemorrhages and hectic fever. Prognosis.—The prognosis of cajicer of the breast is that of car- cinoma generally. The prognosis after an operation will be stated after the account of the treatment. Treatment.—The indications in the treatment of cancer of the breast are the same as those mentioned in the general treatment of carcinoma; but the frequent development of this disorder in the female breast, and the intense suffering, both mentally and physi- cally, which it induces, demand a more special consideration at present. When a tumor presenting the hardness, pain, and other symptoms of scirrhus, forms in the breast, it should be regarded as a source of irritation, and it will be found to be good practice to leech it freely all round its base or a few lines from it, so as to abstract the blood without increasing the irritation in the tissue of the tumor. After free leeching, apply for twelve hours the CANCER OF THE MAMMA. 197 warm water dressing, or a warm poultice, giving the patient a thorough purge, and following.it by a moderate dose of anodyne, such as Dover's powder. To re- tain a poultice or other warm dressing in position, and support the breast so as to prevent its drag- ging on the lymphatic vessels and the adjacent cellular tissue, fold a handkerchief into the shape of a triangle; place the dressing on the breast; lay the apex of the triangle over the shoulder of the affected side; carry its base obliquely across the chest, from the opposite side of the neck under the axilla of the affected side, and tie the ends to- gether behind the back, attaching a piece of ribbon if they are not long enough. Then placing a hand on the breast as thus covered, draw the %pex of the handkerchief over the affected shoulder until it fully supports the breast and dressing, and fasten it by a pin to the other ends on the back. As thus dressed the patient can readily change the dressing, and yet have the breast fully supported simply by carrying the hand of the sound side over the affected shoulder and unpinning the end. After changing the dressing let her pin it as previously directed. In order to diminish the pain, keep up the action of the perspira- tory glands, and prevent the patient from handling the tumor and thus increasing the flow of blood to the adjacent parts whence it draws the materials for its development, it will prove very useful to cover the breast with the emplastrum belladonna?, or cicutae, or opii, or the emplastrum saponis mixed with these anodynes, and spread on kid cut to fit the breast, the plaster being retained by means of the sling of the breast, Fig. 45, which is also useful in supporting the gland and exercising the gentle pressure of a well applied bandage. To make this, cut a square piece of muslin large enough to cover Fig. 44. Representation op the Handker- chief Cap of the Breast as suggested by Mayor, op Lausanne.—1. The apex of the triangle carried over the shoulder of the affected side. 2, 3. The angles, which are to be carried obliquely around the neck and axilla of the affected side. (After Nature.) 198 PRACTICE OF SURGERY. the breast, and nick it in the middle of its four sides to the extent of one inch. Have these neatly hemmed to prevent their tearing, attach along one side a broad piece of tape, as at 1, 1, Fig. 45, and also attach to its two opposite corners similar pieces of tape Fig. 45. A view op the Sling op the Breast.—1, 1. The horizontal tape around the waist. 2, 2. The shoulder tapes which fasten on the back to the horizontal tape. (After Nature.) (2, 2, Fig. 45). In its application carry the tape 1, 1, around the waist so as to encircle the body, and fasten the other two tapes (2, 2) to the horizontal tape behind, by carrying them over each side of the neck and down the back. When the ulcerated stage of cancer is established this sling may also be employed to retain lint wet with liquor sodae chlorinat., or lint covered with the powdered carbonate of iron, or with oint- ments of cicuta or belladonna. The operation of excision or extirpation of the mammary gland is performed by making elliptical incisions in the skin, and then dissecting out the entire breast, with all such lymphatic glands and adjacent portions of cellular tissue as are indurated, in the manner which has been detailed in the volumes on operative surgery.1 After removing the breast, and checking the hemorrhage, unite the wound by adhesive strips; apply over them a piece of lint spread with simple cerate; place over this a good compress, so as to pre- 1 Operative Surgery, by the Author, vol. ii. p 39. CANCER OF THE MAMMA. 199 vent any accumulations of pus beneath the skin, and retain the dressing in its place by carrying a four inch wide and ten yards long roller, once or twice around the waist; then coming round from the affected axilla, pass over the breast, around the opposite side of Fig. 46. A view op the Crossed Bandage of one or both Breasts.—When one breast alone requires dressing, the turns on the opposite breast should be omitted. (After Gerdy.) the neck to the same axilla once or twice, and then again around the waist (Fig. 46), making a sufficient number of turns to cover in the part, allowing it to remain untouch- ed for forty-eight or seventy-two hours, when the dressing should be renewed. As it is sometimes desirable also to sup- port both breasts, the figure represents the bandage as thus applied, the second breast being covered like the first with alternate circular and oblique turns. When cancer of the breast returns after an operation, it usually shows it- self by the development of round masses of various sizes, in or near its original seat, as represented in Fig. 47. Such secondary tumors, as well as the pri- A view of the numerous Nodu- mary growths, when Small, may Often lated Tumors which often form in , . , , , , the cicatrix after the extirpation of be advantageously treated by the CaUS- the former growth. One is repre- tics previously advised; the caustic plas- S^^r^um^ °f 200 PRACTICE OF SURGERY. ters-, as well as the warm water dressings or poultices being subse- quently retained in position by means of a broad band of muslin which encircles the breast and the waist, and is prevented from v slipping down by the attachment behind and in front of two broad • shoulder-straps, which are to be applied in the manner represented Fig. 48. A representation of the Body Bandage for the retention of Caustics, Poultices, Ac, to the Breast. (After Nature.) in Fig. 48. Compression of the tumor by compresses and a band- age in order to check the flow of blood and favor its absorption, has been advised by Young, of England, and in a modified form by Mr. Arnott, by means of a ring which compresses the circumference, but not the apex of the tumor. This plan of treatment has not, however, gained any extended degree of professional confidence, and, in two instances in my hands, was so great a source of irri- tation as to require its removal. Prognosis of the Operation.—It appears, from the observations of Leroy d'EtioUe, Lebert, and others, in regard to the prognosis of the operation for the extirpation of cancer of the breast, that the average duration of life after the operation is two years and six months, whilst the average duration of life without an operation is three years and six months. Paget, however, makes the time shorter, and says1 that, of 66 1 Lectures on Surgical Pathology, p. 525. GANCER OF THE MAMMA. 201 cases which came under his notice, and in which the disorder was left to take its natural course without an operation, the average duration of life was about forty-nine months, and that the more tender the age of the patient, the more rapid was the progress of the disease. In 47 cases operated on, the duration of the disease was somewhat longer; and he expresses the opinion that the re- moval of the local disease makes no material difference in the average duration of life, but that the operation retards the progress of the more rapid cases. But neither Paget nor Lebert has seen a case in which its recurrence was delayed longer than eight years. Such cases, however, have been recorded in the United States, by Drs. Hartshorne and Parrish, of Philadelphia, in one of which the patient lived, free from the disease, for twenty years after the operation. Out of 68 cases reported by Lebert, the disease returned after the operation, in 23 cases, in from one to three months; in 22 cases, in between three and six months; in 8 cases, in between six and nine months; in 7 cases, in between twelve months and two years; in 3 cases, within three years; in 1 case, within four years; in 2, within six years; and in 2, in eight years. Mr. Paget expresses the opinion1 that the old rule of not ope- rating when the lymphatic glands of the axilla are affected is a bad one, and he mentions cases to show that the operation will produce that temporary relief which alone is to be expected from it in these as well as in other cases. " Thus, in 20 cases of the removal of the breast alone, the average recurrence of the disease was eight months, and death ensued within twenty-four months after the operation; while in 10 cases of the removal of the enlarged glands the average time of recurrence was thirteen months, death taking place in twenty-four months, or about the same period as in the other cases. He also thinks there is no evidence to sustain the rule that ulcerated cancers, and those ad- herent to the skin, should not be operated on." As the opinions and statistics of the operation, as usually prac- tised among American surgeons, have been given in full in vol. ii. p. 45 of the Operative Surgery, it is unnecessary to repeat them here. Summary.—The most judicious treatment of cancer of the breast is—1. To allay the local irritation and inflammation by means of 1 Op. cit., p. 527. 202 PRACTICE OF SURGERY. leeches, warm water dressings, anodyne plasters, and perfect rest of the arm of the affected side. 2. To improve the general health by purgatives, tonics, and chalybeates. 3. When, notwithstanding the employment of the preceding means, the tumor continues to be heavy, and is constantly painful, and a source of mental as well as bodily distress, to extirpate it, and any axillary glands that may be involved. 4. To remove small tumors by caustic. 5. To treat the reappearance of the disease by caustic. § 10.—CANCER OF THE PENIS. Cancer may commence in the Penis either upon the prepuce or upon the glans, but especially upon the glans. It occurs generally in men who have passed beyond the age of fifty years, in those who have suffered from phymosis, or in whom the part has been fre- quently and constantly irritated by accumulations of the smegma around the corona glandis. It is also seen in sailors, carpenters, and others whose occupations are such as to expose them to injuries of the penis by contusions from ropes, the yard-arm of a vessel, &c. These causes, acting upon the penis of persons of the cancer- ous cachexy, generally suffice for the development of the disorder. Symptoms.—Cancer of the penis shows itself first as a hard wart or knot in which there is no pain until it is irritated. It therefore, at first, not unfrequently causes the patient no mental uneasiness, and but little local pain. When irritated, however, the wart rapidly becomes painful, enlarges, ulcerates, extends, and creates a cancer- ous ulcer with everted edges and fungous irregular granulations, which gives rise to an ichorous discharge that is extremely offensive, particularly if the patient is of filthy habits, or unable from phymosis to cleanse the parts thoroughly. In consequence of the swelling in this last case, the orifice of the prepuce sometimes contracts till the urine cannot pass through it; when inflammation being de- veloped, ulcerations occur at various points through the prepuce, by which the urine escapes, passing over and irritating the granu- lations which are formed in the reparative efforts. As the disease progresses, a train of symptoms appear, which are such as might naturally be expected from the locality of the disease, such as shoot- ing pains along the line of the lymphatics of the groin, and either in one or both groins. When the lymphatic glands become in- CANCER OF THE TESTICLE. 203 volved, pains are developed in the back, the glands of the lumbar region evidently participating in the disorder. The glands of the groin now usually begin to enlarge, the skin over them becomes distended; sloughing and ulceration ensue, and extensive cancerous ulcers form in this region. In the mean time, the usual constitu- tional symptoms of cancer have rapidly progressed; the digestive organs become deranged, the patient emaciates and presents all the appearances of the cancerous cachexy, until at last he dies worn out by hectic. Diagnosis.—The diagnosis of cancer of the penis is a matter of some importance in reference to the operative treatment; thus it may be distinguished, for example, from venereal warts by the different color, by the ulceration, by the presence of the cancerous cachexy, by the history of the case, by the hardness and weight of the cancer, and by the comparatively light, spongy character of the warts, &c, &c. With chancre, when phagedenic, there could be but little difficulty in arriving at a correct conclusion when a truthful previous history is obtained and the duration of the disorder is noted. Treatment—The treatment of cancer of the penis is based on precisely the same indications as the treatment of cancer elsewhere. It may, however, be stated, in regard to this seat of cancer, that the removal of the tumor with the knife is preferable as a general rule to the use of caustic. When the disease is limited to the prepuce, the operation of circumcision may suffice for its removal; or it may even be useful to pare off the small portion of the glans penis that may be affected. But as the disease generally begins in this part, it is better when the latter is much involved to perform the operation of amputation of the body of the penis. (See Operative Surgery, vol. ii.) When, however, the glands of the groin are much involved, unless the penis has attained great size, which is rarely the case, it is not worth while to operate, as the inconvenience caused by the subsequent dribbling of the urine augments the patient's suffering when the disease reappears in the stump. § 11.—CANCER OF THE TESTICLE. Cancer of the testicle is a very rare affection; encephaloid dis- ease, fungus, or tumors of a benignant character, being much more 204 PRACTICE OF SURGERY. common. Great care is, therefore, necessary in the diagnosis, as it is sometimes advisable to remove the testicle for cancer, which would seldom be desirable in the chronic enlargement, which has been designated as sarcocele. Diagnosis.—Inflammation and induration of the testis," such as sometimes accompanies gonorrhoea, simple epididymitis, or the " Hernia Humoralis" of the old writers, may be confounded with can- cer of the testicle; and so, indeed, may hematocele, or hydrocele, particularly if they are combined with ossification of the tunica vaginalis testis. These two latter cases, however, would be at once distinguished by an examination with an exploring needle. Another condition which requires care to diagnosticate from cancer is an effusion of lymph into the cavity of the tunica vaginalis testis, con- stituting what has properly been known as sarcocele. One such case occurring in the practice of a most intelligent surgeon is well known to me, in which the testicle, which was perfectly sound, was removed in consequence of such a mistake. The absence of pain, of ulceration, of the cancerous cachexy, and the other symptoms of cancer should, however, suffice for a diagnosis. So, also, there may be a simple hypertrophy of the scrotum, such as occurred in the negro Nelson, whose scrotum was removed in 1837 by Dr. Picton, of New Orleans. This, however, may be diagnosed by its great bulk and by its indolent and painless character. Sometimes it happens that the irritation produced by developing scirrhus will induce an effusion into the tunica vaginalis testis. Of course in such a case it will be difficult to diagnose the presence of scirrhus until after the evacuation of the serum by a trocar. To this condition the name of Hydrosarcocele was given by the old writers. Symptoms.—Cancer of the testicle begins in the shape of a small hardened tumor, which enlarges, becomes painful, and involves glands of the groin, just as cancer of the penis did. As it enlarges the tumor invades the scrotum, which becomes adherent, tense, and ulcerated, after which the ordinary symptoms of open cancer ensue; but the ulcer in this case does not present a well-marked fungus; and by this fact, as well as by the smaller size of the tumor, cancer of the testicle can be readily diagnosed from fungus haBmatodes, or encephaloid cancer. Prognosis.—The prognosis of cancer of the testicle is unfavorable, extirpation being generally followed by the return of the disease! CANCER OF THE TESTICLE. 205 Treatment.—From the prognosis it is apparent that the treatment of cancer of the testicle is only followed by temporary relief. There are, however, many cases in which the operation of castration is justifiable, yet, before resorting to so serious a measure, the diag- nosis should be made with great certainty. There is, also, a true fungus of the scrotum consisting of exuberant granulations, which, springing up from a scrofulous or syphilitic ulceration, may readily be cut down with escharotics, and then healed by the proper consti- tutional and local treatment, but which it is, sometimes, difficult to distinguish from cancer, unless close attention is given to the his- tory and symptoms of the case. It may not be amiss to state here with regard to any abscesses of this organ, that great care should be taken not to pick away sloughs from the cavity of the abscess after it has been opened either by nature or by the knife; the whole proper structure of the testis having been thus picked out in strings, and irreparable mischief done through want of expe- rience in the operator. After the testicle has been removed for cancer, the patient will, sometimes, survive longer without a return of the disease than after any other operation for a similar deposit elsewhere. Fig. 49. A representation of the Handkerchief Suspensory Bandage of Mayor. (After Mayor.) During the existence of cancer, the enlarged state of the part, and the necessity of retaining a dressing upon it, render the use of the 206 PRACTICE OF SURGERY. ordinary suspensory bandage impracticable. Under these circum- stances, one formed of two handkerchiefs, and applied as directed by Mayor (Fig. 49), will prove very useful. In its application fold one handkerchief like a cravat, and tie it round the pelvis, then taking the other and folding it from corner to corner to form a triangle, apply its base behind the scrotum, tie the two ends of this base to the circular cravat around the pelvis, and then turning up the summit, fasten it as in Fig. 49. § 12.—CANCER OF THE RECTUM. Cancer sometimes shows itself in the rectum, where it occurs first as a deposit in the cellular tissue beneath the mucous mem- brane, just above the internal sphincter muscle. As the disease progresses, the deposits of cancerous matter encroach upon the mucous membrane; it ulcerates, and a thin sanies or extremely offensive ichor is discharged, which excoriates the orifice of the anus and the parts adjacent. At the same time the symptoms of the cancerous diathesis make their appearance, and pain is expe- rienced, both locally and in the back, from complication of the inguinal and lumbar glands. As the mass of diseased matter increases in size it produces a contraction of the orifice of the rectum, and the stool is squeezed out through the contracted orifice in the form of a broad tape. Diagnosis.—Cancer of the rectum may be mistaken for simple stricture of the rectum resulting from inflammation; for piles; for fistula in ano; for fissure of the anus, &c, &c.; but it is to be dis- tinguished from these complaints by the character of the discharge and of the constitutional symptoms. Prognosis.—The prognosis of cancer, when thus seated, is de- cidedly bad, the patient's life being a mere question of time. Treatment.—The treatment may be both local and constitutional, but chiefly constitutional. Thus, means should be taken to allay pain, to support the strength, and to keep the bowels free; whilst locally, means are required to prevent irritation of the diseased parts by the use of injections of a soothing character, and to cor- rect the fetor of the discharge by the use of disinfectants. FUNGUS H^EMATODES. 207 SECTION II. OF MEDULLARY SARCOMA, ENCEPHALOID CANCER, OR FUNGUS H^MATODES. The synonyms just mentioned are applied to the variety of ma- lignant disease that is sometimes also designated as Soft or Spongy Cancer, from its consistence. The term Encephaloid Cancer, indi- cates the brain-like appearance of the deposit, whilst that of Fungus Hxmatodes is given to it from its disposition to produce a fungous growth, from which violent and repeated hemorrhages are very apt to occur. The best term for the complaint is certainly Medullary Carcinoma, as this at once indicates its true character and appearance. Like carcinoma reticulare, or hard cancer, medullary carcinoma observes certain general laws, which are very much the same as those stated in the former variety. Thus, it has a tendency to transform the tissues in which it is deposited; to enlarge and en- croach upon surrounding structures; to travel along the course of the lymphatics, and invade the nearest glands; to attack more than one point at the same time; and, when removed, the wound heals rapidly, and the disease is reproduced speedily either in the cicatrix or some other part of the body; the chief difference between the two being the greater development and more rapid course of me- dullary carcinoma. Symptoms.—The symptoms of medullary carcinoma in all its seats are as follows: In the commencement it shows itself as a small deposit which creates a moderate, defined, smooth, and even swelling. At first it is firm, and therefore may be confounded with scirrhus, but very soon the difference in consistence becomes obvious to the touch, and even in its earlier development the tu- mor, though firm, is not hard like cancer, and is wanting in the weight which is so apparent in scirrhus. The congestion of the capillaries and small superficial veins over the tumor is also, more marked in this variety than in hard cancer, the whole adjacent structure becoming congested with blood, whence doubtless the rapid development of this form of car- cinoma. As the deposit progresses the tumor increases in size, and soon attains a considerable bulk, presenting at the same time 203 PRACTICE OF SURGERY. so deceptive a feeling of fluctuation, that a surgeon who is not on his guard, may be tempted to plunge a lancet into it, mistaking it for an abscess. As the tumor of medullary carcinoma increases in size, its deve- lopment distends all the tissues which cover it; the skin becomes thinner, and finally yields, cracks, ulcerates, and is followed by ex- tensive sloughing of the diseased mass; or exuberant, pulpy granu- lations, of an imperfect shape, like a fungus, may show themselves, and sprout rapidly like a mushroom, bleeding upon the slightest touch. It is this stage of the complaint which is usually designated as Fungus Hsematodes. As the fungus increases in size, being Fig. 50. A representation of the bleeding fungous stage of Medullary Carcinoma of the Breast, or the form often designated as Fungus Haematodes. (After Miller.) limited about the neck by the orifice in the skin through which it escaped, it assumes more and more of the mushroom appear- ance, whilst the constriction of the stem destroys the vitality of the head-like fungus, and causes it to slough and bleed. In its development inwards, the progress of the disease is such as frequently to create the absorption of surrounding parts; thus, it may destroy muscles and fascia, and encroach upon and lead to the absorption of bone itself, as is not unfrequently seen in its develop- ment in the eye, and in the. bones of the extremities, where it FUNGUS H^EMATODES. 209 creates such changes as were formerly designated by writers as spina ventosa. These will be again alluded to. While the tumor is small, there is generally but little pain, but as it increases in size the pain is very great, often excruciating, yet sometimes better tolerated than the pain of hard cancer, the nerves near the tumor being probably less firmly compressed in soft than they are in hard carcinoma. The fungus which sprouts from the ulcer in medullary carci- noma is of a bloody or livid color, bleeds upOn the slightest touch, and, when it sloughs extensively, gives rise to a most stinking discharge. As the disease progresses, the neighboring lymphatic glands soon become involved, and the patient finally dies, worn out by hectic or by hemorrhage. The constitutional symptoms are such as have been described under the general head of cancer, though they generally occur in a more marked degree in this variety, and have superadded to them the constitutional symptoms which might be expected to arise from a loss of blood. Pathology.—The pathology of medullary carcinoma has been most carefully studied, ample opportunities having been afforded patholo- gists, the disease being by no means uncommon, and soon terminating in death. The present position of the knowledge on the subject is as follows: The disease presents itself in two forms: in one variety a section made through the tumor shows a structure which is soft and brain-like, or rather like decomposed brain or the brain of calves; whilst in the other the substance is firmer, though not hard and tough like scirrhus, but comparatively dense, elastic, and compact, resembling somewhat in its consistence fibro-cartilage or coagulated albumen such as is obtained by boiling an egg. In the soft variety there is that deceptive sense of fluctuation, to which allusion has been made. This tumor is generally round, oval, smooth, or, per- haps, variously lobed, and extending deeply into the adjacent struc- ture, inserting itself into the interstices between muscles, and into the cavities made in the neighborhood of bones, as, for example, between the clavicle and the first rib. In consequence of this tend- ency it may even receive a covering of muscle which is sometimes so attenuated—as the Platysma-Myodes in the case of medullary carcinoma of the neck—as to be scarcely recognizable. Or the deposit may surround vessels, such as the carotid artery in the case of medullary carcinoma of the parotid gland, where the carotid 14 210 PRACTICE OF SURGERY. is found passing through the middle of the tumor. In this respect soft cancer differs from scirrhus, which generally compresses the bloodvessels, and not unfrequently produces an obliteration of their cavity, but seldom or never surrounds them so that they can remain patulous and imbedded in its substance. When a section is made of the medullary tumor, it appears lobed, and presents the outline of cysts. These are often filled with a soft brain-like matter, gray in color, often suffused with pink, which, when squeezed, yields a milky fluid that renders water turbid, but does not float about it in shreds, being the same as has been already designated as "cancer juice." Owing to the great vascularity of the malignant structure, true apoplectic effusions are often found in its tissue, the liquid parts of the blood thus effused being absorbed, leaving a blackish or brownish deposit, resembling coffee-grounds or chocolate. Accord- ing to the amount of these deposits, the vascularity of the tumor, &c. &c., the appearance of a section of an encephaloid tumor will vary considerably, a fact which at once accounts for the great dis- crepancies which exist in descriptions of its character. The firm variety corresponds in shape, in seat, in size, and in constitutional symptoms with the soft, but is tougher, resembling somewhat in appearance the substance of the pancreas, or of the parotid gland. It is not nearly as hard, however, as scirrhus, and yields to pressure, though it requires some little force to compress it. In color, when it is cut through, it may resemble the soft variety, but more frequently it is yellow streaked with pink; and it does not yield the cream-like cancer juice with the same facility as the soft form, though it can be made to do so by soaking it for some time in water. Microscopic Characters.—■Under the microscope both varieties, the soft and firm, are found to present much the same characters, a delicate fibrous tissue being observed to be the stroma or basis of the deposit. It is reticulated in its arrangement, and forms cavities which contain caudate or tadpole-shaped cells with indistinct cell- walls, and not unfrequently free nuclei (Fig. 51) floating in the fluid and surrounded by a little group of granules. These cells are more caudate and have not the same dense cell-membrane as those of scirrhus, as previously described. In the medullary deposit of the breast, Mr. Paget has seen free FUNGUS HJ2MAT0DES. 211 Fig. 51. Fig. 52. Fig. 53. Fig. 51. A microscopic view of the Nuclei of soft Medullary Carcinoma imbedded in a molecular basis substance or stroma without cancer-cells.—Magnified 500 diameters. (After' Paget.) Fig. 52. A representation of various fully-developed Cells and Nuclei of Medullary Car- cinoma, as seen under the microscope.—Magnified 500 diameters. Some of them are larger than the average, others more peculiarly slender, elongated, strip-like or caudate cells, with darkly dotted granular nuclei. (After Paget.) Fig. 53. A representation of the dotted Nuclei of Medullary Carcinoma of the Breast, described by Mr. Paget.—Magnified 500 diameters. (After Paget.) clustered nuclei of a round or oval shape, containing four or five shining granules, but no special or distinct nucleolus (Fig. 53). In another patient, with tumor of the head and neck and deposits in the lungs, he found the appearances shown in Fig. 54. In the former variety of the disease the cells are more generally caudate, and by their parallel and nearly fascicular arrangement give the appearance of fibres. (See Figs. 55 and 56.) Fig. 54. Fig. 55. Fig. 56. Fig. 54. A representation of the clustered Nuclei of Medullary Cancer, composed almost exclusively of round shaded nuclei with three or four shining particles arranged in groups or clusters of five to twenty or more.—Magnified about 400 diameters. (After Paget.) Fig. 55. A representation of the Caudate and variously elongated Cells of a firm Medul- lary Cancer. Magnified 450 diameters.—(After Paget.) Fig. 56. Small elongated Cells and Nuclei with a Nucleus of the ordinary shape from a firm Medullary Cancer.—Magnified 500 diameters. (After Paget.) The practical value of these facts is to be found in their influence on the prognosis of the result of the operation of extirpation. Thus, after having removed a tumor supposed to be medullary sarcoma, if 212 PRACTICE OF SURGERY. a microscopic examination of its substance showed that no such structure as those above represented were present, it would be a great relief to the patient and her friend, and enable the surgeon to make a much more favorable prognosis respecting the case. Diagnosis.—Errors of diagnosis, especially in reference to the existence of an abscess, have been made in numerous instances of soft cancer, and should serve as beacons to those who may here- after encounter it. In one case, an inmate of a public institu- tion fell in the yard, and injured her leg near the middle of the calf. A swelling rapidly followed, which presented a sense of fluctuation so perfect that a very able surgeon, presuming that the blow had resulted in suppuration—so distinct was the sen- sation of fluctuation—plunged a bistoury into it for the purpose of evacuating the pus. No pus was, however, found, but from the wound thus made a fungus sprouted in a day or two, and thus soon revealed the true character of the disease. A cast of the limb is now in my cabinet. The difficulty of making a diagnosis be- tween medullary carcinoma and abscess is indeed much greater than might at first be supposed. In both there is apt to be capil- lary congestion, heat of skin, pain, swelling, and often, in the tumor as well as in the abscess, a distinct sense of fluctuation, owing to effusions of blood into its cells. When, therefore, there is the slightest doubt upon such a subject, time should be taken before an attempt is made to open the supposed abscess; as by such a delay the character of the swelling will shortly become apparent. If it be an abscess, it will soon develop its characters beyond the pos- sibility of a doubt by pointing, whilst if it is a medullary deposit the longer the soundness of the skin is maintained the better for the patient. The hemorrhage which occurs under these circumstances can be controlled by the potential cautery, but it may be kept to some extent within bounds by pressure made upon the parts by a band- age and a compress wet with some styptic, such as the muriated tincture of iron, a weak solution of sulphate of zinc, of alum, or of tannic acid. Prognosis.—In regard to the prognosis of medullary carcinoma, and its progress towards a fatal result, it may be said that, as a general rule, it progresses much more rapidly than scirrhus, and that its return, after removal by an operation, is also much more speedy. MEDULLARY CARCINOMA. 213 Treatment.—As the general indications for the treatment of car- cinomatous disorders have been already given, very little now re- mains to be said, except to express caution against the occurrence of hemorrhage. When this supervenes, as has been already said, caustic and the hot iron will rather add to the mischief than alle- viate it, and pressure, with such means as will facilitate the forma- tion of a clot, only can be relied on. A mass of cobweb, a piece of agaric, or of patent lint or charpie wet with the muriated tincture of iron, may be fastened on with a bandage, and so applied as to make pressure, and is the most successful mode of checking it. If the diseased mass is to be removed by an operation, it should be done only in the early stages of the complaint. The result of such operations is, however, much more unfavorable, that is to say, the disorder reappears much more quickly than after the operation of extirpation in scirrhus. Yet, when extirpation has been per- formed early, it has been found to be comparatively useful, and for the reason that has already been given when speaking of the ope- ration for scirrhus—to wit, that it removes a mass which, in slough- ing, becomes so offensive as to drive off' friends, and render the patient loathsome even to herself. The progress of the disorder and the benefits from an operation, may be well seen in the comparative results given by Messrs. Paget and Lebert, in cases that have, and cases that have not been ope- rated upon. From these writers it appears that the average duration of life in medullary carcinoma, in cases which were not operated on, was about two years from its first being noticed by the patient, which is about one-half the average duration of life in cases of hard can- cer; very few of these cases lasting as long as four years in the slow cases of cancer. But Mr. Paget1 thinks that in some of these life was prolonged by an operation, as the average duration in some of those operated on was twenty-eight months, being four months longer than that which was obtained by general treatment without the operation. The duration of life was as follows: In 51 cases operated upon by Lebert (including 9 of extirpated cancer of the eye), 1 returned within six months after the operation, 13 between six and twelve months, 7 between twelve and eighteen months 8 between eighteen and twenty-four months, 11 between twenty- four and thirty-six months, 3 between thirty-six and forty-eight months, and 8 above forty-eight months. 1 Paget's Lectures, Philad. edit., p. 561. 214 PRACTICE OF SURGERY. But these results are perhaps slightly more successful than usual, as in several of the cases the deposit was situated in the most favor- able parts. Thus, in the list just given, there were nine cases of fungus of the eye, where the disease does not progress as rapidly to a fatal result as in some other parts. Prognosis of the Operation.—The prognosis of the probable period of the return of the disease varies somewhat in connection with the part operated on. Thus, a patient will live longer after the opera- tion of castration for medullary carcinoma, than after the removal of it from any other part of the body. The eye gives the next greatest longevity, then the bones, and last of all the soft parts, of which those of the extremities present the least possible chance of success, as, after amputation of the thigh for this disorder, the patient not unfrequently dies in a few weeks, with general medul- lary infiltration through the lungs and other viscera. § 1.—MEDULLARY CARCINOMA, OR FUNGUS OF THE EYE. Medullary carcinoma of the eyeball is not a very common dis- order, yet it is seen more frequently than scirrhus of the same organ. It is also found in a different class of patients; scirrhus of the eye being seen in the aged, medullary carcinoma almost always in children, and most frequently in those beautiful fair-skinned, fine-haired, blue-eyed children, whose beauty, though too sure an evidence of the scrofulous taint, is so attractive. Symptoms.—Often the first indication of the approaching inroad of medullary disease of the eye will be that the little patient com- plains of dimness of vision, or of some slight weakness of the eye, which is shown in increased lachrymation, and moderate tumes- cence of the conjunctival vessels, as well as of those of the sclerotic coat. Attention being thus drawn to the organ, the surgeon will some- times see an appearance in the posterior chamber which resembles the lustre of polished steel or iron. As the disease progresses, the pupil becomes dilated and immovable, the iris changes its color, and at last a solid substance shows itself through the pupil, distends the coats of the eye by growing forwards, and protrudes the ball by growing backward, till at length the cornea and other coats of the eye burst, and a bloody fungus makes its appearance. Meantime the lids are distended, ulcerate, and present fungous granulations; COLLOID CANCER. 215 the pain becomes intense, and indicates great suffering, and a frightful appearance of the parts and of the countenance is created. Diagnosis.—Medullary carcinoma may be distinguished from hard cancer of the eye by the difference in the age of the patient affected, by the fact that hard cancer commences in the anterior structures of the eye or of the orbit, such as the conjunctiva or cornea, or the lids, lachrymal gland, &c, while medullary carcinoma begins in the pos- terior part of the ball, as in the choroid coat and retina, growing from behind forwards. The size of the tumors is also different, the medullary carcinoma creating the greatest vascularity of the skin over it. Prognosis.—The prognosis is unfavorable. Treatment.—Some temporary relief may be afforded by extirpa- tion of the entire eyeball in certain cases, but the disease will, of course, return and carry off the sufferer.1 The other seats of this deposit are the same as those detailed under the head of Scirrhus, and require but a few words. Some- times it is found in the Parotid Gland, where it frequently attains an enormous size. It also attacks the Breast not unfrequently; the general diagnosis and prognosis of carcinoma generally being appli- cable to it in all these situations. When the disease attacks the Testicle, there is of course swelling of this gland, with great enlargement and a disposition in the de- posit to travel along the course of the cord. The disease is also seen in the Skin, in the structure of the Limbs, &c, but these do not require further allusion. SECTION III. COLLOID CANCER. Colloid cancer, or the "carcinoma alveolare" of Miiller, is a variety of carcinoma sometimes alluded to as a special form. It is, how- ever, only a greater degeneration of the medullary carcinoma, and is generally found deposited in the internal organs, as in the sto- mach, the intestines, the uterus, &c, and therefore seldom requires 1 For an account of the operation, see Op. Surg., vol. i. p. 292, 2d edition. 216 PRACTICE OF SURGERY. direct surgical interference. The constitutional symptoms are the same as those of medullary carcinoma. Yfhen this form of the disease is examined under the microscope, a reticulated structure is seen filled with cells which contain a pe- culiar colloid, glue, or jelly-like substance, from which the disease derives its name. It is a mere degeneration of the other forms of the disease. SECTION IV. MELANOSIS. Melanosis, or black cancer, is a rare variety of carcinoma cha- racterized by the deposit of a blackish or bluish matter. It is generally found in the reticulated tissues, and particularly in those connected with the skin. It is also found in connection with the choroid coat of the eye. The microscope reveals that in all these cases the coloring is produced by a deposit of peculiar black pig- ment-cells. Fig. 57. A representation of the Cells of a Melanotic Tumor of the Cheek, which are more or less loaded with black pigment. (After Bennett.) Mammary and pancreatic sarcoma were old names applied to the firm variety of medullary carcinoma, and intended to designate the resemblance in appearance between sections of the diseased mass and of the pancreas or mammary gland. BENIGNANT TUMORS. 217 CHAPTEE II. OF BENIGNANT TUMORS. Tumors present a class of complaints which are interesting to the surgeon not only because they often require operative inter- ference, but because they illustrate some of the modifications of the processes of healthy development and nutrition. So attractive has this subject proved, that these growths have been carefully studied, whilst many excellent monographs have been written upon them among which the American student may find that of his dis- tinguished countryman, the late Dr. Warren, of Boston. With so extended a range it would be impossible, in a general treatise, to do more than give a very brief outline of their general character. For the purpose of limiting discussion we shall confine ourselves to Hunter's definition of Tumors, although not strictly accurate, nor corresponding entirely with our present knowledge. Accord- ing to Hunter, " tumors are circumscribed substances produced by disease, and differing in nature from the surrounding parts." This definition, it will soon be apparent, is, in some points, inac- curate, for tumors may be produced by an action (such as simple hypertrophy), which cannot be properly called disease, because, as in the case of adipose and other homologous tumors, they do not differ in nature from the surrounding parts. A close investigation of the origin of tumors would also lead to the consideration of some of the most occult questions connected with the process of nutrition, and though interesting, it is one which belongs more properly to a treatise on physiology than to one on surgery. It may, therefore, simply be stated that a tumor is gene- rally the result of a modification of structure commencing, as Vogel says, in the organization of a blastema. Sometimes, however, tumors are formed, not from a blastema, but solely by an obstruc- tion in the ducts of certain follicles or glands, as the ducts of the sebaceous follicles—in sebaceous tumors—or the ducts of the sali- vary glands—in ranula or salivary tumors—or the ducts of the 218 PRACTICE OF SURGERY. mucous follicles of the Schneiderian membrane, as in certain forms of polypus of the nose and of the uterus. The exciting causes of tumors is unknown. They have been at- tributed to a great variety of causes, but it is better to confess our ignorance on this subject. With regard to their seat, it may be stated that they are generally found in connection with the areolar or dermoid tissues, and in the lymphatic and other glands. Varieties.—Tumors may present many varieties, and have been variously classified:— I. As Analogous or Homologous, where they consist of a struc- ture similar to that of the surrounding parts; and 2, as Heterogeneous where the structure differs from that of the surrounding parts. Then again they have been classified as Benignant, when the tendency of the disease is kind, and when the tumor seldom does other mischief than such as results from its bulk and its encroach- ment on surrounding parts; and as Malignant, the characters of which have been already described. So also there are Cystic tumors, which consist of one or more cysts; and Fibrous tumors, which consist of a structure resembling the white fibrous matter of normal tissues; Adipose tumors, which consist of fat, and Sarcomatous or fleshy tumors. A very interesting question arises in this connection. Can be- nignant tumors become malignant, and the reverse ? With the pre- sent knowledge of histology there need be no hesitation in saying that there are circumstances depending upon the constitution of the patient, upon the diathesis, upon hereditary influences, &c, in which tumors primarily benignant may assume all the characters of malignant growths. But such change can not be accurately desig- nated as a degeneration, the original cells not losing their true cha- racters, though as a tumor of the benignant class may serve as a focus of irritation in a patient of the cancerous cachexia, it may become the nidus of a malignant deposit, which will subsequently blend itself with it, as it does with normal glands and healthy tissues. A brief enumeration of such points of the history and characters of benignant tumors as will suffice for their diagnosis is all that can now be offered. SIMPLE sarcoma. 219 SECTION I. THE SIMPLE SARCOMA. Sarcomatous tumors have been so designated because they pre- sent to the naked eye the ordinary appearance of flesh. These tumors consist either in changes of the skin due to hypertrophy, an example of which is to be seen in the case of the scrotal tumor of the negro Wilson already alluded to; or they may be due to changes in a gland in consequence of which the structure of the gland dis- appears and a tumor presents itself. This, when cut through, ap- pears to be homogeneous, and to consist not of muscular fibre, as its name would indicate, but of fibrous tissue variously arranged, and the fibres of which can sometimes be seen when well developed with the naked eye. Under the microscope these tumors are found to contain cells like those of organizing corpuscular lymph, exuda- Fig. 58. A Series op Diagrams representing Microscopic Sections op a Sarcomatous Tumor, as removed from the Female Breast, consisting mainly of the Fibrous Structure of the Gland, with enlargement of the included Ducts and their Epithelial Linings.—A. Section of the epithelium from one of the tubes, a. Section of epithelium, b. Group of epithelial cells, c. Same after addition of acetic acid. B. Thin sec- tion of the same tumor after the addition of acetic acid. C. Another section transverse to former, and similarly treated. (After Bennett.) tion or granulation corpuscles. Fibres will also be observed; these fibres being like those found in the ordinary fibrinous lymph al- ready described in connection with the subject of inflammation. 220 PRACTICE OF SURGERY. In external appearance these tumors vary very much. They vary also in size, and are most apt to occur in early life. Generally they are oval or globular in their shape, firm and doughy in feel, and present no sense of fluctuation. They are very loosely attached, and are not liable to inflammatory action, this last fact being of import- ance as aiding in their diagnosis. They also increase very slowly in bulk, are without pain, are surrounded generally by a fibro- cellular capsule which isolates them, and seldom degenerate, although cases will occur occasionally in which a deposit of cancer cells may be made in them in persons laboring under the cancerous diathesis. The name by which they are designated (simple sarcoma or sarcomatous tumors) is a very objectionable one, and is a remnant of an old nomenclature based upon deceptive appearances to the naked eye, which the microscope has exploded. These tumors, properly speaking, are not sarcomatous; they are not fleshy, they contain no muscular fibres, and the name given to them by Lebert, of Fibro-plastic, and which indicates their true character, is an infi- nitely preferable one. These tumors may be situated in various portions of the body. They are not unfrequently found upon the ocular conjunctiva, where they attain sometimes the size of a pea or of a small pistol bullet. They are also often found in the neigh- borhood of the mammary gland, being generally more or less dis- tant from the nipple, with which they do not contract adhesions, and do not, therefore, retract the nipple as the tumors did which were caused by malignant deposits. They are also often found in the deeper portions of the areolar tissue of the body, between the muscles, or buried in their inter- stices, as among the muscles of the buttock and of the thigh. Treatment.—-The treatment of these tumors is necessarily purely operative. It is useless to attempt to cure them either by resolu- tion or by suppuration, as the firm, fibrous sack, by which they are surrounded, prevents anything like absorption. They do not take on inflammatory action nor suppurate, and the only mode of getting rid of them is by extirpation. ADIPOSE OR FATTY TUMORS. 221 SECTION II. FIBROUS TUMORS. Fibrous Tumors are also called Desmoid, from the Greek 8tsfio;{\) a ligament. They are firm and dense in structure, and often lobu- lated on the surface, being invested generally by a thick, strong sac, which surrounds them. They are circumscribed and movable independent of the surrounding tissues. When, on account of their size, they attain considerable weight, they induce elongation of the skin by traction, and hence they are very often pendulous, having a circumscribed base. They are painless, of slow growth, and have their seat in the neck, the mammary, or parotid gland, the back, the uterus, &c. The chief inconvenience which they induce is from their bulk and their pressure upon surrounding parts, as they are indisposed to take on inflammatory action, and seldom become the seat of malignant deposits, although of course that result may occur in those who are predisposed to carcinomatous disorders. They are never absorbed, and, like the sarcomatous or fibro-plastic tumors, can only be removed by extirpation. A favorite seat of these tumors is in connection with the bones, which sometimes they cause to be absorbed, producing, according to their position, de- formities, which are very striking in certain localities, as, for ex- ample, where the antrum Highmorianum is involved, this locality being one of the most common seats of the complaint. SECTION III. ADIPOSE OR FATTY TUMORS. The class of Fatty tumois, to which in old times the name of adipose sarcoma was applied, but which are better designated as adipose tumors, present various characters. To the eye they re- semble ordinary fat, but, when examined with the microscope, present crystals of margarin and cholesterin, with cells containing a peculiar fatty matter, which has been designated as " Cholestea- toma" by Miiller. 222 PRACTICE OF SURGERY. Fig. 59. FiS- 60- Fig. 59. A representation of the Structure of an Adipose Tumor removed from the Back. a. Isolated cells, showing the crystalline nucleus of margaric acid. (After Bennett.) Fig. 60. A view of Cholesteatoma or Fatty Tumor removed from under the Tongue. It was as large as an orange. (After Liston.) SECTION IV. LIPOMA. By the term Lipoma is designated a tumor consisting of cells which present a marked resemblance to the ordinary cells of fat. Such a tumor, when cut through, appears simply like a mass of ordinary fatty tissue. Lipomatous tumors present the following general characteristics. They are generally lobulated, globular, oval, or cylindrical in their shape. They are elastic to the touch, and in true Lipoma give a sense of fluc- tuation which is very deceptive. Like fibrous tumors, or fibro-plastic, when they attain any very great size, they are apt to become pedunculated from stretch- ing the skin by their weight. Their growth is slow, but steady; they are never absorbed, and cannot be discussed: they must, therefore, be extirpated, if the patient is disposed to get rid of them. They are not very vascular, and, when they are removed by operation, do not gene- a representation of the Lobu- rally bleed freely; and although hemor- lated Lipomatous Tumor, with its i_ xi i -n o ,i various lobuii. (After Miller.) triage takes place occasionally from the cut edges of the skin, it is seldom of a character to require the ligature. Fig. 61. ENCYSTED TUMORS, OR WENS. 223 SECTION V. ENCYSTED TUMORS, OR WENS The Encysted tumors, or Wens of common language, demand also a brief notice. The term wen is indiscriminately applied by the vulgar to all swellings of a chronic character. It should, however, be restricted to a class of tumors which are variously formed of cysts or sacs. Sometimes they consist of condensed areolar or cel- lular tissue; and sometimes the whole tumor is only the result of the obstruction of the ducts of certain glands or follicles, the cyst being formed by the enlarged and hypertrophied duct. Such is sometimes the case in obstruction of the duct of the submaxillary gland, where the tumor is designated by the special name of Ea- nula. Sometimes the obstructed duct is that of a sebaceous folli- cle, and then of course the tumor will contain sebaceous matter. These encysted tumors have sometimes been designated as Cysto-Sarcomatous, an improper name, to which the objections already urged against the name Sarcoma will apply. One point may be mentioned here which is of practical importance, and that is that if in the removal of the tumor any portion of the cyst be allowed to remain, it has been found that the patient is liable to a repetition of the complaint, this being particularly the case in those forms of encysted tumors which are due to the obstruction of the ducts of glands. Encysted tumors are not unfrequently seated in the scalp, in the eyelids, in the cheeks, and upon the neck. Treatment.—In the cure of these tumors it is essential that they should be tho- roughly extirpated, the sac being entirely removed, either by the knife or caustic. There are certain old names used to designate these tumors derived from the appearance of their contents, rather than from Example of the Cysto-sarco- matous Tumor of the Breast— the cysts being distinctly lined by a secreting membrane, and filled with a glairy fluid. The cells are part of the original structure dilated. (After Miller.) 221 PRACTICE OF SURGERY. their structures—such as melicerous, atheromatous, and steatoma- tous. By a melicerous tumor is meant an encysted tumor, the contents of which bear a resemblance in appearance to honey (from the Greek word ps\, Honey. The term Atheromatous was applied to tumors containing a thicker material than the contents of the melicerous tumors, and was be- stowed upon them on account of their consistence, resembling that of pap; the derivation being the Greek word aflapa*, signifying pap. Then, again, there are other encysted tumors, to which the term Pilous is applied, from the fact of their containing hair. How the hair gets into this position may be conceived when it is remembered that these, encysted tumors are often due to the obstruction of the duct of the sebaceous gland, and that the sebaceous glands are closely connected with- the hair follicles, the latter often opening into them. It can therefore be easily understood that when a hair follicle becomes so involved as to get within the cavity of such a tumor, the hair may continue to grow, perhaps more rapidly than nor- mally, on account of the hypertrophied condition of the parts, until a considerable amount of it will have accumulated. There is an- other class of pilous tumors sometimes found externally, although more frequently in connection with the ovary, which consist of the remains of a degenerated and disorganized foetus. Such tumors frequently contain not only hair, but also bones and teeth. Treatment.—When it is intended to extirpate encysted tumors, a bistoury should be run through both the skin and the tumor, so as to slit them open; after which one-half of the sac should be seized with one pair of forceps, whilst the skin of the corresponding flap of the wound should be held by another, when the sac can be drawn out. If any little portion remain it should also be removed or cauterized freely, lest it continue to secrete, and thus reproduce the tumor. This plan of evulsion is a much simpler and expeditious mode than thoroughly dissecting out the sac without rupturing it, and there is less danger of hemorrhage, because the little vessels sup- plying it with blood are lacerated and not cut. CHONDROID TUMORS. 225 SECTION VI. CHONDROID TUMORS. Another variety of tumors are those to which the name of chon- droid or enchondromata has been applied, on account of their re- semblance to the general characters of cartilage. These tumors are often found in connection with the bones, with the joints, and with certain glands, as the testicle, mammary, sub-lingual, and the paro- tid glands, whilst many other forms of tumors will often take on this chondroid character. The enchondromata or chondroid tumors are composed of a mass of cartilage-like material, or of numerous masses, held together by condensed fibrous tissue. They are hard, especially to the touch, when they have a bony base, and, when cut into, act precisely like gristle or cartilage. In their chemical characters they are identical with foetal cartilage, contain- ing, like them, large quantities of that peculiar modification of gelatin which is known as chondrin. Like the tumors already described, these can only be removed by extirpation. Under the microscope, chondroid tumors present a great diversity of struc- tures, which Mr. Paget1 describes as follows: A basis or intercel- lular substance, variable in quantity, the cells or nuclei lying wide apart (Fig. 63); in some closely crowded, and varying in con- Fig. 63. Fig. 64. Fig. 63. A microscopic view of a thin section of an Enchondroma from the Pelvis. (After Bennett.) v Fig. 64. A microscopic view of the Corpuscles from the softened part of the same Tumor. (After Bennett.) 1 Lect. Surg. Pathol., p. 423, Phil. edit. 15 226 PRACTICE OF SURGERY. sistence with all possible grades. Sometimes they are composed of a fasciculated tissue, in which cartilage cells lie elongated and im- bedded. (Fig. 64.) Some present the typical form of healthy pre- paratory cartilage cells. Osseous tumors will be treated of hereafter when we come to speak of the diseases of the bones. SECTION VII. TUBERCULOUS OR LYMPHATIC TUMORS. Tubercular or scrofulous tumors are those which are the result of the deposit of tuberculous matter in certain structures, as the lymphatic glands, particularly those of the neck and axilla. They are usually of moderate bulk, though they may attain considerable size, especially when several lymphatic glands are involved at the same time. They are very apt to be indolent in their character, but their natural tendency is to inflammation and suppuration. Treatment.—In their treatment they may not unfrequently be dispersed. Locally they do mischief by pressure and by exciting inflammation in the subjacent structures. As a general rule they will be benefited by the constitutional treatment proper to scrofula, as tonics, good diet, iodine, &c. &c. When chronically enlarged, indolent, refusing to be discussed, and of sufficient bulk to cause serious inconvenience, they may sometimes require extirpation. SECTION VIII. GENERAL RULES FOR TREATMENT OF TUMORS. In the extirpation of the above, or indeed of any other tumors, the following general rules ought to be observed: 1. Make the exter- nal excision sufficiently large to give free room to work, there being no greater mistake than to refrain from making the primary inci- sions sufficiently free. 2. Select such a shape for the incision as will best give a free opening, and yet unite neatly. If the tumor is a small one, a simple V-shaped incision will suffice, the incision being commenced a little beyond the circumference of the tumor, GENERAL RULES FOR TREATMENT OF TUMORS. 221 and drawing towards the centre for the first cut, and the reverse for the second. Larger tumors, particularly those that are pedun- culated or pendulous in their character, may be removed by making two simple semicircular, semilunar or elliptical incisions. Two in- cisions formed in the shape of an L or a T, will give very free openings, but the freest will be obtained by making a simple crucial incision and turning back the four flaps. As a general rule all these incisions should be made from the circumference towards the centre of the tumor. There are certain other rules which deserve to be remembered, a very excellent one being that laid down by Dr. Alexander Stephens, of New York, in a valuable paper written by him some time since upon this subject, to wit, to make the first or second cut of the knife pass down on to the tumor itself, this always being thoroughly done before commencing to dissect it out. If this rule is not followed, the surgeon may wander off from the tumor into the surrounding healthy tissues. Another rule is in regard to the manner of using the knife, which should be held like a pen, and drawn with long sweeps; for if the surgeon holds it so that the point can be used, and pricks at the bottom of the wound with short cuts, he may open a large artery, wound a nerve, or do some other mischief, which attention to this rule would have avoided. The entire tumor should be removed, and none left if possible, as the patient will then be much less liable to a return of the com- plaint. In order to control the tumor, it is a good practice to pass through it, at the commencement of the operation, a large needle, armed with a strong ligature, which, after the needle is removed, should be tied in a loop, so as to give the surgeon perfect hold of the mass to be removed. When large vessels or nerves are in the neighborhood of tumors, they should be protected from the edge of the knife by holding them out of the way by a blunt-hook. It is also a good rule, as suggested by Langenbeck, to use the knife, and especially its point, as little as possible in the neighbor- hood of large vessels; the tumor being separated rather by traction with the fingers, or by the knife-handle. After the tumor is re- moved, the wound should be carefully examined, to see that the 228 PRACTICE OF SURGERY. work is thoroughly done, any little portions that may have been left being then removed. In operations upon the neck, in which the large veins are in- volved, great care should be taken to prevent the entrance of air into them. In the after-treatment, the surgeon should be careful not to allow the wound to unite superficially before the deeper parts have adhered. Another good rule is to keep a little piece of lint in one corner of the wound of the skin, so as to prevent its healing till the deeper parts have thoroughly united.1 A very few words may be said in this place with regard to the microscope as a means of diagnosis, this being a point upon which there has been much discussion, and on which there is yet much diversity Of sentiment. The general opinion of surgeons at pre- sent appears to be as follows: that, as a means of diagnosis, the microscope is certainly of great utility, though it must be em- ployed with care, and seldom can be used until after the tumor has been removed, when it will materially aid in deciding finally the question of diagnosis, and confirm or relieve the fears of the surgeon and patients as to the malignant character of the dis- ease. It should, however, be chiefly regarded as an adjuvant to the knowledge of the general characters of tumors furnished by clinical experience. When a diagnosis formed upon a thorough investigation at the bedside is confirmed by the discovery with the microscope, after an operation, of the characteristic details of cer- tain growths, the prognosis of the result of the treatment will be rendered much more certain. The two together (microscopic and clinical observation) are as nearly perfect in their conclusions as our finite senses can make any observation; but either, alone, is liable to mislead the observer, and establish incorrect results. 1 For further details on the removal of tumors, see the volumes on Operative Surgery by the Author. PART IY. OF INJURIES OF THE SOFT TISSUES. After the consideration of the varied action created in the soft tissues by the modification of their nutritive powers, as seen in inflammation and in the development of malignant and benignant tumors, the process of repair after injuries, and the formation of new tissue, is naturally the next subject that should be presented to the student's attention. Process of Repair in the Soft Tissues.—The changes seen in the repair of injuries in the soft tissues of the body, may be briefly stated as follows: In the first place, inflammatory action being de- \ veloped by the injury, lymph or plasma is effused, becomes or- ganized, and finally approximates in its character to the general appearances of that tissue which has been destroyed, as was men- tioned under the section on the effusion of lymph (page 83). That the presence of the nuclei in the adjacent tissues exercises a marked influence upon the peculiar character of the new cells formed in the plasma, seems to be probable, from the fact that lymph formed by or on the periosteum ultimately results in the development of bone, whilst that from tendons, muscles, and skin approaches more nearly to the character of these tissues. The reparative process seems also to be modified, to some extent, according as the newly effused material is exposed to the direct action of atmospheric air, or so situated as to be protected from its influence. The effect of the atmosphere on the repair of injuries of the soft tissues appears to have been early noticed by surgeons, and to have attracted the especial attention of Mr. John Hunter, who laid down the general principle that those injuries which do not communicate with the external air seldom inflame; whilst those to which it has access usually take on a degree of inflammation that is very apt to result in the establishment of 230 PRACTICE OF SURGERY. suppuration. In the first case, the repair is prompt and certain; whilst in the second it is tedious, and liable to failure. Various instances might be cited in corroboration of the correctness of this principle, such as the rapid healing of the tendo-Achillis, when divided in the treatment of club-foot by the subcutaneous section, the tendon being firmly united in this case in forty-eight hours; whilst in its division by an open wound it would be many days be- fore the reparative process would be completed. The same thing is noted also in injuries of the hard tissues, where the process of union is much more rapid in a simple fracture than it is in a compound one, or one that has a wound in the integuments that permits the entrance of the atmosphere to the seat of injury. As the details of the reparative process in the soft tissues are usually studied under one general class of injuries, the subject of wounds may now be presented. CHAPTER I. GENERAL CHARACTERS OF WOUNDS. A wound is usually defined as "a solution of continuity in the soft tissues, produced by violence, and communicating externally." When created, the injury results in hemorrhage, &c, as will be presently stated. SECTION I. OF THE HEALING OF WOUNDS. There are three principal methods in which wounds may be closed by nature. The first is that by "immediate union;" or the first intention of McCartney. The second, "union by adhesive inflammation." The third, "union by the second intention," or by granulation. To this some writers add another under the head of " the scab- bing process." THE HEALING OF WOUNDS. 231 Union by the first intention of McCartney, that by adhesive in- flammation and that by granulation having been already explained, the scabbing, or that process in which a wound heals under the pro- tection of a scab or crust, becomes the first object of attention. Healing of wounds by the scabbing process has lately attracted notice, and is supposed by some to be an extremely desirable mode of union, so much so that they direct, in cases of certain wounds, and especially those which communicate with closed cavities, the creation of an artificial scab, or one made by dusting some dry powder over the wound, applying dry lint, or covering it with the white of egg or collodion and permitting it to dry. This scabbing process may, in some instances, prove useful; yet in many it is objectionable. If the scab is sufficiently complete to exclude the air, which is one benefit supposed to be derived from its use, and the wound is of any size, the discharges will be retained—be liable to burrow—to become acrid, and to retard the process of granula- tion; and if it is not complete enough to produce this effect it ■ admits the atmosphere, and the benefits claimed as peculiar to it cannot possibly be obtained. In very superficial wounds, the scabbing process answers very well, but in those of considerable depth it is objectionable. An- other mode by which wounds heal is by that which is designated as the " Modelling Process of McCartney." This process being the result of the effusion of plasma, is really only a modification of the ordinary union by granulation, and although it has been much dis- cussed, does not appear to be deserving separate consideration. With regard to the comparative value of the two processes of healing in wounds, that is, " union by adhesion" or " union by granulation," there is a diversity of sentiment. Generally it is sound practice to seek for union by the first intention, or by adhe- sive inflammation in every wound, as it is the safest and most rapid mode of cure, whilst if it fails, it does not in any way retard the subsequent union by granulation. As the production of wounds was attended by hemorrhage, the question soon arose among surgeons whether effused blood was employed by nature as a bond of union, or whether it did not retard the cure. As all wounds give rise to an effusion of blood and this was considered in fact as " the life of the creature " the earlier surgeons believed that the blood was useful, and never removed a clot from the wound, but rather encouraged its forma- 232 PRACTICE OF SURGERY. tion in all instances. Even as late as the time of Mr. Hunter this opinion was generally maintained, and was subsequently supported by the experiments of Sir Everard Home, Carswell and McCartney, who supposed the clot to be useful because they knew it contained fibrin, which they believed capable of organization, because they had succeeded in injecting a clot. Subsequent examination confirmed the fact that ablood-clot"might become organized and even assume the character of a tissue, coalesce with adjacent parts and become vascular,"1 as was shown in 1845 by the experiments of Dr. Zwicky. In 1848 Mr. Paget also had an opportunity of confirming Zwicky's account of this organization in a clot obtained from the arachnoid of an insane person, where a thin layer of a pale ruddy membrane lined the whole internal sur- face of the dura mater, and adhered to it, whilst its color, &c, satis- factorily proved that it had been a thin clot of blood effused in apoplexy. " Numerous small vessels could be seen passing from the dura mater into this clot membrane, and while they were still full of blood, Mr. Paget made the sketch shown in Fig. 65. "The minute structure of this clot is shown in Fig. 6Q, and bears Fig. 66. (After Paget.) a strong resemblance in its general structure to the characters seen m the material formed for the repair of subcutaneous injuries, as in 1 Paget's Lectures, Phil, edit., p. 120. THE HEALING OF WOUNDS. 233 the substance of what appeared like a filamentous clot of fibrin sprinkled over with minute molecules, the addition of acetic acid brought into view corpuscles like nuclei or cytoblasts, very elon- gated, attenuated, and, in some instances, like short strips of flat fibres."1 Notwithstanding these appearances, so analogous to the reparative process in fibrin, Mr. Paget became satisfied " that ex- travasated blood had usually no share in the repair of wounds; as the smallest portion of blood was effused in cases where the largest amount of reparative material was produced in the shortest time, and that therefore extravasated blood was not necessary for union by the first intention, though the lymph around it became organized."2 After showing how the blood-clot was removed from a wound by ejection, and how it is absorbed as unnecessary, he states the following as his conclusions, in which every experienced surgeon will doubtless coincide. " 1. Blood is neither necessary nor advantageous to any mode of healing. " 2. A large clot, if at all exposed to the air, irritates the part and is ejected. "3. In more favorable conditions, the effused blood becomes in- closed in the accumulating plasma, and, while this is organizing, the blood is absorbed. " 4. It is probable that the blood may be organized and form part of the reparative material; but even in this case it probably retards the healing of the injury."3 As the blood-clot thus retards the healing of wounds, it might be deemed advantageous to keep the wound open until all hemor- rhage had ceased, and the clots could be ejected; but this is not so, it being sound practice to close it as soon as possible and thus pre- vent the further flow of blood by direct contact of the sides of the wound by gentle pressure. • To illustrate the importance of promptly closing wounds in which adhesion is desired as well as the occurrence of union under most unfavorable circumstances, the following cases are cited from the work of Mr. Thompson:—4 When Pharavant, a surgeon of the 16th century, was in Africa, " there happened," says he, " a very strange affair; a certain gentle- 1 Op. citat., p. 121. 2 Ibid., p. 122. 3 Op. citat., p. 124. 4 Thompson on Inflammation. 234 PRACTICE OF SURGERY. man, a Spaniard, called Gutiers, of the age of 29 years, upon a time walked in the field and fell at words with a soldier, and began to draw; the soldier seeing that, struck him with the left hand and cut off his nose, and there it fell down in the sand. I then hap- pening to stand by, took it up and pissed thereon to wash away the sand, and dressed it with our balsamico artificial, and bound it up, and so left it to remain eight or ten days, thinking that it would have come to matter. Nevertheless, when I did unbind it I found it fast conglutinated, and then I dressed it only once more, and he was perfectly whole, so that all Naples did wonder thereat, as is well known, for the said Signor Andreas doth live, and can men- tion the same." Bleigny also mentions a case in which, after the nose had been cut off for some time, it was applied and perfect union resulted ; and Balfour records one in which a finger, being chopped off in a carpenter's shop, in cold weather, fell down among the shavings and remained some time; yet afterwards, being taken up, washed in warm wine and reapplied, perfect union occurred. Duhamel and Hunter also performed numerous experiments on this subject, by successfully transplanting the spur of a cock to his comb, and the teeth of one individual into the mouth of another, &c. &c. In the latter cases, though union doubtless occurred, yet it was not the result of a true adhesive process, but rather due to the effusion of lymph around the transplanted bodies and the prolongation of bloodvessels through it from the healthy tissues. These facts, however, certainly show, that even when the separa- tion of divided parts has existed for some time, the surgeon should attempt in case of the lopping off of small portions of the body to replace them, particularly if they are such that great deformity or inconvenience would result from the loss. The experiment may often fail, but it will also sometimes succeed, and the result justifies a trial. The process of union in wounds by means of granulation and cicatrization yet requires a few words in addition to what has been already mentioned. When wonnds heal by these processes, the coagulable lymph which is effused as the product of the inflamma- tory action consequent on the creation of the wound passes through the changes of the formation of granules, nuclei, and cells, and soon becomes organized by the fusiform enlargement of vessels, these HEMORRHAGE FROM WOUNDS. 235 vessels soon creating granulations, and giving rise to the secretion of pus. Such vessels in a suppurating wound are usually arranged as seen in the figure. Fig. 67. A representation of the general arrangement of the Vessels on the surface of a Suppurating Wound, or one healing by the second intention. (After Paget.) In the healing of wounds of such a character and extent as pre- vents the approximation of their sides, the lymph is simply effused on the cut surface; becomes vascular, as seen above; connects the two surfaces by the formation of numerous granulations; "forms on their surface, near the edges of the wound in the skin, a thin layer of cellular tissue, on which a very delicate layer of cuticle is soon developed, and a cicatrix commences to form; the smooth shining surface of this new cuticle giving the peculiar character to the recent scar, which is so constantly seen after the healing of all wounds."1 The time required for these changes varies according to the amount of new material that is required; the whole process being dependent on the preservation in the part of such a degree of heat and moisture as will favor the organization of the granulations. SECTION II. OF HEMORRHAGE FROM WOUNDS. An important point for study in connection with the treatment of wounds is the various means at our disposal for the arrest of hemorrhage, and in order that the student may more readily un- 1 Paget on Repair of Tissues. 236 PRACTICE OF SURGERY. derstand this subject, a brief description of the coats of the arteries must be given, their vital action being essential to this process. Coats of the Arteries—-The coats of the arteries are three in num- ber : 1. The external or fibrous coat, in which Henle has detected genuine elastic tissue, and which gives the chief strength to the vessel. It is this coat which generally sustains the traction prac- tised upon the artery in the movements of life as well as by the ligature after the division of the internal and middle coats. 2. The middle coat, which is muscular in its character, and presents circu- lar fibres internally, as well—judging chiefly from analogy—as lon- gitudinal fibres or an elastic tissue externally. This muscular coat is frequently, in old persons, and in those accustomed to the free use of alcoholic drinks, the seat of osseous deposits, which make the artery so brittle that it will break off in tying it, whilst the cal- careous matter keeps its orifice as patulous as a pipe-stem when the vessel is divided. 3. The lining membrane of the artery, or, as it is commonly called, its serous coat, is thin and delicate in its struc- ture, lines the heart and arteries throughout their extent, and, like all serous membranes, readily takes on inflammatory action, the tendency of which is to adhesion rather than suppuration; a very important point to be remembered in connection with the subject of the ligation of arteries. Besides studying the anatomical structure of the arteries, it is important to understand the physiological effects produced upon them by such wounds as divide their coats, as well as to examine the steps by which nature closes them. Effects of Wounds on the Arteries.—After an artery has been wounded, certain changes occur which vary in accordance with the line of the incision; these changes being chiefly due to the con- traction of its muscular coat. Thus, a simple perpendicular cut through the coat of an artery, becomes, in consequence of this con- traction, a gaping wound. (Fig. 68, 1.) An oblique cut (2) gives a wound like that seen at the upper part of the same figure, the wound being dilated by these same contractions of the muscular coat. It follows, therefore, that a partial division or puncture of an artery, will give a more patulous orifice, and one more likely to bleed, than a wound which completely divides the vessel, because, if the artery is cut entirely across, the fibres which in a partial division dilate the wound by drawing it to each side, will, by their circular contraction, close the orifice, and thus prevent hemorrhage. NATURAL HAEMOSTATICS. 237 Fig. 68. 1 2 3 A DIAGRAM TO SHOW THE EFFECTS OF WOUNDS OF AN ARTERY AND THE ACTION OF the Muscular Coat upon the Size of the Orifice in the Vessel.—1. A simple lon- gitudinal incision, near the bottom of the figure, which is represented as gaping at the upper end, under the action of the circular fibres of the muscular coat. 2. An oblique incision, with its consequent enlargement by the action of the muscular coat. 3. A trans- verse, but smaller wound, which gaps much more in proportion to its length than either of the others. 4. A'transverse incision of the same length as those represented in 1 and 2, but causing a very wide gap by the action of the elastic coat of the artery. (After Liston.) Hemorrhage resulting from the di- vision of an artery may be arrested either by natural or by artificial means, such means being designated as haemostatics {aifta, blood, sta^s, stagnation). § 1.—OF NATURAL HEMOSTATICS. The means by which nature checks hemorrhage are to be found, first, in the arrest of the local circulation, and the formation of a coagulum, or clot, which takes a certain position, and plugs up the vessel and wound, so as to check its further flow. If the artery is sim- ply punctured, the blood will escape from it, in consequence of its gaping, and be effused into the surrounding tis- sues so as to form a clot in them, while, owing to the retraction of the coats of the vessel, the wound in the artery will no longer correspond with that in the skin. The blood that continues to escape will, therefore, also form a plug Fig. 69. A PLAN OF THE NATURAL AR- REST of Blood in a wounded Ar- tery.—a. Shows the divided end of the artery, which has assumed a conical shape by the contraction of the circular fibres of its muscular coat. b. The sheath of the artery left vacant by the retraction of the artery through the contraction of its elastic tissue; the sheath is seen as occupied by a clot. c. The clot or coagulum of blood projecting from the orifice of the sheath. (After Jones.) 238 PRACTICE OF SURGERY. in the surrounding sheath of the vessel until it closes the wound by a firm mass, and thus checks the hemorrhage. (See Fig. 69.) The retraction of the artery by which its relation to the external wound is changed (see Figs. 70, 71), forms an important fact in the study of hemostatics, and it should be specially remembered, that when an artery is cut entirely across, it not only contracts, but also retracts; or rather, it first retracts itself within its sheath, and then contracts its calibre, a change being thus made in the relative position of the opening in the vessel and in that of its sheath (see Fig. 71); the contractile and retractile force both act- Fig. 70. Plan of a Punctured Wound of an Artery immediately after its production ; the wound in the integuments and the vessel being uniform and,continuous, and thus favoring hemorrhage. (After Miller.) ing to draw the artery within its sheath, and cause it to assume a conical shape. (Fig. 72.) By this action the connection of the clot Fig. 71. A Punctured Artery, showing the change in the openings in the integuments and in the vessel, with the infiltration of blood and the formation of clots both within and without the vessel; that within becoming adherent to its coats, and thus firmly fixed. (After Miller.) which forms in the vessel and adheres to its sides is facilitated, the latter being also supported from without by the external clot. NATURAL HAEMOSTATICS. 239 Fig. 72. A few minutes, therefore, after the entire division of an artery, its orifice no longer corresponds with the cut end of the sheath, but must be drawn out with the forceps or with the tenacu- lum before it can be tied with advantage. The natural means of arresting hemor- rhage owe much of their success to the fact that loss of blood produces syncope, and a diminution of the force of the heart in consequence of the want of action in the brain, resulting from a diminution of its usual supply of blood. During syn- cope the hemorrhage ceases, because the blood being no longer actively driven for- ward by the heart, clots are more readily formed, and when formed are not so rea- dily thrown off from their attachments. Faintness is therefore a condition favorable to the arrest of hemorrhage; a fact which should be remembered, because, though wounds may not bleed while the patient is in a state of syncope, yet will they fre- quently do so when he revives, the heart's renewed action driving out the partly formed clots. Caution is also requisite, after surgical operations, in watching for the renewal of the circu- lation before closing the wound lest hemorrhage should occur subse- quently from vessels whose points were at the time not apparent. But in the majority of accidents and operations, the natural haemo- static effort should not be relied on, as it is often uncertain, and often only temporary. More permanent measures must therefore be em- ployed, all of which have for their object the production of such a change in the condition of the artery as will lead to the formation of a permanent obstruction within the vessel, by creating a suffi- cient amount of adhesive inflammation to glue its walls together, and induce an entire modification of its whole structure. The arrest of hemorrhage by these means is generally described as due to artificial hsemostatics, and is essentially the same whether accomplished by the application of styptics, the ligature, cautery, pressure, or any other means. Plan to sh6w the rela- tive Connections between the interior and exterior Clot of Blood in the pro- cess OF ARRESTING HEMOR- RHAGE BY NATURAL HAEMO- STATICS.— a. The external clot, or that in the wound, in- corporated with the coagulum as found in the sheath at b. c. The length of the internal coagulum, which generally rises as high as the point where the first collateral or anastomosing branch is given off. (After Jones.) 240 PRACTICE OF SURGERY. § 2.—ARTIFICIAL HEMOSTATICS. Action of the Ligature.—-When a ligature is applied to an artery and firmly tied, it produces the division of its internal and middle coats, but does not divide the external coat or the sheath of the vessel. This division of the internal and middle coat results in inflammation of the adhesive character, in consequence of which an effusion of fibrinous lymph occurs, and the blood-corpuscles coming in contact with it adhere and form the clot which blocks up the vessel. By and by this lymph contracts, the more liquid portions of the clot are squeezed out, the lymph becomes organized by the adhesion of the clot to the sides of the internal coat, and thus glues the sides of the artery together (see Fig. 73); when it continues to contract until finally the artery becomes merely a round fibrous cord. This obliteration of the caliber of a vessel takes place as high up as the first anastomosing branch, through which, as well as by the other anastomosing branches, the blood circulates to re- join its own channel a few inches below the point at which a liga- ture has been applied. (See Fig. 74.) At the same time another change progresses; ulceration being ' established in the external coat of the artery, which, it must be remembered, was not divided by the ligature. As this ulceration soon destroys the external coat, the ligature comes away, not by any destruction or change in its own substance, as is proved by its coming off in the form of a loop, but by the vital process of ulceration which divides the coats of the artery, and thus sets the ligature free. The older surgeons not being acquainted with this process, and supposing that the ligature came away only when its own texture yielded, paid much attention to the selection of the material of which their ligatures were composed, and wrote many treatises upon the subject. Hence buckskin, the tendon of the deer, and other animal substances which speedily decomposed when brought in contact with the discharges of a granulating surface, were once highly recom- mended, and even at the present day are lauded by some as afford- ing very superior materials for this purpose. Experience has, howeyer, shown that any ligature that is strong enough, and that is properly applied, answers equally well. As a fine thread cuts through a vessel sooner than one that is broader, the thickness of the ligature should be made in reference-- ARTIFICIAL HEMOSTATICS. 241 to the size of the artery, and the length of time that it is desirable it should remain on the vessel. For small arteries a single strand of good round saddler's silk is sufficiently thick, but for the femoral Fig. 73. Fig. 74. !■• Fig. 73. A view of the Carotid Artery of a Dog, 48 hours after the applica- tion of a Ligature, showing its Effects.—a. The internal and middle coats as di- vided by the ligature. The external as yet being sound, ulcerative action not being fully established. The plasma is seen in the inside of the vessel around the seat of the ligature, and a clot is represented as forming on each side of the vessel, so as to close the ends and prevent hemorrhage when the ligature ulcerates through the external coat. (After Miller.) Fig. 74. A view of another Carotid Artery of a Dog, six days after it was tied, showing the ulceration of the external coat, the removal of the ligature, the formation and shape of the coagulum in each end. The sheath of the vessel is shown as pinned out with external vessel as at a, coursing onwards to occupy the interior. (After Miller.) or carotid arteries it is better to twist two or three strands together having them well waxed whilst being twisted. A ligature about twelve inches long is of a convenient length for ready application. In ligating the end of a divided artery, as in an amputation or in 16 242 PRACTICE OF SURGERY. a wound, it is requisite that the vessel should be separated from the adjacent'nerves before it is tied, and that as little as possible of the surrounding tissues should be included in the loop of the ligature. In order, therefore, to apply the ligature, the end of the artery should be transfixed with the point of a tenaculum or seized with a pair of forceps, and drawn out of the tissues, and whilst thus held should be tied by a firm double knot, after which one end of the ligature should be cut off within a line or two of the vessel. Formerly much stress was laid upon the form of the knot, and pe- culiar ties were directed under the name of the " surgeon's knot," or the "sailor's knot," &c, but a simple firm double tie, drawn with sufficient firmness to cut through the internal and middle coats of the vessel, suffices, and is quite as secure as the more compli- cated knots. Instead of the ligature, Torsion may be employed to arrest hemorrhage, the vessel being made to contract by twisting its coats in the grasp of a pair of forceps, which are usually desig- nated as " Torsion forceps." In employing them, seize the end of the artery, hold it firmly in the grasp of the instrument, aDd, rotating it two or three times in the fingers, twist the vessel until its middle and internal coats yield, which they do very readily. Torsion, by lacerating these coats without at the same time tearing the external coat—owing to its greater toughness—causes the con- traction and retraction of the muscular coat, and in the case of numerous and small arteries, has an advantage over the ligature, as it checks hemorrhage without delaying the healing of the parts by the presence of the ends of numerous ligatures. It is not, how- ever, so certain in its effects as the ligature, and should not be relied on in bleeding from the larger vessels, lest it give rise to secondary hemorrhage by a subsequent relaxation of the muscular fibres. Pressure as a means of arresting hemorrhage may be employed in two ways: 1st. By its direct application on the spot from which the blood issues; and 2d. By its application above the wound, upon the main trunk of the artery which, supplies the part. When pressure is made at the wounded point, it may be accom- plished simply by placing the point of a finger on the artery, as in operations where it sometimes prevents the delay which results from the application of ligatures; or it may be made by means of a graduated compress (see Fig. 75), which should be retained on the ARTIFICIAL HAEMOSTATICS. 243 wounded point by a bandage. When pressure, as is most fre- quently the case, is required on the main trunk of the artery, it may be applied by pressing the thumb upon the artery whilst the Fig. 75. b b Plan of the Action of a graduated Compress as applied to a deep-seated Punctured Wound of an Artery.—a. The wounded artery, b, b. The graduated com- press so arranged that its apex is in immediate contact with the orifice of the artery, whilst its base occupies the wound and reaches a little above the level of the integuments. (After Miller.) fingers embrace the limb, or by means of the padded end of a key, or some similar substance, though when such pressure is desired, it is a safer plan to employ the Tourniquet of Petit. This consists of two plates of metal made to separate from each other by means of a screw, the plates being fastened on the limb by a good strong piece of webbing and a buckle, which is thus made to constrict the entire limb. Previous to its application, form a compress by folding three or four turns of a bandage, lay it over the course of the artery, and retain it in this position by making one or two circular turns of the bandage around the limb at this point. Then placing the tourniquet with its plates closely adjusted to each other, directly over the compress which is on the artery, carry the strap of webbing around the limb, in the course of the turns of the bandage just applied, and buckle it tightly. On turning the screw of the tourniquet the plates will then be separated, and the lower one made to act directly on the compress, and through it on the artery. In the selection of a tourniquet it is important to obtain good webbing and a buckle which is strong, and the teeth of which are not too sharp, lest it break off when on the strain, or tear through the webbing. The application of the compress and turns of a bandage to the limb prior to the application of the tourniquet tends to make the pressure more directly on the artery, whilst it also protects the skin from being chafed by the strap or by the plates of the instrument. The tourniquet of Petit checks the cir- culation not only in the artery, but also in the veins, as it encircles the limb. Of course, it cannot be borne for any length of time— 244 PRACTICE OF SURGERY. say over one hour—without exposing the patient to the risks of mortification. In cases, therefore, in which it is necessary to arrest the hemor- rhage by pressing upon the main artery, whilst it is desirable that the circulation through the veins should remain unchecked, recourse may be had to the King Tourniquet, or to Bellingham's Compressor (see Aneurism), which are well calculated to make firm pressure, and yet allow the circulation to go on in the rest of the limb. Another tourniquet is that which is designated as the " Field Tourniquet," from the fact that it is easily carried in the pocket, taken out upon the spur of the moment, and placed by the patient around his own limb. It consists of a single pad, and a strap which hooks on to the plate, and is promptly tightened as desired. It is a useful in- strument in the case of soldiers about to go into battle. When none of these instruments are at hand, resort may be had, in an emergency, to the "Spanish Windlass," which is prepared as fol- lows : Fold a common handkerchief into the shape of a cravat, roll it into a narrow cord, and, tying a knot in its middle portion, carry the cravat around the limb so that the knot shall come over the artery; then tying the two ends loosely together, insert a short stick into the loop, and twist it up until the compression of the artery by the knot, and the constriction of the limb, arrest the circulation.1 Cold may sometimes be employed advantageously as a haemosta- tic agent. When thus used, it creates a diminution of the capillary circulation, and is followed by a contraction of the bloodvessels. Its application should, therefore, not be carried further than the production of this result, or the usual depressing effects of cold will occur, and gangrene be induced, a point which should be constantly remembered in the treatment of hemorrhage by this agent. Various methods may be employed in its application, as by the use of a bladder, partially filled with pounded ice, and laid upon the part; or by means of lint saturated with cold water. But the use of cold water as a haemostatic agent is objectionable in many cases of wounds, because the constant flow of the water over the part washes away the effused fibrin, and thus prevents the successful efforts of nature to form that clot which is the natural check to 1 For many other points connected with the arrest of hemorrhage, see the Ope- rative Surgery, 2d ed., vol. i. p. 215. ARTIFICIAL HAEMOSTATICS. 245 all hemorrhages. Moreover, in wounds of arteries of any size, cold will either fail totally, or produce merely temporary effects; and hence it may be stated to be quite unreliable, except in cases of capillary oozing. Styptics are also frequently employed for the arrest of hemor- rhage, and of these there is a great variety, as we have at our dis- posal all the astringents of the materia medica, and many of those substances which at the same time are more or less stimulating or tonic in their character. The Tinctura Ferri Chloridi of the Phar- macopoeia is a very admirable styptic in many cases, and may be applied by laying a piece of lint soaked in it upon the parts; or it may be dropped into the wound, taking care that it does not come in contact with any part of such a delicate texture that it could be Beriously injured by the acid which it contains. This article is very stimulating in its character, and, if it be recklessly employed, may develop such inflammatory action as will cause the wound to slough. Tannic acid, powdered acetate of lead, sulphate of zinc, alum, kino, matico, &c. &c., in fact the whole class of astringents, have been employed, and act both by diminishing the caliber of the ves- sel, and promoting the formation of a clot. Like cold, styptics are adapted only to cases of capillary oozing, and are of little value where vessels of any size are involved. The actual cautery is a more potent agent, and one formerly ex- tensively employed. The instruments used for this purpose are made of iron, and of various shapes; thus, the cauterizing iron is sometimes pear-shaped, a form which is especially applicable to the cases of deep wounds in which it is desirable to cauterize a single point, as, a small artery so situated that it cannot be tied. The cautery of such a shape as to make a linear burn may also be similarly employed, though this form is not used so much for controlling hemorrhage as for other purposes. A short cylinder, a bullet-shape, etc., have also been recommended. Cauteries may be occasionally required by the surgeon in cases of secondary hemorrhage. When required for use they should be heated to a red heat and applied lightly on the parts, but the in- strument must not be allowed to remain any time in contact with the tissues, else the eschar will be deeper than is necessary, the vessels will become adherent to the iron, and the eschar thus be dragged away. The heat thus applied checks hemorrhage by producing the contraction of tissue ordinarily seen in a burn, and 246 • PRACTICE OF SURGERY. leaves a dry stiff coating over the surface which covers it and prevents the escape of blood. But this mode of arresting hemor- rhage is liable, in the majority of cases, to serious objections: thus, there is always risk of troublesome secondary bleeding when the slough created by the cautery is thrown off; and this happens the more readily, because the attachments of the vessel to the stiff unyielding eschar prevent that contraction and retraction of its coats which alone are to be relied upon for the permanent sup- pression of the flow of blood. Secondary hemorrhage, or that which occurs some days after the injury, may result from other causes than the removal of a slough; but although the simple slipping of a ligature may create it, or it may follow the throwing off of an eschar made by the actual cau- tery, yet most frequently its occurrence is indicative of diseased action, such as the contused state of the edges of the vessel, as is found in the case of gunshot and contused wounds. Constitutional Effects of Hemorrhage.—If hemorrhage, whether pri- mary or secondary, be not duly arrested, it produces serious consti- tutional disturbance. This is shown first in the state of the pulse which becomes quick, irritable, and thread-like. The pulse is not only quick, but it is frequent, counting 120,140, or even 150 beats per minute. From the removal of the blood-corpuscles, moreover, the blood is impoverished, and there result all the symptoms of anemia, with the pallor of skin and general bloodless aspect seen in this condition from any other cause. Constitutional Treatment of Hemorrhage. — In the constitutional treatment of hemorrhage it has been recommended to administer astringents internally. These may sometimes prove useful in cases of hemorrhage where it is impossible to get at the bleeding surface, as in the case of uterine hemorrhages, &c.; but, as a general rule, this treatment is not applicable to surgical cases. Opiates, also, by diminishing the heart's action and allaying irritation, sometimes proves useful, but the chief security in the arrest of surgical hemor- rhage is to be found in a reliance on local measures. Venesection is sometimes demanded for the purpose of assisting in the control of hemorrhage, as in the case of wounds of the chest where, from excessive vascular action, the hemorrhage is troublesome, but it is only required in special cases. Occasionally patients are seen who bleed profusely upon the most trifling injury, the prick of a needle or the scratch of a pin pro- UNION OF WOUNDS. 247 ducing a hemorrhage which is difficult to control.. Such patients are said to possess the hemorrhagic diathesis, and every wound therefore to which they are exposed should be carefully watched. § 3.—OF THE USE AND PREPARATION OF SPONGE FOR THE TREATMENT OF WOUNDS. As it is often necessary to cleanse a wound in order to arrest the hemorrhage, a few words may be said in regard to the use and pre- paration of sponge in the treatment of wounds. When required for surgical use, sponge should be specially prepared. As found in the shops it is filled with broken fragments of coral, and if used in this condition would produce pain whenever it touched the surface; and here it may be remarked that, as a general rule, a sponge should not be allowed to touch the surface in cleansing a wound, but should be held over it filled with water whilst it is gently squeezed so as to allow the water to run down upon the wound. But if in cleaning the blood from a wound during an operation, it is necessary to wipe the surface in order to show clearly the divided ends of the vessels, it should be done by pressing the sponge lightly against it, and then allowing the sponge to expand quickly till it has imbibed as much blood as it will contain. Preparation of Surgical Sponge.—Hammer it well whilst it is dry, and shake out as much of the sand and dust as possible; then soak it in muriatic acid, diluted with sixteen parts of water to one of the acid. This treatment will cause the sand to be decomposed with the evolution of carbonic acid. The sponge should then be washed in a solution of one ounce of carbonate of soda in a quart of water to free it from any excess of acid that may remain, and then allowed to remain for fifteen minutes in running water so as to wash away the soda, after which it will be ready for use. SECTION III. UNION OF WOUNDS. After having arrested the hemorrhage by any of these means, attention must next be given to the wound from which it proceeds. 248 PRACTICE OF SURGERY. It will usually be noticed upon inspecting this that it gaps, this gaping, if the skin alone is involved, being due to the simple con- traction of this tissue; but if the wound has penetrated deeper the contraction of the muscular fibre will produce the same effect on a larger scale. The surgeon will therefore be obliged to resort to various contrivances for bringing the edges of a wound into appo- sition ; such as uniting bandages, strips of adhesive plaster, collo- dion, and sutures. The latter are of various kinds, consisting of the interrupted, the continued, the twisted or harelip, the dry, and the clamp suture; in the selection of which he must be chiefly guided by the position, size, depth, and character of the wound. The continued suture is seldom employed in the treatment of wounds, being used generally for sewing up dead bodies in the dissecting rooms, or in post-mortem examinations. The interrupted suture, so called because the stitches are made separately, is formed by passing a needle armed with a ligature from one side of a wound to the other. Having put in a sufficient number of stitches, tie them so that the knots will fall on one side of the flap, taking special care to avoid making them over the course of the wound, as they would then create irritation and retard union. In angular wounds the first stitch should be placed at its angle, and tied, the others being subsequently placed as re- quired. The stitches of this suture should never be closer to each other than 3 or 4 lines, and seldom so close; strips of adhesive plaster, when necessary, being applied between them so as to sup- port the parts, and take the strain off the thread. The twisted suture, or, as it is more commonly called the harelip suture, on account of its employment in the operation for that de- formity, was introduced by Heister, of England, who says that it was suggested to him by seeing tailors wrap their threads around the needle in their sleeves when about to lay aside their work. For this suture a pin is required, which may either be the ordinary silver-plated pin of the toilet table, or the harelip pin, with a movable point, as made by the cutler, though the latter is liable to the objection of leaving the point fast in the flesh if the pin is withdrawn before Ijeing passed through the flaps. In the applica- tion of this suture, pass the pin through the edges of the wound so as to transfix them, placing the first pin lowest down if in an angular wound such as that in harelip, in order to secure the more perfect apposition of the angles. Then wrap the ligature around UNION OF WOUNDS. 249 Fig. 76. A representation of the Harelip, or twisted or figure of 8 Suture, as applied to the union of a Vertical Wound. (After Miller.) Fig. 77. the two ends of the pin in a series of figure of 8 turns and tie them in a knot as in Fig. 76. Having made as many such stitches as the nature of the case demands, cut off the ends of the pins with a pair of bone nippers; or if the silver pin of the cutler has been employed, remove its point. Subsequently, when this suture is to be removed, make slight traction jupon the pin with gentle rotation, and it will be easily withdrawn without disturbing the parts; when the ligature, which is usually glued to the flesh by the dried blood and other discharges from the wound, should be left to aid in retaining the parts for a few days, the wound being also covered and approximated by adhesive plaster until the union is firm. The dry suture is made by means of strips of adhesive plaster, or bandages, fastened firmly on each side of the wound, and afterwards approximated by stitches, so as to draw its edges together (see Fig. 77). It is ap- plicable to cases where the irritation of the stitches in the skin is likely to do mischief, as where erysipelas, or sloughing of the wound is apprehended. Another mode of closing wounds, which has been lauded very highly of late, especially in France, is by the use of the serres-fines of Vidal. These consist of a little clamp of wire made sometimes plain and some- times with teeth to give a firmer grasp, and hold the parts together simply by the elasticity of the wire. They may be employed in superficial wounds. Al- though the inventor claims for them the advantage of not producing as much irritation as stitches, it will it is thought generally be found that they create more or less ulceration at the points where they are in contact with the skin. The quilled suture is one of great antiquity, and is analogous in its action to the more modern "clamp suture," being especially A representation of the applica- tion of the Dry Suture to a Trans- verse Wound of the Leg. (After Nature.) 250 PRACTICE OF SURGERY. applicable to wounds in which direct union of the deep-seated as well as of the superficial parts is desired. It is made by cutting two bougies, pieces of wood, or of quill of a sufficient length to extend throughout the entire length of the wound, and arming three or four needles with double ligatures, so that a loop of each ligature will be on one side of each needle. In its formation, pass the needles through both lips of the wound, in such a manner, that all the loops shall be on one side, and all the free ends of the liga- ture upon the other; insert one quill through all the loops, and tie the ends of the ligatures over the other quill with sufficient firm- ness to approximate the parts as closely as necessary (see Fig. 78). Fi, to stretch) is a nervous disorder character- ized by spasm (from spasmo, I draw). It is recognized by the fact that it presents tonic rather than clonic contractions of the muscles, and it has already been alluded to as one of the most serious com- plications of gunshot wounds. Tetanus is called Idiopathic where it is dependent upon constitu- tional causes, such as exposure to cold, the presence of irritating ingesta, &c. &c. It is called Traumatic where it arises from wounds. Symptoms.—The symptoms of traumatic tetanus are as follows: There is first a soreness in the muscles of the jaw, wdiich feel as if the patient had been eating something hard and was tired. This stiffness soon spreads to the muscles of the neck, producing the sensations of stiff neck, or such as is caused by a draught of cold air, and often described in this way by the patient. A peculiar expression of countenance is then soon observable, which may be characterized as a painful smile, and is due to the fixed contraction of the zygomatic muscles. At the same time the eyes have a pecu- liar look; they stare, and are gathered at the corners by contraction of the orbicularis palpebrarum. The affection of the muscles of mastication soon becoming more marked, the masseter contracts so powerfully that the jaws cannot be opened, while the saliva or liquid, &c, cannot be swallowed on account of the muscles of de- glutition being involved. A pain in the stomach now comes on, as if an attack of colic were about to begin, and the diaphragm is soon affected, the patient suffering from difficulty of breathing and a spasmodic pain along the insertion of the diaphragm. The abdo- men next becomes hard and knotted, presenting the appearance of 1 For the further consideration of this question, see Op. Surgery, vol. ii. p. 408, 2d edit. 288 PRACTICE OF SURGERY. a tumor, from contraction of the recti muscles, while from spasm of the muscular coat of the bowels and bladder there are constipation and difficulty of micturition. Meanwhile the intellect of the sufferer continues clear, and the pulse natural, or by no means so much excited as might be ex- pected from the symptoms. If the paroxysms continue, they become more violent, and the patient dies in a period varying from two to fourteen days, the shorter period being rarely seen. Tetanus receives certain designations according to the muscles which are chiefly involved in the spasm; thus, when those of mastication are principally affected, it is called Trismus. When the patient is bent backward into the shape of an arch by the con- traction of the spinal muscles and the flexors of the legs, it is called Opisthotonos; when he is bent forward, Emprosthotonos; when sideways, Pleurosthotonos. Tetanus shows itself under various circumstances, and often after very slight wounds, when conditions favoring its development exist, atmospheric changes, and other causes which are not well known, seeming to act as predisposing causes. The wounds most likely to produce tetanus are wounds of nerves, wounds of tendons, of fascia, &c; lacerated and punctured wounds being more apt to result in it than the other class. Yery slight punctured wounds, indeed, may produce it. In one instance in my experience it was excited by the slight puncture made by taking a top, with a very sharp plug, into the hand while it was spinning; and in another instance, a waiter at a hotel had tetanus induced by pricking his finger with a fork while setting the table. Diagnosis.—Hydrophobia might be confounded with this com- plaint, which it resembles in the difficulty of swallowing, and the increase in the violence of the spasm from very slight causes, such as the opening of a door, a breath of air, &c. It may be remarked, however, that the spasm in tetanus is continuous (tonic); in hydro- phobia it is intermittent (clonic). In tetanus, the mind is clear; but in hydrophobia, a delirium, which is of a maniacal character, is present at least in its latter stages. The diagnosis from myelitis or inflammation of the spinal marrow and its membranes is to be found first in the fact that in myelitis the patient complains of a constant burning pain in the back, and has high fever and often paraplegia, neither of which are found in tetanus, except in cases complicated with myelitis. TETANUS. 289 Prognosis.—The prognosis of tetanus is very unfavorable, and although I do not indorse the French aphorism, "tants des cas tants des morts" (so many cases so many deaths), yet it is very rare for a patient to recover from tetanus when it is once thoroughly developed. Pathology.—The pathological condition of the organs of the body in tetanus is doubtless a disordered condition of the spinal cord, brain, and ganglionic system, but only involving the lower portion of the brain, and this chiefly towards the close of the disease. This disordered condition of the brain is not inflammatory in its charac- ter, nor is it very well understood, but may be described as being in the great majority of instances rather functional than organic, though sometimes vascular congestion is marked. Treatment.—The treatment of tetanus may be divided into (1) the prophylactic and (2) the palliative measures. 1. The prophylactic treatment consists in such means as will avoid or remove the source of irritation. When tetanus is feared, nerves merely pricked should be entirely divided, ill-conditioned sores be freely cauterized, &c. &c. But, when the disease is once developed, it is worse than useless to amputate the affected limb, as this operation does not check the disease, and has in some cases proved to be an additional source of irritation. 2. The palliative treatment is as follows: A purge should be given, if it can be swallowed, to clear out the primae viae; but this is fre- quently impossible, on account of the trismus, the latter being one reason why patients die, as it is difficult to administer remedies or food to them in sufficient quantities to obtain their prompt action. The difficulty of nourishing them is also increased by the fact that the muscular coat of the alimentary canal does not propel the food through it, owing to the continuous spasm which characterizes the disorder. Opium may follow purges when it can be readily administered, but it should be remembered that though immense doses of this drug will be borne without producing sedation, we should not be induced by this fact to give it in such quantities as to risk a com- plication of the disease by producing congestion of the brain. Anaesthesia has also been recommended, and is, doubtless, useful as a means of rendering death easy, but it has as yet produced no curative results. Perhaps the most useful, as it is certainly .the most plausible plan of treatment, is counter-irritation to the spine, 19 290 PRACTICE OF SURGERY. as recommended by the late Dr. Hartshorne, senior, of Philadel- phia. His plan of treatment, which resulted in a few cures, con- sisted in making a free cauterization along the course of the spine with caustic potash, or the actual cautery, or in the formation of a large issue. The extract of the Cannabis Indica has been highly recommended of late, and among others by Mr. Miller, of England, but though fairly tried in three cases it has not given the same results in my experience. CHAPTER Y. WOUNDS OF THE REGIONS OF THE BODY. Under the head of wounds of the regions of the body we may now study the effects produced upon certain parts, in consequence of the presence of the various organs which they contain, rather than from the character of the wound itself, the peculiarities of each variety of wound, as previously described, being very much the same in all regions. The prognosis of all regional wounds is very much modified by the peculiar character of the adjacent organs, inflammation of these structures often adding the specific signs of such disorders to those due to the wound. It is in the treatment of such injuries that it is impossible to separate the practice of medicine from that of sur- gery, and, unless the surgeon is also a good physician—as he must necessarily be if properly qualified for his duties—the patient may sink from the effects of what is usually regarded as an internal or medical complaint, and therefore without the limits assigned to surgery. Such a series of circumstances frequently supervenes on wounds of the head and chest, the first creating Meningitis, and the latter Pneumonia or Pleurisy, all of which disorders are usually regarded as belonging to the Practice of Medicine. The student of surgery must see, therefore, in these results, the import- ■ ance of studying all the disorders and physiological actions of the human system, if he desires to treat scientifically and successfully any, of those which, for the advantages of methodical investigation and the simplifying of the subject of wounds, are usually assigned WOUNDS OF THE SCALP AND ERYSIPELAS. 291 to the practice of surgery. Besides the chances of the develop- ment of inflammation of the adjacent organs, the prognosis of regional wounds will likewise be materially affected by—1, the variety of the wound. 2. Its extent. 3. The age of the patient; and 4, the character of his general health and habits. In the consideration of regional wounds, they will be presented in the natural order of arrangement of the parts of the body, com- mencing at the head and passing thence to the trunk and extremi- ties. SECTION I. OF WOUNDS OF THE HEAD. Wounds of the Head may be of any of the varieties previously described; that is, incised, lacerated, punctured, or gunshot; but, most frequently, the wounds of this region are either incised or lacerated; poisoned and punctured wounds of the hbad being sel- dom seen, though they are possible. In order to understand cor- rectly the effects produced by wounds in this region, its general structure should be borne in mind, as the character of the scalp and the numerous branches of the temporal artery ramifying beneath it; the thickness of the cranium, and the character of its two tables, with the intermediate diploe. The ramifications of the middle artery of the dura mater, just within the bone, and the size and position of the sinuses, as well as the characters of the membranes and of the enclosed brain, with the proneness of both to take on inflammatory action, should also be noted. Complications.—The chief complications of wounds affecting the scalp, is erysipelas, and the sloughing consequent upon it; of those affecting the cranium, meningitis or inflammation of the mem- branes of the brain, and cerebritis, or inflammation of the substance of the brain itself; besides which there may be in either case the dangers arising from compression and concussion of the brain. § 1,—WOUNDS OF THE SCALP AND ERYSIPELAS. Erysipelas of the scalp presents us with the ordinary symptoms of erysipelas before detailed, although it is not accompanied by so much swelling as in portions of the body where more cellular tissue 292 PRACTICE OF SURGERY. is present. When erysipelas of the scalp involves a considerable portion of this integument it will be very apt also to involve the membranes of the brain, and produce meningitis, owing to the vascular connections between these two tissues. The symptoms and treatment of meningitis belong to the practice of medicine. Inconsiderate traction upon the hairs in dressing a wounded scalp, the presence of sutures, the slightest causes will often suffice for the production of erysipelas of this region. Treatment.—The treatment of erj'sipelas of the scalp, when esta- blished, does not vary materially from that required for its cure elsewhere. The prophylactic measures consist in treating all wounds of the scalp so as to favor their rapid healing and prevent suppuration. If the wound be of the incised variety, the scadp should be carefully shaved in order to avoid the irritation from the hair, and to prevent it from getting into the wound and acting as a foreign body; after which, the hemorrhage should be arrested. This is sometimes a matter of diffi- culty, for the scalp is so firm, dense, and adherent a tissue, that it is al- most impossible to draw out the arteries and tie them, without in- cluding part of the dense sur- rounding cellular structure in the ligature, in consequence of which, in three or four hours, the knot will probably slip and hemorrhage ensue. The best mode of checking hemorrhage in this situation is by pressure made by applying a gra- duated compress upon the course of the temporal or of any other artery that may supply the wound- ed spot, subsequently retaining it and the dressing upon the head by means of the turns of a " recurrent bandage" (Fig. 86). The wound should also be closed by adhesive plaster and not by sutures, the latter having, in many instances, proved dangerous from their creating irritation by the punctured wound made by the needle as well as by the presence of the threads which act as A view of the Recurrent Bandage, as applied to the Head.—In its appli- cation make one or two circular turns of the forehead and occiput, with a two inch wide roller, reverting it backwards and forwards till the head is covered, and then fastening the ends of the recurrent turns by one or two additional circular turns. (After Nature.) WOUNDS OF THE SCALP AND ERYSIPELAS. 293 Fig. 87. foreign bodies and give rise at times to suppuration and abscess. It may, therefore, be laid down as a general rule, to which there are but few exceptions, that it is better not to employ sutures in clos- ing wounds of the scalp. As the skin in these wounds has a tend- ency to heal rapidly, and will sometimes do so before the sides of the wound are united in its deeper portions, abscesses are sometimes created, and proceed to such an extent as to require the scalp to be freely opened. It is better, therefore, i n bad cases to keep some portion of the wound open and not to let it close entirely until all the deeper parts are fairly united. When it is necessary to retain a poultice or the warm water dressing on the head, it may be readily accomplished by the application of a handkerchief in the manner shown in Fig. 87. In arresting the hemorrhage from wounds of the scalp, particularly before the parts are shaved, it should be remem- bered that the hair sometimes becomes the nidus of a clot, which will then pre- sent a long capillary appearance not un- like the projection of an artery. Occasionally contusions of the scalp produce a bloody tumor, which is soft and fluctuating, and it may become a question whether it should be evacuated or not. Practice has, however, proved that it is better, generally, not to open it when the collection of blood is exterior to the pericranium, as can be easily ascertained by the touch, the collection beneath the pericranium being much harder than when it is exterior to this membrane. These bloody tumors should generally, instead of being evacuated, be treated with cold water or other means cal- culated to prevent further effusion, and favor the absorption of the blood, as the tumor will generally do well and give but little trouble when it is not incised; whereas, if opened so that the air can enter its cavity, we will generally have troublesome suppuration, or, per- haps, sloughing of the integuments over it. There is a tumor, however, sometimes seen in infants and in mid- wifery, which has been designated as cephaluematoma, or the bloody tumor of the scalp, which is due to an effusion of blood between A view op the Handker- chief Cap of the Head.— The handkerchief being folded into the shape of a triangle, carry its summit over the head and fasten it by a circnlar turn of the two angles, pinning the ends together on the forehead. (After Nature.) 294 PRACTICE OF SURGERY. the pericranium and the bone. This is a circumscribed tumor, hard and elevated upon the edges, but soft at the centre, and has some- times been mistaken for depressed fracture of the skull, the feeling of which it closely resembles. The hardness upon the edges of this tumor is due to the attachment of the pericranium to the bone and to some effusion of lymph, whilst the softness in the centre arises from the liquid blood. When, by the history of the case and the age of the patient, it is satisfactorily ascertained that one of these bloody tumors is present, the proper plan of treatment, if called at an early period, is to attempt to check its development by cold, &c.; but if the swelling continues to increase in spite of this treatment, or has already existed several days, the best treatment is to incise it freely, turn out the clots, enable the pericranium to come again in contact with the bone, and thus diminish as much as possible the danger of caries or of exfo- liation of the external table, whieh is apt to supervene when the pericranium is separated from the bone by the effusion. Occasionally a blow upon the head, particularly if the course of a nerve has been involved, gives rise to neuralgic symptoms in the scalp. • If this neuralgia is exceedingly violent, and resists the ordi- nary treatment of neuralgia from other causes, it may become neces- sary to make an incision upon the main track of the nerve and divide it so as to temporarily paralyze the part, though union of the nerve will generally occur, with a return of sensation, without a recurrence of the neuralgic symptoms. Lacerated wounds of the scalp are to be treated upon the general principles which apply to lacerated wounds elsewhere. Of course it would be perfectly useless in these wounds to attempt union by the first intention, as the edges almost invariably slough to some extent. The lacerated scalp should therefore be accurately replaced after it has been cleansed from foreign matter, and only supported in its proper position, without uniting its edges. In gunshot wounds of the head, it must be borne in mind that the cranium presents a convex surface, and that this will often cause a deviation in the course of the ball. It should also be recollected that the cranium consists of two tables, and that a ball may, there- fore, penetrate the outer table without involving the inner one. So also a ball may be driven into the frontal sinus and there embedded and remain without involving the brain or even the inner table of INJURIES OF THE BRAIN. 295 the bone. Depressed fractures of these parts, as from sabre cuts, axes, &c, may also exist without involving the encephalon. Sabre cuts, wounds from circular saws, or from axes, &c. &c, are generally dangerous in proportion to their depth, which sometimes is very slight, and sometimes most serious. Wounds made by the circular saw are generally the most dangerous of Tall wounds of the head. Still, patients constantly recover from severe wounds of this kind, considerable portions of the cranium having been, in my ex- perience, shaved off without involving the dura mater; the patients recovering without a bad symptom. When a ball has entered the cavity of the cranium, the danger to be feared from probing is nearly as great as any that-is likely to result from the presence of the ball. The probe should, therefore, never be used, nor any attempts made to remove balls imbedded in the substance of the brain lest it add to this irritation, the find- ing of a ball once introduced into the brain being always pro- blematical, and death certain. § 2.—INJURIES OF THE BRAIN. Sometimes blows and other forces applied directly or indirectly to the head, and altogether independently of the production of any external injury, produce an effect on the brain that is desig- nated as "concussion of the brain," or, as it is ordinarily called, stunning. They may also create compression of the brain by causing the rupture of bloodvessels and effusion of blood within the cavity of the cranium. 1. Concussion of the Brain, from a blow or fall, produces a train of symptoms which are much influenced in their character by the nervous connections between the brain and other parts of the body. Thus a sympathy exists between the brain and the sto- mach, and that so great that it has been said that a man has two brains, one in his abdomen (the solar plexus), and the other in his head, in consequence of which, if a man receives an injury to his head he is very apt to vomit, whilst a violent blow upon the stomach will often destroy consciousness by impairing the action of the brain. Concussion of the brain is a marked interruption of its func- tion, that is sometimes unaccompanied by any visible injury, and may be caused by any force that shakes or jars this structure. It 296 PRACTICE OF SURGERY. may be produced by falls, either upon the head or upon the feet, as well as by blows, and similar causes. Symptoms.—The symptoms of concussion of the brain have been arranged by Mr. Abernethy into three stages. In the first stage the condition is that of collapse, and this is the state in which the surgeon, if he has been promptly called, will generally find the patient. The second stage presents the symptoms of reaction, and the third those of inflammation. In the first stage the patient will be found lying motionless, uncon- scious, insensible, and unable to answer questions. The skin is cold, and the pulse feeble, while the pupil is usually contracted or irregu- larly dilated. If the injury is not a very severe one, the patient may be roused by shaking him and shouting in his ears, so far as to enable him to answer questions imperfectly, after which he is apt to relapse into his comatose condition. This state may continue for a varied period of time, as from half an hour to four or five hours, after which evidences of reaction appear. The pulse now becomes fuller, the skin warmer ; there will be a slight return of color to the lips; and the patient will become restless and pitch himself about like a per- son in a troubled dream, muttering, and, perhaps, speaking in a language which he had long forgotten, or which his friends had not supposed him to know. Whatever he may say is, however, generally very incoherent and disconnected in its character. After this he begins to vomit, and after vomiting is often much relieved, and from this period will often begin to improve, his con- sciousness gradually returning, though he continues for some time feeble, and recovers perfect consciousness very gradually. In more severe injuries, however, he remains unconscious, the surface con- tinues cold, the features pallid, the pulse quick, particularly when he is roused, it sometimes rising under a little excitement from 90 to 130 or 140 beats per minute, or even so fast that it is impossible to count it. Sometimes, however, the pulse is more full and regular. The respiration is also varied; it being sometimes very feeble or followed by a deep sigh, and then by an almost total absence of breathing for a few seconds, so that one is tempted sometimes to apply a glass to the lips to see if it is actually going on; auscultation hardly giving a sound. This state of things may last for some time, the patient being still able to swallow although un- conscious, until finally the case terminates in recovery or in death. In these cases many phenomena—which fully deserve the name INJURIES OF THE BRAIN. 297 of eccentric that has been applied to them—will be observed at times; thus patients will begin to answer a question afld not com- plete the sentence, or they will begin a sentence in one language and complete it in another, &c. Diagnosis.—The diagnosis of concussion of the brain is highly important, and will be treated of fully under the head of compres- sion; this being the condition with which it is most liable to be confounded. A post-mortem examination in concussion of the brain shows various appearances; thus there maybe congestion of part or of the whole brain, or effusion of blood, but the latter is seldom to any extent if the symptoms have not been complicated with those of compression. Most frequently there is no structural change what- ever to account for the symptoms, thus indicating that the disorder of the brain in this injury is merely functional. Prognosis.—The prognosis of concussion should alwaysbe guarded. The disease is not only dangerous in itself, but also on account of the congestion and inflammation of the brain which may supervene. Treatment.—The treatment of concussion will depend upon the stage at which the patient is first seen. If seen in the state of col- lapse, the attempt must be made to excite action in the surface by frictions, mustard poultices, and stimulating injections into the rec- tum, such as salt and water, the turpentine injection, &c. A yery common mistake made by an inexperienced surgeon in these cases is to yield to the popular desire, or the wishes of friends, and extract blood. But it should be recollected that if blood is taken at this stage the collapse will be increased, and none should, therefore, be drawn before reaction comes on. If, however, the reaction threatens to become violent, blood may be taken to such an extent as would be proper under the same condition proceeding from any other cause. After reaction is fully established and inflammation begins to be developed, the symptoms of meningitis may appear. Thus mania may present itself, during which the patient may shriek out or scream violently, and it is because this shrieking indicates the presence of meningitis that it has been spoken of as one of the fatal symptoms in cases of concussion. But although meningitis in these cases fre- quently proves fatal, the patient may yet recover under the ordi- nary treatment of meningitis proceeding from any other cause; thus, the stomach and bowels should be evacuated, and counter- 298 PRACTICE OF SURGERY. irritants and mercurials employed, for in these cases it is said that if we can succeed in salivating the patient he will generally recover. Opiates should never be administered in cases of concussion, no matter how restless the patient may be, as they are apt to add to the congestion which may already exist in the brain; and thus eventually increase the symptoms. 2. Compression of the Brain.—Instead of the simple disturb- ance of the functions of the brain just described, an interruption of its action by some mechanical cause acting directly upon it and producing compression of its structure, sometimes occurs. This cause may be force applied to the walls of the cranium so as to drive them in, or there may be an effusion of blood upon the mem- branes of the brain, that is, between them and the cranium, or in the substance and cavities of the brain itself, or between the brain and its membranes. Symptoms.—If the compression is great enough, complete insen- sibility results from this condition, precisely as is seen in apoplexy. Besides general insensibility a case of compression of the brain presents a slow, full pulse and a dilated pupil, with stertorous breath- ing, the latter being due to the paralysis of the muscles of the soft palate. The respiration is also exceedingly slow, being often not more than five or six times in a minute, and the breath escapes with a peculiar whiff or puff from the corners of the mouth, in con- sequence of the imperfect action of the buccal muscles. If the patient recovers a little from this condition, headache and torpor of the intellectual faculties will be observed, or symptoms similar to those detailed under compression, though generally he either re- covers entire consciousness or dies with the evidences of apoplexy. Diagnosis.—Compression of the brain, whether due to a blow or to a depressed fracture, may be told from concussion by the fact that in concussion there is feeble respiration ; in compression it is ster- torous ; in concussion the pupil is generally dilated; in compres- sion it is contracted; in concussion we have a quick, feeble pulse; in compression it is slow, labored, and full, counting often only 30 or 40 in a minute; in concussion the patient may be partially roused, but in marked compression he is totally insensible. Compression of the brain may be told from drunkenness by a close examination of the circumstances of the case, though it will be much aided by discovering the odor of liquor upon the patient's breath. Still, the two affections may exist together, and the pre- FUNGUS CEREBRI AND FUNGUS OF THE DURA MATER. 299 sence of compression or concussion in a case of drunkenness can often be positively ascertained only by time. Prognosis.—The Prognosis in compression of the brain depends upon the amount and character of the injury. If it is due to a clot of blood, and the stupor increases, whilst the other symptoms grow more and more marked, the danger of death is imminent; but if the symptoms remain stationary, or materially improve, there is greater probability of the patient's recovery. If the com- pression is due to a depressed fracture, and this can be raised, the prospect of recovery is usually fair, unless meningitis supervenes. Treatment.—The treatment of compression must depend upon circumstances. If the symptoms are evidently due to a depressed fracture of the cranium, recourse should be at once had to the ope- ration of trephining; but if there is no such fracture, and the symptoms of compression steadily increase, as after the receipt of a blow, we may fairly conclude that the compressing cause is an effusion of blood. In this case it would be useless to trephine with a view to the evacuation of the blood which has been effused, for there can never be any certainty as to its situation. Yet if there is such a fracture of the skull that the surgeon can see through the cranium to the dura mater, and perceive beneath it a large and in- creasing effusion of blood, it may become a question whether this blood should be evacuated or not, and this question may be answered by laying down the rule that if the symptoms are such as show that the immediate dangers from compression are so great as to over- balance those arising from the meningitis which the puncture may induce, the operation should be performed. Still, even after the clot is evacuated, there is no certainty that the hemorrhage will be arrested, and we must, therefore, strike a balance between the dangers in such cases. Hemorrhage from the middle artery of the dura mater may be checked by compression, and by plugging up with a bit of wood the little channel made in the bone for the artery, when it was accessible through a fracture. § 3.—FUNGUS CEREBRI AND FUNGUS OF THE DURA MATER. Fungus cerebri and fungus of the dura mater are two fungoid growths which differ materially in their characters, though appear- ing in the same region of the body. Fungus of the dura mater 300 PRACTICE OF SURGERY. Fig. 88. presents simply the structure and appearance of exuberant granu- lations, its formation being due to lymph having been effused and become organized. As this growth progresses, it produces absorption of the inner table of the cranium, and then by pressure stimulates an increased development of the structure of the diploe and external table, so as to create the various bony structures which coalesce and constitute what was formerly known as spina ventosa. This tumor may even go so far as to encroach upon the cavity of the orbit by causing absorption of its bony plate, and then push the eye forward. Fungus Cerebri, on the other hand, is created by an expanding of the* proper substance of the brain which is protruded through some wound or opening in the skull (Fig. 88), by pressure from within, such as that made by the collection of pus in abscess of the brain, &c. This complaint occurs sometimes after the operation of trephining. The fungus expanding in this in- stance pushes through the orifice made by the trephine, and shows it- self outside in the shape of a mush- room-like projection. It grows by degrees larger and larger, till finally the neck being constricted the mass may slough off; the neck then be- gins to develop itself anew, and thus the complaint goes on. Generally, these complaints are incurable, par- ticularly fungus of the dura mater. In fungus cerebri we may give the patient some chance of recovery by removing the fungus, but generally it is reproduced. When, after trephining, or wounds of the head, there is reason to anticipate the formation of a fungus, a moderate amount of pressure should be cautiously employed, in order to prevent the escape of any of the contents of the cranium. If a fungus has formed, it will sometimes be desirable to remove it by applying a ligature, and tightening it writh the greatest caution, from day to day, till the whole has sloughed off. After which, a compress wet A representation of a true Fungus Cerebri consequent on a fracture of the skull which was trephined. (After a cast from Nature.) WOUNDS OF THE FACE. 301 with lime-water may be applied to the part, as was first recom- mended by Sir Astley Cooper; or the tumor may be shaved off by the scalpel, and the lime-water applied to the cut surface. The disease is very apt to return; but it is worse than useless to attempt to prevent this by the use of caustics. After a wound penetrating the cavity of the cranium, it may happen that instead of a true fungus, we will have simply a protrusion of the brain substance, constituting hernia cerebri, or encephalocele. Sometimes the part thus protruded breaks offj and a portion of the brain is lost, and yet the patient recovers. Hernia cerebri, it is said, may also be dependent upon abscess in the substance of the brain; but this would produce the con- dition already described as fungus cerebri, and not a true hernia. The treatment of hernia of the brain is that of hernia everywhere; Fig. 89. jgjftM^^ A view of the single T Bandage as applied to retain a light dressing after the operation of trephining, the vertical strip being carried over the wound, and retained by the hori- zontal piece. (After Nature.) that is, carefully to replace the protruded parts if possible, and retain them in their position by means of a light bandage, applied as shown in Fig. 89. SECTION II. WOUNDS OF THE FACE. Wounds of the face may involve any part of this region, and although they may produce very great deformity, are not generally 302 PRACTICE OF SURGERY. dangerous to life. Still, they are not unfrequently very serious. Thus, for instance, in a gunshot wound, in which the ball passes through the base of the nose, there is not only the deformity, but risk of injury to the parts connected with the nose, such as the lachrymal sac or the ethmoidal cells, through which the force of the concussion may be transmitted to the brain itself. Such a wound will of course require the whole antiphlogistic system. If the lach- rymal sac is injured, the proper treatment for this complication (as will be detailed under the head of fistula lachrymalis) must be adopted. So, also, there may be Wounds of the eye, of the cheek, of the antrum, of the mouth, &c. &c, and in all these cases, there may be trouble from the character of the structures which are involved. In wounds of the cheek, perhaps the most troublesome injury is the formation of salivary fistula, which is to be treated by means of the punch, as described in the operative surgery.1 Another in- convenience is paralysis of the muscles of the face from section of the portio dura. When this occurs, all that can be done is to promote the healing of the wound, then stimulate the nerve to the fulfilment of its function by blis- ters over its exit from the head at the mas- toid foramen. Sometimes there is trouble- some hemorrhage from the facial artery, and here we must ligate the artery, or use pres- sure to check the hemorrhage. Occasionally, severe wounds of the face, accompanied by burns, are produced by the premature explo- sion of a blast of rocks. In such cases a handkerchief, applied as in Fig. 90, is an ex- cellent mode of retaining a dressing. Sometimes it will happen that the wound will involve the soft structures merely. Thus the nose may be cut with a sabre or a knife, or it may be bitten in a fight. In this case, whether the cartilages are involved or not, the treatment is the same, the wound being closed as soon as possible by sutures or adhesive plaster, whichever seems most applicable. If sutures are used, they should only involve the integuments, as a suture passed through the cartilages would develop such an action in the parts as would prevent the healing of the wound. A view of the Mask of Mayor.—Fold a hand- kerchief into a triangle; cut holes for the eyes, nose, and mouth, and apply as shown in the figure. (After Nature.) 1 See Operative Surg., vol. i. p. 363, 2d edit., 1855. WOUNDS OF THE FACE. 303 Occasionally, it has happened that a ball has gone through into the antrum Highmorianum; and not having been extracted has deve- loped inflammation, which has resulted in the formation of an ab- scess of the antrum. In such an event, we must treat the abscess as if it had resulted from any other cause, as by drawing out a tooth, puncturing the cavity of the antrum through the alveolar process, evacuating the pus, washing the antrum out with a syringe, and after- wards extract the ball by such means as may seem most judicious— as by trephining, &c. When the lip is cut, the sides of the wound should be united by the harelip suture, or if this is not at hand, by means of a handkerchief folded into a cravat, and applied as shown in Fig. 91. Sometimes it happens that wounds are inflicted within the mouth, knocking out teeth, and involving the tongue, the gum, the alveolar process, the palate, &c. I have several times seen wounds of this sort made in marble yards, by the end of an iron crowbar flying up and striking the patient in the mouth. Under these circumstances, the treatment consists in A view of the Uniting Handker- moulding the parts into a proper posi- ^"pfuS"^'!^.'t™ tion, and then keeping down inflamma- ends of the handkerchief being . , , , , crossed on the lip over com- tory action by COld and detergent appll- presses placed on each side of the cations. woun The tongue maybe bitten by the patient himself, as in convulsions; or it may be wounded by balls, especially those passing into it from under the lower jaw. In these cases, if the deeper seated portions of the organ are wounded, the hemorrhage will be trouble- some, and when such is the case the ligature should be employed to arrest it, a suture being resorted to if the wound is large, for the purpose of closing it. In order to apply a ligature to the artery in this case, some means of controlling the organ is required and it would be useless to attempt to do so by holding it between the fingers, or even with a towel. The best plan is to hook it with a tenaculum and draw it out from the mouth, when the ligature and the suture may be applied and their ends cut close off, after which the tenaculum being removed the tongue may be returned into the mouth. It has been recommended to pass a needle and ligature through the end of the tongue for the purpose of controlling it, but 304 PRACTICE OF SURGERY. the tenaculum is quite as efficient, and not so painful. Neglect, of decided measures, from a mistaken tenderness in these cases, has been the cause of much of the trouble that has sometimes arisen in cases of wounds of the tongue. If, after the tongue is returned to the mouth, it should swell much, or should inflammation come on, cold applications and anti- phlogistic measures must be resorted to. SECTION III. WOUNDS OF THE NECK. Wounds of the neck, as already stated, vary materially; there may be a simple incised wound, and this again be modified in its result by its position. In the case of persons who have attempted to commit suicide, the wound is generally made between the oa hyoides and the top of the larynx, producing little danger to life. Such a wound requires that it should be closed by suture, yet closed so as to leave a free exit for the pus lest it burrow under the superficial fascia of the neck. If the individual is maniacal, and attempts to tear out the stitches after the wound is dressed, as is not unfrequently the case, he must be controlled by means of a strait-jacket or by stout assistants. A stiff stock of leather has been recommended in these cases, with a view of preventing the overlapping of the edges of the wound, but it does not control the motions of the head except to a limited degree, and is not equal for this purpose to the hand- kerchief bandage of Mayor, as applied with the view of keeping the head stationary. (Fig. 92.) Sometimes wounds are made upon the side of the neck, so as to involve the external or internal jugular vein or the carotid artery, and thus cause serious or fatal hemorrhage. Or the laryn- geal or other vessels may bleed from being partially divided, until the patient faints, and then the bleeding be arrested. I remember tying up several branches of the laryngeal in a case of this sort, and then leaving the patient, telling the friends that he would pro- bably be dead in a few hours; but the next day I found him much better, and he finally recovered. I mention this case as bearing upon the prognosis of all wounds; as the surgeon should never give a WOUNDS OF THE CHEST. 305 patient up, or desert him while life remains. In suicidal attempts patients will sometimes commit very trifling injuries upon the neck, which yet will be followed by serious consequences. Fig. 92. The Uniting Handkerchief of Mayor, as applied to "Wounds of the Neck.— In its application carry a cravat circularly around the chest beneath the axilla, and then depressing the patient's head upon his chest, to the proper degree, apply another broad cravat to the head, and fasten it as in the figure. (After Mayor.) Wounds and blows upon the back of the head and neck produce sometimes a remarkable train of symptoms, as when the cerebellum is involved the patient will frequently lose entirely his virile power. As illustrative of this, Henen relates the case of a dragoon, famous for his amorous propensities, who, in consequence of an injury of this description, suffered a wasting of the testicles, and never after- wards experienced the slightest venereal desire. The treatment in such cases should be such as is calculated to remove the deposit of lymph or the congestion which is generally the source of the mischief, and for this purpose a resort must be had to counter- irritants, the free use of mercurials, &c. SECTION IV. WOUNDS OF THE CHEST. In wounds of the chest we have a train of symptoms modified by the depth to which the wound has penetrated. Thus there may be a simple wound of the muscular parietes giving rise to hemorrhage from a branch of the external mammary artery, which being 306 PRACTICE OF SURGERY. arrested, the wound may be readily closed by sutures, or by strips of adhesive plaster. If a wound of the chest is complicated with an injury of the lung, there may be an escape of air externally, or into the cellular tissue surrounding the chest so as to produce emphysema; and this may proceed to such an extraordinary degree, as to swell up the whole body; or the tissues may be similarly engorged with blood, a condi- tion which is much more serious. Effusion of blood in these cases may show itself externally, internally, or both. If it shows itself internally, the individual will cough up blood, owing to its escape into the bronchial passages. Occasionally in wounds involving the pleura, pleurisy will ensue. Sometimes foreign bodies are driven into these wounds and cre- ate violent inflammation; the latter commencing at the seat of the wound. When a ball enters the chest it is useless to search for it, as most frequently it will work its way downward and be found upon the diaphragm. Fragments of rib, bits of clothing, and other foreign bodies, will sometimes share the same fate. Injuries of this kind generally run on to suppuration, and as the surface of the pleura is a continuous one, the suppuration which results may be very exten- sive, the cavity of the chest becoming filled with liquid and dis- tended to a very considerable degree, constituting empyema. Treatment.—The treatment of wounds of the chest will depend entirely upon the character of the attending circumstances. The treatment in mere flesh wounds is the same as in wounds of other parts of the body, whilst wounds breaking a rib and opening the intercostal artery will require that this vessel should be secured. This may be done by drawing it out with a tenaculum, and ligating it in the ordinary manner, as has frequently been done. Occasion- ally, when a rib is broken there may be some little difficulty in ligating it, but the hemorrhage can be arrested by passing a needle armed with a ligature—to which is fastened a little compress— behind the rib so as to bring the compress over the artery, and then tying the ligature externally, the artery will be secured by the pressure. If the wound penetrates a little deeper and pleurisy results, it must be treated in the same manner as pleurisy arising from any other cause. When emphysema ensues from a puncture of the air-cells of the lungs, it should be treated precisely as emphysema WOUNDS OF THE CHEST. 307 resulting from wounds of other portions, that is, by the application of a firm bandage around the part. If foreign bodies have been introduced and empyema has en- sued, paracentesis may be resorted to, a puncture being made at some convenient point, as between the fifth and sixth ribs,1 and the foreign bodies removed if they can be reached, the pus present evacuated, and the chest washed out with warm milk and water,' the patient having been previously placed in a convenient position for that purpose. Where there is internal hemorrhage from the lung, as shown by the expectoration of blood, it is generally essential to bleed very freely, and repeat it, if the activity of the heart's action is not dimi- nished, after which the whole antiphlogistic system becomes appli- cable, as antimony, mercury, digitalis, aconite, &c. &c, carried to their utmost limits, owing to the great vascularity of the lung. If portions of the lung protrude, they should be replaced, if pos- sible, by dilating the wound freely for that purpose if necessary; but if the prolapsed portion is strangulated and its vitality partially or completely lost, it should be surrounded with a ligature which should be cautiously tightened from time to time till the protruded part sloughs off. Fig. 93. A representation of the Handkerchief Bandage for retaining a dressing to the Axilla Shoulder, or upper part of the Chest. (After Nature.) 1 See Op. Surg., vol. ii. p. 55, 2d edit. 308 PRACTICE OF SURGERY. As a general rule, in all wounds of the chest involving the thoracic viscera, the wound should be closed as speedily as possible, and a tight bandage applied so as to compel the patient to breathe by his diaphragm, and thus prevent all motion of the ribs. A wound of the axilla or shoulder should have its dressings re- tained to the part by a handkerchief folded as a cravat, and applied as in Fig. 93. SECTION V. WOUNDS OF THE ABDOMEN. The danger in zoounds of the abdomen arises chiefly from their liability to produce peritonitis, and the prognosis, therefore, is always serious. The treatment will be modified by the character and contents of the viscera involved. Thus, wounds of the liver give rise to very troublesome hemor- rhage ; but a formidable danger is that resulting from the hepatitis which may be set up. It should be treated upon the same princi- ples as hepatitis uncomplicated by wounds. Should abscesses form, they should be evacuated, but before this is done adhesion should be brought about between the peritoneum covering the liver and that lining the abdominal walls by proper means, such as by cut- ting down nearly to the peritoneum, and applying nitrate of silver and caustic potash.1 When the surgeon is sure that adhesion has taken place, the pus may be evacuated without danger of its escaping into the peritoneal sac. In wounds of the stomach, there will be hemorrhage depending for its violence upon the position of the wound. Thus, wounds of the greater and lesser curvatures of the stomach will be likely to produce greater hemorrhage than wounds in other parts of its pa- rietes. Wounds of the stomach, when it is full, as after eating, will also be likely to result in the escape of its contents into the cavity of the abdomen. In view of these dangers it might be supposed that these wounds would be necessarily fatal, but, on the contrary, patients very often recover from them, and there is a well known case on record, in which a man having had such a wound inflicted upon him, a cobbler who 1 See Operative Surgery, vol. ii. p. 65. WOUNDS OF THE INTESTINES. 309 was in the neighborhood went to work with his awl and waxed ends, and deliberately sewed the whole wound together, making the viscus fast to the abdominal walls, and yet the patient reco- vered. And this course is far from being irrational treatmentr as stitching the wounded stomach to the abdominal parietes will diminish the dangers of the escape of gastric juice or other mat- ters into the peritoneal sac. Of course, the patient should be kept upon the lowest possible diet, and be informed of the risks of his wound.1 SECTION VI. WOUNDS OF THE INTESTINES. Wounds of the intestines may also give rise to trouble by allowing their contents to escape into the peritoneal cavity. In closing wounds of the intestine various sutures have been recommended, the details of which belong to operative surgery, and are given with plates in the work alluded to.2 In transverse wounds Lembert's suture will be found desirable. In its forma- tion, a needle is to be introduced about an inch and a half beyond the wound, and brought out half an inch from it; entered again about half an inch the other side of the wound, and again brought out an inch and a half beyond the wound. Then traction being practised upon the ligatures thus placed, the two peritoneal coats — that of the intestine and that of the abdominal parietes—are brought in contact, and adhesive inflammation taking place, the wound will be firmly closed. Jobert's suture is made by passing a needle from without in, about half an inch from the wound, and then from within out half an inch from the edge of the opposite flesh; finally from within out in the first flap at the same distance; after which the ligature is to be tightened and tied, as shown in the Operative Surgery, vol. ii. Palfyn's loop suture is made by passing a ligature through a piece of wood in such a manner that when each end is passed through a flap of the wound, and the ends tied, the wood will draw the intestine firmly forward against the abdominal wall. Pellier's suture is the ordinary continued suture, so arranged that 1 See Op. Surg., vol. ii. p. 78, 2d edit., for other cases. 2 See Op. Surg., vol. ii. p. 79, 2d edit. 310 PRACTICE OF SURGERY. by drawing upon each end it may be tightened to such an extent as may be necessary. Ledran's suture, which is particularly applicable to longitudinal wounds of some extent, is made by passing in four, five, and six stitches, or as many as may be necessary, of the interrupted suture. The ends are then brought together with the thumb and finger, and, by rotating them, are firmly twisted into a cord, thus approxi- mating the edges as closely as may be deemed desirable. The Glover's suture is some- times employed in these wounds, as shown in Fig. 94. Of course, the selection of any one of these sutures will depend upon the nature of the wound and the accompanying circum- stances. Thus, sometimes we have wounds of the intestines which will be best treated by simply surrounding the whole wound with a single ligature) such, for example, as wounds accidentally made in operations for hernia, or such as result from a mortified spot in an intestine that has been strangulated. , Fig. 95. A representation of the Glover's Suture, as applied to a Longitudinal Wound of the Intestine. (After Miller.) A representation of a simple Method of retaining a Catheter in the Bladder in the Treatment of Wounds of this Viscus, or in cases of Stricture of the Urethra.—A square piece of muslin, with a tape to each corner, and a hole for the penis, is to be applied and fastened around the pubes, the two tapes from the perineum being tied to those which go over the groins. Then the four ends of two ligatures tied around the catheter are to be tied as shown in the figure. (After Velpeau.) WOUNDS OF THE GENITO-URINARY ORGANS. 311 In wounds of the kidney, inflammatory action is the principal danger to be feared; this, of course, should be combated by appro- priate means, but such wounds are generally fatal. In wounds of the bladder, a catheter should be introduced, and retained in position, as shown in Fig. 95, till the urine passes rea- dily by the natural channel. SECTION VII. WOUNDS OF THE GENITO-URINARY ORGANS. Wounds of the generative apparatus vary considerably; some- times the penis has been cut off by the patient himself, or by others, and in these cases the organ is usually violently retracted, and there is profuse hemorrhage. To check this, the body of the penis should be drawn out of the skin with a tenaculum, and the arteries tied. If the hemorrhage seems to come from the corpora cavernosa, or the corpus spongiosum, a piece of lint wet with tr. ferri chloridi, or some other astringent, may be applied. Sometimes individuals have cut off their testicles while laboring under maniacal excitement; and I have known cases where persons confined in prisons, and others, have attempted this with the edge of a broken bottle, &c. Fortunately for these unhappy patients, the means by which they attempt to effect their object are generally such that there is very little hemorrhage, owing to the lacerated character of the wound. If, however, free hemorrhage should occur, it may be arrested by ligating the vessels of the cord, the wound being treated upon general principles. Wounds of the female generative appa- ratus may occur, very extensive lacerations of these parts having been produced by falling astride of the stopper of a bath tub, &c.; In such cases, usually, the chief danger is from the inflammation which will ensue, and this should be combated upon general princi- ples. Wounds of the buttock and perineum are also sometimes created by falls, or, as once occurred, by the breaking of a chamber- pot under the weight of a heavy man. Under these circumstances the wound should be freed from all particles of foreign matter, and the parts covered by a poultice, &c, as directed in lacerated wounds. The best means of retaining a dressing to this part of the body is by means of the handkerchief bandage of Mayor—one 312 PRACTICE OF SURGERY. handkerchief in the form of a cravat being tied around the pelvis, and the other, in the shape of a triangle, being applied by its base Fig. 96. A representation of the Handkerchief Bandage of the Buttock, as applied by Mayor. (After Mayor.) around the thigh, whilst its summit is pinned to the cravat, as shown in Fig. 96. PART IY. INJURIES AND DISEASES OF THE BONES AND JOINTS. The Bones, like the soft tissues, are liable to certain changes, which not unfrequently eventuate in a marked modification of their normal condition; thus they may inflame, suppurate, ulcerate, slough, mortify, and be thrown off from the system, whilst the void thus left will granulate and reproduce a new bony structure by very much the same steps as were noted in similar affections of the soft tissues. In fact, in nearly all the injuries and diseases of the bones, but little difference will be seen between them and the same affections of the soft tissues, except such as are due to the difference in their chemical composition and density, lime predominating in the bones, whilst the protein compounds form the chief ingredients of the soft structures. A brief allusion to the structure of the bones will facilitate the comprehension of their diseases, and point out the modifications between their injuries and the same condition in the soft tissues. General Structure of Bones.—Bones present two varieties of struc- ture, an outer or compact tissue, which predominates in their dia- physis, as well as in their circumference, and an inner, reticulated, or cancellated structure, which is found in the medullary canal or in the interior of the bones, as well as in their epiphyses and extremities. In the long bones these two structures—the compact and cancellated— are so distributed that the portion nearest the joints, or their articu- lating extremities, is chiefly composed of cancellated tissue, whilst the shaft, which is more solid, is formed of the compact matter. But in the short or thick bones the cancellated tissue forms the great bulk of the bone, the compact structure being only a thin shell spread over their surfaces. The bones are also covered exter- nally by a strong, tough, fibrous tissue, which, in adult life, can 314 PRACTICE OF SURGERY. only be separated from them with difficulty, though less firmly attached in the young bones; whilst internally in the medullary canal, and throughout most of the cells of the cancellated structure, they are lined by a more vascular and delicate membrane. These two membranes are generally designated as the external and inter- nal periosteum, the latter being also known as the medullary mem- brane, in consequence of its connection with the soft pulpy medulla which it contains, and which is popularly known as the marrow. To these two membranes the bones are chiefly indebted for their nourishment, most of the processes of repair in either disease or accident being due to the healthy action of these tissues. The sup- ply of blood from other sources than through the vessels of the external periosteum is comparatively limited, the chief point of supply being the nutritious foramen of the bone, through which the main artery enters in its course to supply the internal membrane. As this nutritious foramen is a fixed point in all bones, it is easy for a surgeon to recognize the influence of the position of certain fractures upon it, and to use additional care in the treatment of any case in which the nutritious supply might be checked by the frac- ture, or to explain to his patient beforehand that the result of such an injury will probably be more serious than it would otherwise have been. Seat of Diseases in the Bones.—The injuries and diseases of the bones may either affect the shaft or their continuity, or its extremities, and the contiguous portions; the latter including all the injuries and dis- eases of the ligaments and joints, as well as the articulating surfaces of the bones. In the methodical arrangement of the affections of the bony tissues and their appendages I shall include under the first variety, or the affections of the bony tissues, fractures, perios- titis, ostitis, caries, necrosis, exostosis, and tumors of various kinds, together with such diseases as are due to a deficiency or redundancy of certain of their component elements, as mollities and fragilitas ossium. In the second variety, or the affections of the contiguous struc- tures, may be placed luxations, sprains, synovitis, hydrops articuli, &c, all of which must be separately studied; and, as fractures are the injuries most frequently met with, they should first receive a careful investigation. OF FRACTURES IN GENERAL. 315 CHAPTER I. OF FRACTURES IN GENERAL. The subject of fractures, or the solutions of continuity in the bony fibres, caused either by mechanical violence or muscular action, is one that demands the most careful attention of the stu- dent, not only in order to prevent deformity of the limbs and the imperfect locomotion which result from the improper treatment of such injuries, but also to protect the reputation of the surgeon, and insure the proper performance of his duties. Nor is this subject less important to every medical man, whether professing surgery or limiting himself to the practice of medicine, as all practitioners are liable to be called on to render assistance in the emergencies- which usually give rise to these injuries. A fracture has been very correctly defined as " a solution of con- tinuity in the bony fibres, which is the result either of mechanical violence or of muscular action." It is generally accompanied by more or less injury to the surrounding soft tissues. Etiology.—The causes of this solution of continuity in the bony fibres may be divided into those which are predisposing, and those which are immediate or direct. 1. Predisposing Causes.—The predisposing causes of fractures are— The exposed position of the bone. Hence the long bones, especi- ally those of the extremities, which are situated between powerful muscles, are most apt to suffer from fracture. The diathesis of the patient has also a marked influence in their production, syphi- litic and cancerous patients suffering from fractures upon the slightest immediate causes. Occupation, also, has its influence; workmen, and those exposed by their trades to falls or blows, being more liable to these injuries than others. 2. Immediate Causes. The immediate causes of fracture may be divided into two varieties, mechanical violence, and muscular con- traction, both of which create fractures by overcoming the natural adhesiveness of the bony fibres. They may be applied in various ways, tbe mode in which fractures are created being innumerable. 316 PRACTICE OF SURGERY. Varieties in Fractures.—Fractures have been classified, 1, accord- ing to the nature of the injury; and, 2, according to the direction in which the bony fibres yield. According to the nature of the injury, they are usually divided into simple, compound, commi- nuted, and complicated; whilst in accordance with the direction in which the fibres of the bone have yielded, they are classified as transverse, oblique, longitudinal, fissured, stellated and depressed, each of which has its special peculiarities. A simple fracture is one in which the fibres of the bone have given way without any external solution of continuity in the soft parts, though the latter may have been bruised, or even lacerated internally. A compound fracture is one in which a wound has been made in the outer surface of the soft parts, by which the atmosphere can communicate with the broken ends of the bone. This wound may be made either by the fragments of the bone being driven through the surrounding soft parts, or by the same violence which produced the injury. To comply with this definition of a compound fracture the wound must therefore communicate with the fragments of the bone, otherwise the injury would properly be only a simple frac- ture complicated with a wound. A comminuted fracture is one in which the bone has been broken into two or more pieces. A complicated fracture is that which is accompanied by some other injury, such as laceration of the bloodvessels or nerves of the limb, &c. A transverse fracture is one in which the fibres of the bone have given way transversely to its long axis. An oblique fracture is that in which the fibres have yielded obliquely. A longitudinal fracture is one in which the division of the bony fibres runs parallel with the axis of the bone. A fissured fracture is one in which there is a simple crack; the term being generally limited to fractures of the cranium. A depressed fracture is also generally confined to the cranium, in which some part of the fragments is depressed below the level of the surrounding portions of the skull. A stellated fracture is an injury of the bones of the head, in which the fissure assumes a radiated, star-like shape. Causes of the Deformity in Fractures.—As the bones serve for the OF FRACTURES IN GENERAL. 317 points of attachment of muscles, and the action of the latter is resisted by the continuity of their fibres, it follows that in the event of a fracture the action of the adjacent muscles, or those connected with the fragments, will be imperfect, and that the frag- ments themselves will thus be liable to be drawn out of their natural line, whence deformity of the limb ensues, as well as dis- placement of the broken ends of the bone. Displacement of the fragments after a fracture may also be pro- duced at the moment, by the force creating the injury, as well as subsequently by muscular contraction after the fracture has oc- curred. This muscular contraction tends towards the reproduction of deformity until the bones have become again firmly united, a fact which should be borne in mind throughout the entire period of treatment. The popular idea is, however, quite the reverse. Thus the ignorant conceive that a bone once set is always set, and often blame the surgeon first seen for having "set the bone wrong;" when the person deserving blame is really the second or third attendant in the case, or the patient himself, by whose constant muscular action, when unresisted by proper mechanical contriv- ances, the bone is repeatedly displaced. Displacement after fracture may occur in five different directions. 1. Displacement in accordance with the length of the bone, is one in which the fragments are drawn upon each other as in oblique fractures, and produces marked shortening of the limb. By it the free surface of the external periosteum of one fragment is liable to be brought into contact with the free surface of the internal periosteum of the other, and as these two structures differ in vascu- larity, there will often be such a difficulty, in the formation of cal- lus, as will retard the cure and increase the probability of the formation of an artificial joint. 2. A displacement, in accordance with the thickness of the bone, is that which is produced in transverse fractures when one frag- ment rides the other. Here the medullary canal of both fragments being exposed, and the external periosteum of one fragment brought into contact with the external periosteum of another, it becomes a question whether these two surfaces can unite, a question which will be more fully alluded to subsequently under the head of Callus. 3. Displacement, in accordance with the circumference of the bone, or that in which one or both fragments rotate upon their 318 PRACTICE OF SURGERY. axes, interferes not only with the formation of callus, but with the subsequent usefulness of the limb; thus, if such a deformity should become permanent in the femur or tibia, the foot would be turned inward or outward by the rotation of the lower fragment, and the patient would walk upon the inside or outside of his foot instead of upon the sole. In the humerus, the elbow would be apt to present inwards, outwards, or even forwards, and the position of the hand would, therefore, be such as would materially interfere with its usefulness as well as with the comfort of the patient. 4. An angular displacement is one of the most common of those consequent upon fractures, and is invariably produced when the muscles on one side alone act, or when the two sets of muscles act unequally. Thus, in a fracture of the leg in which the heel is not well supported, there will be more or less angular displacement of the upper end of the lower fragment, but this displacement usually interferes but little in the formation of callus. 5. The fifth displacement is that present in impacted fracture, in which one fragment is driven into the other by the force producing the injury. In this displacement, the external periosteum of one fragment, or the bone denuded of its periosteum, presents to the internal periosteum of the other, in consequence of which diffi- culties in the formation of callus as well as shortening, angularity, &c, are very likely to ensue. Symptoms.—The symptoms of fractures are divided into two general classes: 1, the rational; 2, the physical. 1. The rational symptoms of fracture are readily recognized; thus, the patient suffers pain, which is generally acute and often intense. Indeed, so marked is the pain from a fracture that it has been said that the accident may be recognized by the cry of the sufferer at the moment of its occurrence, or at the first dressing. Frequently, however, there is impaired or irregular sensibility of the affected limb from the pressure of the fragments upon the nerves supplying the part. There is also more or less inability to perform the functions of the limb; thus, if the fracture affects the femur or tibia, the patient will be unable to stand, whilst if it is the humerus he will be unable to perform the usual motion of the arm, which hangs as a dead weight at his side. 2. Among the physical signs of fracture, the most important is that of crepitus, or crepitation, or that sensation caused by the friction of the fragments against each other. This sensation has OF FRACTURES IN GENERAL. 319 been compared to the impression made upon the sense of touch and hearing by rubbing two pieces of loaf sugar, or similar porous bodies together. In order to diagnose this condition, which is often rather felt than heard, the inexperienced observer should exercise every caution; but once perceived there will be little difficulty in recognizing it again. In some cases it is quite difficult to distin- guish the crepitus of a broken bone from certain other conditions, as a diseased state of the bursa connected with certain tendons, where, owing to lymph being effused into the cavity of the bursa, the movements of the tendon produce a sensation which has been con- founded with the crepitus of fractures. So also the impression made by the motion of a joint during certain inflammations of its' structure. Both these conditions, however, give the impression of the action of moist surfaces, while the crepitus of fracture gives rather the idea of the friction of two dry porous bodies upon each other. Emphysema of the cellular tissue is accompanied by a crackling upon pressure which, under certain conditions, might be mistaken for the crepitus of fracture, but a diagnosis may be rea- dily made by noticing that the crackling or crepitation of emphy- sema is superficial, while that of fracture is deeper seated. Besides crepitus, the physical signs of fracture consist in increased or diminished mobility, in displacement or deformity of the part, and in loss of motion, or too great a degree of mobility. Prognosis.—The prognosis of fractures will depend upon the age, constitution, and habits of the patient, as well as on the extent and nature of the injury. As a general rule, the fractures of the aged, if they unite at all, unite more tardily than those of the young. There is also more 'endurance, more vascularity, and more ample formative and repara- tive power in the young than there is in the old. The prognosis will also vary with the bone that is broken; a fracture of a single bone situated between powerful muscles, such as the humerus or femur, being more difficult to treat successfully, and without de- formity, than one in which two bones are concerned, particularly if but one of them is broken, as the radius, or the tibia; since in this case the other bone—the ulna, or the fibula—acts as a splint, so as to keep the parts at rest and prevent shortening. The relation of the fracture to the attachment of muscles also influences the prog- nosis. If the fragments have muscles attached to them, which have a constant tendency to reproduce the displacement, the cure will 320 PRACTICE OF SURGERY. take a longer time, although, with care and proper treatment, it may be ultimately accomplished. The rapidity of the cure, and the probability of deformity, are affected moreover by the nature of the fracture, whether it is impacted, simple, transverse, or oblique. The social position of the patient has also its effects upon the prognosis. If in wealthy circumstances, surrounded by all the luxuries of life, and able to obtain the little comforts and attentions so necessary for the sick, the chances will be better than when a fracture occurs among the laboring classes. On the other hand, these men have generally more robust frames and better consti- tutions, and hence their chances are better than too many of the wealthy, who are liable to be debilitated by their mode of life. The general health of the patient also influences the rapidity of the cure, and even the chances of life. The relation of the bones to certain cavities should moreover have its weight in the progno- sis, the injury being always severe in fractures of the pelvis, on account of the liability of injury to the viscera, either by the force producing the fracture, or by the effusions which are apt to ensue. Process of Repair in Fractures.—As it is absolutely essential to a cure that there should be the formation of a proper amount of reparative material, in the healing of the injuries of a structure which, like that of a bone, must gain a considerable degree of close consolidation before its functions can be correctly performed, the investigation of the process of union has always been most carefully conducted. From an early period of surgical science, the mode of union in fractured bones was regarded as one of the most interesting questions in surgery, and the physiology of the repara- tive action has since then received general attention, so that its course is now well understood. Callus, or the material furnished by nature for the union of the broken ends of a bone, is an example of the modification of struc- ture created in an effusion of lymph by the action of the tissues concerned in the injury. In its formation, the same general steps may be noted as were seen in the effusion of that plasma which served to repair the injuries of the soft tissues. As the cause creating a fracture is always productive of considerable laceration of the vessels of the adjacent tissues, an effusion of blood into the surrounding parts is usually noted soon after the occurrence of the injury. This blood being effused within the integuments, soon creates more or less swelling, as well as discoloration of the skin, OF FRACTURES IN GENERAL. 321 at or near the seat of fracture, rendering the limb black and blue to some distance from the part, and especially in the line of the muscles which have been most violently strained at the time of the accident. Like the effusions of blood in wounds, this blood is soon acted on by absorption, whilst the inflammatory action developed by the injury, leads to an effusion of plasma around it, and to the steps of organization already explained in a previous chapter.1 In addition to the laceration of the fibres of the adjacent tissues, a fractured bone is always attended by some laceration of both its external and internal periosteum, and the inflammation developed from the injury of these membranes seems to have a marked influ- ence in regulating the character of the deposit which occurs around Fig. 97. 1 2 3 Diagram of the Earlt Stages of Union after Fracture of the Humerus.—1. The pouch of blood and the ends of the bone surrounded by it. 2. Plasma occupying the place of the extravasated blood. 3. Organization advanced in the callus which new holds the fragments as in a ferule. (After MiUer.) the broken ends of the bone. The effusion of lymph consequent on the development of inflammation in all the soft structures around a 21 1 See page 77. 322 PRACTICE OF SURGERY. broken bone is soon apparent in the thickening and enlargement felt at the seat of the fracture a few days after its occurrence. (Fig. 97.) This effusion of lymph being noted by Dupuy- Fig. 98. tren, in his experiments upon animals, to be both around as well as within the ends of the bones, he attributed the exterior mass to the action of the external periosteum, whilst that connected with the ends of the fracture he assigned to the reparative efforts of the medul- lary membrane. As he thought that the exterior mass of callus, though marked at first, disap- peared after the lapse of a few weeks or months, he termed it the "Provisional Callus;'''' whilst that from the ends of the bone, which completed the continuity of its structure, he designated as the "Definitive or Permanent Callus.11 These opinions of Dupuytren being in accordance with the observations of others, have long been re- ceived as the true explanation of the condition of parts after a fracture had united by callus or new bony matter; and surgeons yet recog- nize, to a considerable extent, the existence of these two forms of bony union. Professional opinion has, however, been recently very much modified in regard to the condition of the ex- terior callus, in consequence of the observations made by Mr.Paget on this subject; Dupuytren'a explanation being objected to on the ground of his having experimented on animals, in which it was difficult to keep the broken bonea at perfect rest. Mr. Paget thinks,1 from his ob- servations, that "the method of repair with an ensheathing or provisional callus is rarely ob- served in man, though frequent in fractures of the long bones of animals;" he "having never seen it in man, as a natural process, in any bones but the ribs."2 Subsequently, however, he admits that he has seen it in the human clavicle and humerus, though in both these instances he deemed it due to the movements A view of the En- nbeathing Callus in a Dog's Tibia, showing that it accumulates sole- ly between the wall of the bone or its compact tissue and the external periosteum, which is thus lifted up from the bone, whilst the bloodvessels which passed from it to the bone in the natural state now pass to their destination through the callus. (After Paget.) 1 Lectures on Surgical Pathology, p. 165, Philad. edit. 1 Op. cit., p. 167. OF FRACTURES IN GENERAL. 323 of the parts having disturbed the more proper mode of repair. That perfect rest and accurate adjustment limit the amount of the provisional callus, must be a common observation of all who have had much experience jn the treatment of these injuries; and per- sonal observation induces me to think that Mr. Paget's first opinion on this point will not be maintained by him on further and more extended observation. Wherever a fractured bone is superficial, as in the clavicle or in the tibia, the lump or protuberance caused by the provisional callus will often be too plain to be mistaken, whilst very many specimens of fractures recently united and sur- rounded by a true provisional callus, that is, one which is larger a few weeks after union than it is some months subsequently, are to be found in most surgical cabinets. The chief objection is cer- tainly correct as respects the use of the term provisional, this callus being always present after the union of a fracture, and shown in the greater thickness of the exterior or compact layer of the bone; and it is therefore more accurate to employ the term " ensheathing callus11 to designate this exterior bond of union, as has been well suggested by Mr. Paget. In explaining the production of both the ensheathing and defi- nitive callus, Messrs. Paget and Stanley regard them as due to the formation of the granulations which result from the organization of the effused lymph, these granulations being created by precisely the same reparative efforts as those already alluded to as the chief agents in the repair of the soft tissues. In the repair of injuries to the bones, as well as in those of the soft tissues, certain conditions are necessary. Thus, (1) there must be upon the part of the patient a sufficient degree of vital power to keep up the necessary amount of inflammatory action; and (2) there must be an absence of such stimulants as might induce excessive inflammation, and result in suppuration, or an absorption of the callus, a condition which may ensue upon a too early, violent, or otherwise improper motion of the fragments. The granulations of repair in fractures form nucleated cells by which ossification is ultimately accomplished, and these spring from the internal surface of the external periosteum, from the compact structure of the bone itself, and from the medullary membrane, as may be demonstrated by an examination of the extremity of a bone in the stump formed by an amputation, where granulations will be seen sproutiug from all these sources, and where they are found 324 PRACTICE OF SURGERY. shooting up, spreading out, and forming a mushroom-like mass at the extremity of the bone.1 Any deviation from these processes of repair, results in a modi- fied callus. Thus, certain circumstances so modify the conditions necessary to the perfect formation of callus, that merely a cartilagi- nous or ligamentous mass results, and some bones consequently pre- sent these conditions so invariably that they seldom if ever obtain bony union, as for example the femur within the capsular ligament, the patella, olecranon, &c. The process of repair and the formation of callus may be divided, for the purposes of study, into two periods. 1. The uniting period, during which the provisional or ensheath- ing and the definite callus are formed. 2. The modelling period. 1. The uniting period presents first a stage of inflammatory exu- dation, which continues for the first two to four or five days after the injury, and, with the effusion of blood already alluded to, pro- duces the swelling which occurs after fractures. ' Then there is a period of four or five days of apparent inaction and decline of inflammatory action, a period of calm after the storm; accompanied by diminution in swelling, pain, and all in- flammatory symptoms. These two periods together give, it will be perceived, from eight to ten days, during which nothing has been done directly for the repair of the injury. The third stage, com- mencing in the neighborhood of the tenth day, and lasting from ten to twelve days, is the formative stage, in which the reparative tissue is formed by an organization of the lymph, as thrown out, and the formation of granulations as stated. This is the period popularly designated as the "knitting" period, during which the patient will often say he can feel the bone knitting, which of course is an erro- neous idea, though what causes the sensation, whence the patient obtains this notion, cannot be told. We have thus obtained a period varying from twenty to thirty days, during which usually no osseous matter has been deposited. It is impossible to limrt these periods nearer than by the generalization above given, for they vary with the age, the bone broken, the degree of inflamma- tory action, and many other circumstances. In the fourth stage osseous matter begins to be deposited, and soon exhibits the true characteristics of normal bones, as the formation of the Haversian Paget's Lect., Pliila. edit., p. 163. OF FRACTURES IN GENERAL. 325 Fig. 99. ossicles, canals, &c, though these are not presented in the fully de- veloped state of normal bone. This stage of ossification is of an indefinite length, varying in different bones, and on account of diverse cir- cumstances not always precisely noted. 2. During the modelling period, which trenches somewhat on the last stage of the first period, sharp frag- ments and spiculae of bone are re- moved or rounded off; any great ex- cess in ensheathing callus disappears; cells are developed on that part of the definitive callus which encroaches upon the cavity of the bone, and the can- cellated structure is reproduced to a greater or less extent. (Fig. 99.) The time required to effect such a degree of union, that the patient may with safety dispense with his splints and bandages, and begin the motion of the limb, varies according to the bone injured. Thus, in the clavicle it is about five weeks, in the humerus six or seven under favorable circumstances. In the case of the femur it would hardly be safe to walk before twelve weeks or three months; and in the tibia it is about eight weeks. But it must be remembered that some fractures never unite by callus, that condition resulting which is spoken of as " false joint," or more properly "ununited fracture;" besides which certain fractures, as be- fore stated, unite only by ligamentous matter, the callus never becoming *erna11 wal1 ftnd cancellous interior 7 ° for the reparative new bone, and bone. A view of the Condition of a Bone after the modelling process has been conducted through its different stages, showing the removal of the sharp points and edges of the frag- ments, the closing in or covering of the exposed ends of the medullary canal, the forming of a compact ex- Treatment.—The treatment of frac- tures may be considered as resolving itself into four stages. lastly, the continuity of these with the walls and cancellated tissue of the fragments.1 (After Paget.) 1 See Paget's Lectures, p. 170. 326 PRACTICE OF SURGERY. The first stage relates to those general rules which must be obeyed in all fractures of sufficient magnitude; such as directing the manner of removal of the patient to his dwelling, of placing him in bed, &c. &c. The second consists in the reduction, or, as it is termed in common language, the "setting" of the fracture. The third consists in the application of such dressings as are necessary to prevent displacement of the fragments by muscular action. And the fourth stage embraces the treatment of the complications and constitutional disturbances, which result from the injury or fol- low the dressing, as chafing, ulceration of the skin, anchylosis of the joints, &c. &c. A few words devoted to the explanation of each of these stages, so far at least as they are applicable to fractures generally, will save much unnecessary repetition in the consideration of particular fractures. The first stage embraces that part of the general treatment of fractures which relates to transporting the patient from the spot upon which the injury occurred to that at which he is to be treated, and to the arrangements which become necessary, not only for car- rying out the treatment, but for the comfort of the patient; the latter being a matter by no means to be overlooked in an injury, where perfect rest is so essential to the cure. The directions to be given in regard to moving a patient will vary, of course, in accordance with the character and position of the injuries. In the majority of severe fractures, as in fractures of the lower extremities, spine, and head, and often in compound frac- tures of the upper extremities and other bones, it becomes the duty of the surgeon to suggest means for the accomplishment of this object without adding to his patient's suffering; it being also de- sirable that he should, if possible, be borne along without jarring the broken fragments, and thus augmenting the laceration of the soft tissue. For this purpose such means must be employed as can be most readily obtained. Where nothing better can be had, a shutter or door taken off its hinges will answer the purpose; but, when a settee can be obtained, it furnishes the most convenient mode of transportation. If the patient is to be carried to his own dwelling, particularly if the house is small and the rooms narrow, care should be taken not to carry the settee into the room in such OF FRACTURES IN GENERAL. 327 a manner as to bring its back to the bedside. This apparently trifling matter is one really of practical importance, as, if it be neglected, it may become necessary either to carry the patient down stairs and bring him up again in the proper position, or to lift him over the back of the settee, by which movement serious mischief may be done to the limb, and unnecessary pain created. It is, therefore, an excellent rule in all such cases to ascertain, before the patient is carried up to his room, the^general arrange- ments of the house, the position of the bed on which he is to lie, &c. &c, with a view of obviating such difficulties. In lifting the patient from the settee to his bed, if the femur is fractured, two strong assistants should slip their arms under him and clasp each other's hands by what is known as the "sailor's grip," that is, by placing the palmar surfaces of their flexed fingers to- gether. These hands should be placed one under the shoulder and one under the hip of the patient, while an experienced assistant or the surgeon himself should lift the injured limb. The position of the assistants should also be so regulated that they may be able to lay the patient easily upon the bed—which should always be a narrow one—by one going on each side, when the patient may be gently deposited upon it, the hands being afterward withdrawn. When these details are overlooked, it often happens that the assistants so place themselves that one comes between the bed and the patient, and has then to crawl over the bed whilst sustaining the patient's weight, which incommodes all parties. Preparation of a Bed.—Previous to this, if the patient has a frac- tured thigh, leg, cranium, or any injury by which he is likely to be confined to his bed for some days or weeks, the bed upon which he is to lie must be prepared for that purpose. The necessity for such a proceeding is easily seen when it is remembered that a patient with a fractured thigh must lie on his back for six, eight, or twelve weeks without motion; during which time his bowels are to be moved every day, his urine is to be passed, his clothes are to be changed, &c.; whilst all this must be done without producing any displacements in the fragments of the injured limb. To accomplish this, some modification in his ordinary bedstead becomes necessary. One modification which constitutes a very excellent "fracture bed- stead" is readily made out of any ordinary single bedstead by sawino- its side near its middle into two parts, at about a foot distant from each other. Then the piece thus marked off is to be split out with 328 PRACTICE OF SURGERY. a chisel, so as to form a depression. (Fig. 100.) Two cleets, similar to those of a counter drawer, are then to be nailed from one side of the Fig. 100. A representation of a Fracture Bedstead, as made by altering the ordinary single bedstead. (After Nature.) bed to the other at the edge of the depression, at such a distance apart that a common chamber pot with a width of brim corresponding with the width of the groove in the cleet thus prepared may be slid along it. Such a bed should support its bedding with slats, not by means of a sacking bottom. If a slat bedstead is not at hand, one may readily be made by taking off the sacking-bottom, breaking off the pegs to which it is attached, and nailing on slats of wood, placed two, three, or four inches apart, according to circumstances. The middle slat should be broad, and at its middle, corresponding with the position of the pot, there should be a hole cut out like a privy seat. Such a bedstead can always be made from an ordinary bedstead at an hour's notice. A very excellent fracture bedstead, admirably adapted for the purpose, often difficult to obtain in private practice, but suitable for hospitals, is a simple iron bedstead, having at a proper point a round opening, which can be closed with a trap, and beneath which are proper arrangements for sliding in the pot. Upon this, or upon the more domestic bedstead described above, the fracture mattress is to be placed. This consists of an ordinary mattress with a hole in the centre, so made as to correspond with the opening in the bedstead. To fill this opening, when not needed for necessary purposes, it is to be kept closed by a pad, shaped like the cover of a privy seat; the edges being sloped so as to enable it to be slipped in and out under the patient's hips without disturbing his position in the bed. OF FRACTURES IN GENERAL. 329 Fig. 101. Although this fracture mattress is very readily made out of an ordinary mattress, still there may be difficulties in the way of obtaining it, or other causes may render it necessary or desirable to substitute a simpler arrangement. Under these circumstances, four clothes-props, or similar pieces of wood may be jointed into a frame; a sacking-bottom stretched over it, a hole made in the centre and tapes tacked along the edges to prevent the sack- ing-bottom from tearing out, as in Fig. 101. If the size of the frame is such as to pro- ject a little beyond the edges of the bed- stead, a contrivance is obtained which will answer every purpose. It may be laid upon any ordinary bedstead upon which a mattress has been placed; a fracture sheet, which consists in a simple sheet, with a hole cut in the centre, being laid upon it and the patient placed on top of the sheet. Then when he desires to have a stool, it is only necessary to elevate the frame from the bed by means of assistants; to rest its ends upon the backs of four heavy chairs, or any contrivance made for the purpose, and place the chamber-pot beneath the orifice in the sacking-bottom. There is another recommendation of this frame, particularly in warm climates, or in the summer season, and that is, that as the patient lies constantly upon his back, his skin be- comes sodden by perspiration, and he is predisposed to bed-sores, besides the discomfort which he necessarily suffers. All this may be prevented by occasionally elevating him from his couch by some such apparatus as this, and a draft of cool air being thus made to pass beneath him, the danger of bed-sores is materially diminished. Attention must also be paid to the mode of making such changes in the bedclothes and linen of the patient as are necessary dur- ing his confinement. As it is often exceedingly important, par- ticularly in fractures of the lower extremities, to accomplish these changes without compelling any motion on the part of the patient, it may be readily accomplished by a very simple manoeuvre. In changing the shirt, take the garment and pass one hand in at A view of the Fracture Frame for elevating patients from the bed, as described in the text. (After Nature.) 330 PRACTICE OF SURGERY. the sleeve and out at the tail; elevate the patient's hands and arms above his head; grasp one of his hands so as to secure all his fin- gers, and prevent them from catching in the shirt, and draw it into the sleeve up to the shoulder, repeating the same motion on the opposite arm; then drawing the shirt well up into both of his axillae, elevate his head a little and slip the shirt over it; after which it can be drawn down into the hollow of the back, but not below the hips, or it will be liable to be soiled sooner than necessary. If it is desired to take the shirt off, it can be accomplished readily by movements directly the reverse of those just described. The removal and replacing of the bedclothes is still more sim- ple. The new sheet should be gathered up into a fold and laid under the neck of the patient, when the upper edge of the old sheet may be made fast to the, lower edge of the new one, and as the patient hollows his back a little, or is eased up by assistants, the same motion which draws the old sheet from under him brings also the new one into its place. When in changing the sheets the splints, &c, are reached, as in a fractured thigh or leg, the surgeon should carefully take charge of them until the changes are com- pleted. These little points may by some be regarded as triflingly minute, but experience has shown their value; and they are closely con- nected with the comfort and welfare of the patient. Reduction of Fractures.—The means to be employed in the reduc- tion of the fractured ends of a bone consist essentially in extension^ and counter-extension. By extension is meant the force applied to the fragment farthest from the centre of the body with the view of drawing the bone into its place. By counter-extension is meant the force applied to the fragment nearest to the body, or to the body itself, with a view of resisting the extending force. Thus, for example, in a fracture of the humerus, if the extension is applied at the wrist, and no coun- ter-extending force applied, the extension would simply draw the body out of line; but when, by a properly adjusted counter-ex- tending force, the upper fragment and the body are rendered a fixed point, the extending force is enabled to draw the fragments into place. Hence, the counter-extending force must be equal to the extending force, excepting only the degree of power which must be applied to the lower fragment before the vis inertia of the upper fragment is overcome. OF FRACTURES IN GENERAL. 331 When the extending and counter-extending forces are applied judiciously and with sufficient power, it next becomes necessary to adjust the ends of the fragments by those manipulations which have been denominated "Coaptation,11 and which simply consists in well- regulated attempts made by the fingers of the surgeon—while ex- tension and counter-extension are being made—to adjust the posi- tion of the ends of the fragments, and bring the parts as accurately as possible into their normal position. The object of the extending and counter-extending force is to remove displacement by overcoming the muscular action which produces it. That these forces shall be efficacious, therefore, they must have sufficient power to overcome the strength of the spas- modically contracted muscles, and a slighter degree of force will answer, if means are emU^ed calculated to promote relaxation in the muscular tissues. ^ It is better, therefore, not to attempt to overcome the spasmodic contraction of the-muscles in a case of fractured thigh, or a badly fractured humerus, without obtaining perfect muscular relaxation, as may readily be done by means of anaesthetics. The advantages of this mode of proceeding are to be seen in the facility with which these powerful muscles, which are usually so difficult to overcome when spasmodically contracted, can be mastered by the strength of a single assistant. Not only is pain to the patient avoided, but the nervous shock and violence which predispose to inflammation, &c, are obviated by this simple and safe mode of proceeding. Hence, I do not hesitate to recommend the use of anaesthetics in the reduc- tion of every case of fracture of a bone acted upon by powerful muscles, provided there is no affection of the brain or heart.1 Retention of Fractures.—The mechanical contrivances employed to effect the reduction of fractures are various, and will be detailed in connection with such fracture, as will also the means employed to retain the fragments in position after their reduction, and prevent the action of the muscles from causing a recurrence of the de- formity. After-Treatment.—The after-treatment of fractures consists in em- ploying such means as are necessary to regulate inflammatory action, stimulating measures being resorted to, if there is a defi- ciency of action, and antiphlogistics, if appearances indicate that it is likely to be excessive. 1 For the administration of anesthetics, see Op. Surg., vol. i. p. 183 2d edit. 332 PRACTICE OF SURGERY. Besides which, some means will be required to guard against stiffening of the joints; to obviate the loss of power which some- times results from the adhesion or wasting of muscles, and to meet the various complications which will spring up from time to time in the course of the mechanical treatment. Thus, fractures may be complicated with Ghafing and ulceration of the skin resulting from too much violence in the employment of the extending or counter- extending forces, as well as from the careless use of the means necessary to produce these forces, or from tenderness in the skin of the patient, &c. So, also, if the patient lies long upon his back, as in cases of fractures of the cranium, of the vertebrae, of the thigh, &c, troublesome bed-sores may result and their treatment become necessary. From long continuance in one position, pain in the fractured limb, and even violent spasm in its muscles may alao result, which, as well as the various complications above mentioned, require to be studied in detail, and will be again alluded to in con- nection with the fractures in which they most frequently occur. CHAPTER II. FRACTURES OF THE HEAD AND FACE. SECTION I. FRACTURES OF THE CRANIUM. Fractures of the cranium may be caused by the exercise of direct force or of indirect violence. In either case the force is ap- • plied to some portions of the arch formed by the cranial bones, and if sufficiently great, either causes a rupture of their fibres at the point to which it is applied, or, being transmitted along the arch to its abutments, makes the bones at the base of the cranium to give way, the fracture of this portion resulting in consequence of the indirect action of a force which is known as "counter stroke" or "contre coup." Seat and Etiology.—Fractures may occur at various parts of the vault of the cranium, and these will vary in accordance with the kind of force applied. Thus, when a man is struck with a fractures of the cranium. 333 bludgeon on the top of the cranial arch, the fracture may occur, if the blow be sufficiently violent, at the point where the force is applied; but if the blow is not violent enough to produce a fracture at this point, it may yet create a fracture of the base of the skull in consequence of its force being transmitted along the walls of the skull to its base, where, meeting the resistance offered by the arti- culation of the occipital bone with the atlas, the fracture results. A fracture of the base of the skull may also be produced in an- other way, as when a man falls from a height upon his hips or feet, the force thus communicated to the sacrum being transmitted along the spinal column to the occipital bone, which then gives way and creates a fracture near its articulation with the atlas. Structure of the Cranium.—r-To understand the symptoms and treatment of these fractures, it is necessary to study carefully the anatomy of the head, a few brief allusions to which will probably be useful in this place. The bones of the cranium are composed of two tables of compact matter containing between them a certain variable amount of spongy or cancellated structure to which the name of diploe is applied; and, as this diploe' is a loose or open bony structure, it acts favorably in the case of blows upon the cranium by diminish- ing their force; hence, fractures of thin skulls are more extended than those seen in thick, the thickness being chiefly due to the diploe. There are several other structural points which should be borne in mind while studying these fractures; thus, the outer table of the cranial bones is covered by a dense periosteum to which the name of pericranium is applied, this membrane being thicker along the median line than elsewhere. As it is very vascular, any force which produces a fracture of the bone beneath it, may rupture some of its numerous vessels and produce the bloody tumor of the head already alluded to, and which is so likely to cause an error of diagnosis in the examination of cases of supposed fracture of the skull. The cranium is also lined by the dura mater and the membranes of the brain; whilst between the dura mater and the bone lies the middle artery of the dura mater with its numerous branches the pia mater which lies within the dura mater being also exceedingly vascular. Of course any force capable of producing a fracture of the skull will be apt to rupture some of these vessels, and the 334 PRACTICE OF SURGERY. hemorrhage which results will occasion all the symptoms of com- pression of the brain. (See Fig. 102.) Besides this it is worthy of re- membrance that the texture of the integuments covering the cranium is such as to render it exceedingly liable to inflammation, and espe- cially to inflammation of an erysipe- latous character. The bones of the skull which are most liable to fractures are those upon its top and sides, next those forming what is properly spoken of as its.base, especially the occipital bone, the mastoid process of the temporal and the sphenoidal bone generally escaping. Varieties.—Like other fractures, those of the skull may be simple or compound, besides which they are divided into several varieties, accord- ing to the manner in which the tex- tures of the bone have given way. Thus a simple crack in the bone is designated as a fissure, and is a simple solution of continuity in the fibres of the bone without any other change. This fissure may be combined with wounds and other complications, as may also any other fracture of the skull. When the blow causes a number of fissures radiating from a single point in the shape of a rude star, w^e have what is known as a stellated fracture. A fracture in which the bone is driven in as well as fractured, is called a depressed fracture or a comminuted fracture. Such fractures require a consi- derable amount of violence for their production. They may be caused by sabre cuts, by blows upon the head with a bludgeon, by a stroke with a brickbat, by the kick of a horse or mule, or by falls upon the head. In some cases these fractures are accompa- nied by a loss of structure in the cranium, though this is rare and generally due to injuries from great violence; thus it has been known to occur from fractures of the skull caused by the cutting edge of a circular saw, or by a blow from an axe, cutting out a portion of the bone and leaving the brain exposed. Repair in Fractures of the Skull.—The bond of union in frac- A representation of an Extravasation of Blood by which the dura mater is separated from the cranium at the ordi- nary site by rupture of the middle ar- tery of the dura mater. (After Liston.) FRACTURES OF THE CRANIUM. 335 tures of the bones of the skull is ligamentous in its character, neither definitive nor provisional callus being thrown out; and it is easy to see that, were it otherwise, serious consequences might result from the callus encroaching upon the brain. Symptoms.—The symptoms of fractures of the skull vary with the nature of the injury and with the degree of violence producing it. Thus, in all cases there will be more or less contusion or wound of the soft parts, and, if the violence has been sufficiently great, there may be superadded symptoms of concussion of the brain; whilst if the fragments are driven in so as to create pressure on the brain, or if there is hemorrhage from injury to the arteries of the dura or pia mater, there may be symptoms of compression. Simple Fissure.—The symptoms of simple fissure are, generally, injury to the soft parts and more or less concussion of the brain, which very often terminates favorably, but at times results in effu- sion and compression of the brain. Treatment.—In the treatment of a simple fissured fracture of the cranium it should be borne in mind that the chief danger is from concussion of the brain; or that having been passed, from such complications as inflammation of the scalp of the membranes of the brain, or of the brain itself. If concussion occurs it is to be treated in the manner that will be detailed hereafter; but if it is not present the treatment will consist in the use of such means as are calcu- lated to guard against inflammation. Thus the head should be shaved and surrounded by cloths wet with cold water, whilst the whole antiphl<$gistic system should be actively pursued, bleeding, purging, or mercury, being resorted to as demanded by the prin- ciples already detailed in the general treatment of inflammation. (See page 70.) Depressed Fractures.—The symptoms of depressed fracture are change in the configuration of the skull, and the signs of compres- sion of the brain. Generally speaking, the depression can be felt by passing the hand carefully over the cranium after the scalp has been thoroughly shaved to free it from its hair. Besides the injury to the soft parts which necessarily accompanies it, this fracture is also generally attended by all the symptoms of compression of the brain, the latter being due either to the immediate pressure of the broken fragments upon the cerebral substance or to the pressure of a clot formed as above explained. Diagnosis.—The diagnosis of depressed fracture is important as 336 PRACTICE OF SURGERY. it involves a question of practice; for, in a case of depressed frac- ture accompanied with symptoms of compression, it will often be necessary to perform the operation of trephining with the view of elevating the depressed fragments. In order, then, to arrive at a diagnosis, the head should be thoroughly shaved and the depression carefully felt for; but it must be borne in mind that every depres- sion felt in the head under these circumstances is not due to a de- pressed fracture, an effusion of blood beneath the pericranium sometimes assuming such a shape as to give, when felt, an impres- sion well calculated to deceive. Or the line of a suture is some- times abnormally depressed, and may be mistaken for a depressed fracture; or an inexperienced observer may mistake for the depres- sion of a fracture the natural depression accompanying those irre- gular elevations of the cranium to which the phrenologists have applied the term Bumps. There is also sometimes a depression around one of the ossa triquetra, which has been mistaken for that of fracture. There is, however, an irregularity about the edge of a depressed fracture which is not simulated by any of the above conditions, and attention to the accompanying symptoms will, as a general rule, make the mistake difficult. The degree of depression will vary with the force producing it. Yet it must not be supposed, that every depressed fracture involves the brain; the thickness of some crania being such that a considerable depression may exist in its outer table, and yet the brain not be involved. It is only when a depression, which is evidently the result of fracture, is com- plicated with marked symptoms of compression of \he brain that the operation of trephining is justifiable.1 Prognosis.—The prognosis in fractures of the skull will depend upon the degree of the injury. Thus a simple fracture without symptoms of compression, and with but a moderate degree of con- cussion, is less dangerous by far than.a depressed fracture; whilst a depressed fracture accompanied by symptoms of compression is, of course, far more dangerous than one without them. Treatment.—If a depressed fracture is accompanied only by those lighter symptoms which are usually found in connection with sim- ple fissure, the treatment, like that of simple fissure, will consist merely of rest and antiphlogistics, with a view of preventing any inflammation from being set up in the brain or its membranes. 1 For further details on the cases suited to the operation of trephining, see Ope- rative Surgery, vol. i. p. 247, 2d edit. FRACTURES OF THE NASAL BONES. 337 The treatment of depressed fracture, when combined with symp- toms of compression, will consist in the same antiphlogistic mea- sures, and in the performance of the operation of trephining with the view of elevating the depressed fragments and thus relieving the compression.1 In order to retain a dressing to a fracture of the cranium, either with or without the performance of the operation of trephining, it will be necessary to apply either a T bandage or the recurrent bandage of the head, as shown in Figs. 89, 86. SECTION II. FRACTURES OF THE BONES OF THE FACE. § 1.—FRACTURES OF THE NASAL BONES. In order to understand the action of the forces which produce fractures of the nasal bones, as well as the rationale of the symp- toms which indicate their existence, attention must be given to the anatomy of the parts concerned. General Relations of the Nasal Bones.—The nasal bones are placed between the nasal processes of the superior maxillary bones, so that the latter support them on each side. They have also a direct con- nection with the septum of the nose, as it exists in the ethmoidal bone, and are thus directly connected with the cribriform plate and crista galli of this bone. A blow upon the nasal bones, therefore, if of sufficient violence, may affect the crista galli, shatter the crib- riform plate, and even encroach upon the brain itself, producing concussion, or more rarely compression of the brain, or be fol- lowed by meningitis. On each side of the nasal bones are the saccus lachrymalis and ductus ad nasum, which transmit the tears to the nose. Blows upon the nasal bone of sufficient violence may there- fore encroach upon these important passages, and cause such inflam- mation as will result in fistula lachrymalis. The inferior part of the nasal bones are attached to the cartilages of the nose, and the carti- laginous septum, whilst above they articulate with the os frontis, and are covered in by the nasal slip of the occipito-frontalis muscle; 1 For the details of the operation of Trephining see Operative Surgery, vol. i. p. 248, 2d edition. 22 338 PRACTICE OF SURGERY. the common integument of the face covering all, whence these fractures sometimes develop erysipelas of the head and face. In- ternally the nasal bones are lined by the nasal or Schneiderian mucous membrane, and hence the epistaxis which generally fol- lows the production of this injury. The nasal bones are so arranged as to present externally the form of an arch, and as they are small, comparatively thick, and well supported by the nasal processes of the superior maxillary bones, it requires a considerable force to break them. Besides which, they are so situated that the prominence of the supra-orbitar ridge of the os frontis, protects them above, from chance blows which, glancing down from the forehead, are more apt to light upon the nasal cartilages than upon the bones themselves. In order then to produce a fracture of these bones of the nose, the force must be direct. Etiology.—A common cause of fracture in these bones is the blow made by the handle of a windlass, carelessly let go, which flying round strikes a bystander in the face, and readily produces the injury; but any similar force may have the same result, as the blow of a bludgeon, kick of horses and mules, gunshot missiles, &c. &c. Symptoms.—When a fracture of the nasal bones is produced by any of these causes, the symptoms are as follows: There is more or less contusion of the soft parts, with ecchymosis and swelling around one or both eyes. There is also more or less deformity caused by the bones being driven out of their normal line; the degree of this deformity depending upon the amount of violence applied; thus the fracture may be limited to the nasal bones, or extend and implicate the nasal processes of the superior maxil- lary. Diagnosis.—The diagnosis will sometimes be a matter of diffi- culty, although at first sight it would appear to be very easy. Thus, the parts swell and become so painful that the patient resists examination, and it is sometimes only when the bones are much depressed that we are able to tell without difficulty whether they are broken or not. Prognosis.—The prognosis in this fracture, as in all surgical in- juries, depends upon the circumstances of the case, the extent of the injury, the nature of the complications, &c. &c. Treatment—The first step in the treatment of this fracture is to FRACTURES OF THE NASAL BONES. 339 bring the fragments into a proper position; a modification of ma- nipulation being required in different cases to effect this object. If the fragments have been driven to one side, it is necessary to push them back into line; if they are depressed, they must be elevated; but in either case when once reduced, they will, as a general rule, retain their position, as there are no muscles of any power acting upon them, and, except from the displacement which might be caused by swelling, or by effusions bound down by dense integu- ments, &c, there is little danger of the deformity being reproduced. Still, as a general rule, it will be found difficult to get the fragments back exactly into the ordinary line; and it will be as well for the surgqpn to prevent misunderstanding and disappointment by tell- ing the patient that most probably after this fracture he will not have a nose like the original one. The fragments may be brought into position by passing a director, or small stiff probe, into the nos- tril, keeping it close along the septum narium, pushing it upwards and backwards so as to elevate the fragments, while, with a finger on the outside, their position may be regulated to the proper degree of convexity. Then, with a view of guarding against any extension of inflammation to the brain, the patient should be put under a strict antiphlogistic regimen for a few days, and any symptoms which may arise be promptly met. If there is excess of action, it should be checked by means of leeches, &c, whilst if from rupture of the bloodvessels of the lining membranes of the nose a trouble- some hemorrhage arises, it may be checked by plugging up the nostril with Belocque's canula.1 Having thus met emergencies, and 48 hours having elapsed with- out the appearance of any urgent symptoms, the patient may be considered as pretty well out of danger. Any accompanying 1 See Op. Surg., vol. i. p. 341. Fig. 103. A view op the Double T Bandage, AS APPLIED TO FEACTURES OF THE NOSE. —It should be formed of narrow tapes, of which the vertical turns should be attached to the horizontal portion about one inch and a half apart, as seen in the top of the figure. In its application carry the verti- cal turns over the head, cross them on the nose over the compresses, and then carry- ing the horizontal portion from the lip around the back of the neck so as to fasten the vertical ends, bring it around the fore- head. (After Nature.) 340 PRACTICE OF SURGERY. wounds of the soft parts of the nose, or of the cartilages, should be dressed by means of sticking-plaster, or if that is objectionable, or if the warm or cold water dressing is to be applied, it may be retained in position by the double T bandage, made of broad tapes, and applied as in Fig. 103. This forms a very excellent means of retaining a dressing to this region, particularly when from too great prominence of the fragments, or from any other cause, it is considered desirable to exercise pressure upon the nose. § 2.—FRACTURE OF THE SUPERIOR MAXILLARY BONE. The shape of this bone, and its position beneath the muscles of the face, are such that it is almost impossible for it to be fractured without wounding the soft parts which cover it. Generally, there- fore, this fracture is the result of great force, though one through the alveolar processes sometimes occurs without laceration of the soft parts of the cheek, and is produced by a blow directly upon the front of the teeth. Such an injury may be created by a blow from the fist of a powerful man, or by any other force acting in a similar manner, and the teeth being thus driven in, more or less injury to the interior of the soft parts of the mouth is produced by their being cut by the teeth, though the exterior structures are only bruised. Treatment.—The fracture of the superior maxillary bone, like the fracture of the nasal bone, is to be treated by coaptating the fragments, keeping the patient at rest, and guarding against inflam- mation and its consequences. As in the case of the nasal bones, if this fracture is once reduced, there is but little danger of the displacement being reproduced by muscular violence. If the teeth have been knocked backward, they should be brought carefully back with the finger into their proper position, and kept as perfectly at rest as possible. The patient should also abstain from chewing hard articles of food for several months. After coaptating the injured bones, any wounds in the soft parts that may exist will next require careful treatment, on the general principles already detailed under the head of Wounds of the Face. FRACTURE OF THE INFERIOR MAXILLA. 341 § 3.—FRACTURE OF THE MALAR BONE. The existence of fracture of the malar bone as an independent injury has been denied by some good authorities; but there are facts which contradict this assertion; and I have now in my pos- session two specimens of fracture of this bone, of undoubted cha- racter. Etiology.—The fracture of the malar bone may be produced by sabre cuts, by blows from bludgeons, from firemen's spanners, &c. Treatment.—The treatment is to be conducted upon general prin- ciples ; thus, the fragments of bone should be coaptated as nearly as possible, and the wounds in the soft part, with which the injury is generally attended, be treated like other wounds, cold water dressings being applied, and any excessive inflammation met by a prompt antiphlogistic treatment. § 4.—FRACTURE OF THE INFERIOR MAXILLA. Fractures of the lower jaiu are by far more common than those of the upper, but even these are comparatively rare; for the lower jaw is so situated, and its mobility is such, that it yields whenever force is applied, a dislocation being, therefore, much more liable to be created by the application of any ordinary violence than a fracture. Even a blow upon the side of the jaw is more apt to produce a dislocation forwards of that side, than a fracture. Seat.—Fracture of the lower jaw may occur at almost any point; but it is most common in the adult, just anterior to the insertion of the masseter muscle, fracture at or near the symphysis being more frequent in young persons, before the bone has become perfectly ossified at that point. The fracture may be either trans- verse or oblique. Etiology.—This injury is most likely to be produced by the ap- plication of great and sudden force to the jaw, particularly whilst it is closed. Perhaps the most common cause is a kick from a horse or mule, a blow of a bludgeon, or some similar violence. The force necessary to produce the fracture is such that the soft parts are often injured, and a compound fracture results, although this is by no means universal. A compound fracture of the jaw 342 PRACTICE OF SURGERY. may, however, exist without any external wound, the fragments communicating with the cavity of the mouth, and such an injury is sometimes quite troublesome, on account of the action of the saliva washing away the reparative lymph as fast as it forms. In order to understand the causes producing the deformity which generally accompanies a fracture of the jaw, it is necessary to bear in mind the anatomical relation of the muscles attached to this bone, and which produce it by their contraction. Thus, the principal muscles acting upon the jaw from above are the masseter and the temporalis, while below is the insertion of the digastric, the genio-hyoid, and mylo-hyoid, with the muscles of the tongue; and indirectly the sterno-hyoid, sterno-thyroid, muscles which act through the mylo-hyoid by their connection with the os hyoides, &c. The muscles of the cheek, of the throat, and of the front of the neck, are thus concerned, and it is easy to understand from their origin and insertion how depression and irregularity of the frag- ments will be produced after the occurrence of this fracture at any point anterior to its angle. Symptoms.—The symptoms of fracture of the lower jaw, in- dependently of the symptoms of the contusion, necessarily pro- duced by a force so violent as that which usually creates the fracture, are as follows: 1. There is displacement, the level of the jaw being no longer preserved. 2. The U shape of the rim of the teeth is destroyed, as is readily seem on opening the mouth. 3. There are crepitus, pain, loss of motion, and the other ordinary signs of frac- ture. Treatment—The object of the treatment is, therefore, to counter- act the action of those "muscles whose tendency is to draw this bone down towards the sternum, as well as that of the pterygoid muscles by the action of which the posterior fragment may be displaced laterally. The indications are to restore the line of the jaw and to draw it up to the upper maxilla, so as to prevent displacement upwards or downwards, whilst it is also kept from lateral displacement, by counteracting the action of the pterygoid muscle. Any means capa- ble of carrying out these indications may therefore be resorted to. One plan of treatment very early employed consisted in wiring together the two teeth next the seat of fracture, but this is neces- sarily a very imperfect proceeding, for no matter how firmly the wire is applied, it is impossible to prevent more or less motion of FRACTURE OF THE INFERIOR MAXILLA. 343 the fragments up and down, and it soon became apparent that in order to effect the cure of this fracture without deformity, some more efficient plan must be resorted to. A firmer dressing was therefore soon suggested, and consisted of a splint made of some soft material, which soon became hard, as white of egg and plaster, or the more recent articles of gutta-percha or wet binders' board moulded to fit, and then retained by a band- age to the part. To make such a splint or mould, take a piece of binders' board of an oblong shape, and cut two slits at each end so as to extend partly through it. Then after soaking it in warm water apply it to the chin, and fold it up around the chin so that the part marked 1, 1 (Fig. 104, A), can be carried up the sides of the face, whilst that marked 2, 2, is turned backwards on a line with the base of the jaw, thus making a very excellent cast of the chin. Fig. 104. A view op Barton's Bandage, with the Mould applicable to the Treat: ment op Fracture op the Lower Jaw.—a. Shape of the piece of gutta percha for the chin. B. The same moulded to the part—the ends 1, 1, being turned upwards, and the sides 2, 2, turned from before backwards. The application of Barton's bandage is described in the text. (After Nature.) A compress of lint should first be laid upon the chin to prevent * the splint from chafing, whilst over the whole a suitable bandage is to be applied. A very excellent bandage for this purpose is that of Dr. Barton, of Philadelphia, which is to be applied as follows:— Place one end of a bandage two inches wide and five yards Ion co- upon the mastoid process of the right side; pass obliquely around the left parietal bone over the top of the head and come down along the side of the face, under the chin; then pass up along the 344 PRACTICE OF SURGERY. opposite side of the face, over the temple, or between the eye and the ear of this side, across the top of the head and right parietal protuberance to the mastoid process, and thence make a turn circu- larly around the neck and front of the chin, and from the chin to the neck, which brings the roller back to the point from which it started. These turns being repeated as often as may be considered necessary to give firmness to the dressing, should be fastened by a pin on the top of the head at the point where the turns cross each other (see Fig. 104), after which, the other points at which the turns of the roller cross may also be secured by pins. In the treatment of the fracture this bandage should be retained in position for several days without being changed, whilst during the whole period of the cure the patient should live upon such fluid articles of diet as he can suck through his teeth, or can be reduced to a pulp with his tongue. It may be here remarked that the bar- barous practice of extracting a tooth in the commencement of the treatment of fracture of the lower jaw, with the view of allowing the patient to suck in liquids through the interspace thus left is at once cruel and unnecessary, for there are always, even in the most perfect sets of teeth, natural or accidental interspaces which are quite sufficient to answer this purpose. After three or four days, the bandage should be removed and reapplied by reversing the turns in its application; the surgeon being careful while removing it to keep the slack well gathered up in his hand, as otherwise he may, by a careless motion, catch a turn of the bandage on the edge of the chin and do the patient mischief by jarring the fragments, as well as cause him great pain. The bandage having been removed, the splint should be supported by the hand of an assistant, and the surgeon should seize the frag- ments to hold them in position before the latter is removed, afteT which the skin over the jaw should be rubbed with a little whiskey ' or soap liniment. When union has taken place sufficiently to justify the laying aside the bandages and splint, the patient should be cautioned against chewing tough articles of food for some time in order to allow the bone to obtain its full firmness before it is used. Gibson's bandage is applied by starting from the point of the chin, and making three circular turns around it and the top of the head, drawing the lower jaw firmly up against the upper. Then reversing the bandage at the temporal region of either side, make FRACTURE OF THE INFERIOR MAXILLA. 345 three circular turns of the forehead and occiput in order to pre- vent the first turns from slipping off the face; then passing down upon the neck make three circular turns of the chin and neck, after which the same turns may be repeated until the dressing is considered sufficiently firm. To make it still firmer, a strip of bandage may be pinned from the forehead to the occiput, and the turns of the bandage pinned at every point at which they cross. This forms a good dressing, and one which will fulfil the indica- tions, but Barton's bandage will be found preferable in the majo- rity of instances. Cases will at times occur—such as certain compound frac- tures—when the patient cannot bear the pressure of either of the above dressings, or there may be cases in which, from the advanced stage of union, they have become unnecessary, but in which some- thing is yet required to prevent motion in the jaw. Under these circumstances, resort may be had to what is also an excellent band- age to retain dressings to wounds of the chin, to wit, the four-tailed bandage, or sling of the chin. This bandage consists of a piece of muslin of proper width split down the middle (as seen in Fig. 104), except at the part corresponding to the chin; it thus presents two tails at each extremity. It is applied on the same principles as the similarly shaped pasteboard splint, the two lower tails being brought up over the top of the head and tied, while the two others (2, 2) are brought round and tied behind the neck: a dressing of considerable firmness, and at the same time exceedingly light, being thus obtained. Some one of these dressings should be worn by a patient who has a fracture of the lower jaw, for from five to seven weeks, after which they may be discontinued with the precautions above referred to. • 346 PRACTICE OF SURGERY. CHAPTEK III. FRACTURES OF THE NECK AND TRUNK. SECTION I. FRACTURES OF THE BONES OF THE NECK. § 1.—FRACTURE OF THE OS HYOIDES. Fracture of the os hyoides is very rare, though, it sometimes occurs in consequence of considerable violence applied directly to it by some efficient means, such as the grasp of a powerful man, or some cause acting in a similar manner, or a blow directly upon the bone itself. When broken, it gives rise to a train of exceedingly serious symptoms. Symptoms.—There is difficulty in deglutition, and a disposition to choking in consequence of the tongue coming back upon the epi- glottis ; with difficulty in respiration from the fact that the larynx is connected with the hyoid bone. This fracture is also often com- plicated with laryngitis, loss of voice, and other serious symptoms due to inflammation of this region. Treatment.—The treatment is to be conducted upon general prin- ciples, the fragments being kept in perfect rest, so far as it may be practicable; but little, it must be confessed, can be done in this way, except by means of strips of adhesive plaster. Leeches may be applied, and violent inflammation, should it ensue, be combated by the antiphlogistic treatment which is applicable in all similar cases. If there is such difficulty in swallowing as interferes with the nutrition of the patient, it should be overcome by means of a sto- mach tube. fc ' FRACTURES OF THE VERTEBRAL COLUMN. 347 § 2.—FRACTURES OF THE VERTEBRAL COLUMN. Fig. 105. Fractures of the vertebrae are comparatively rare, but may be pro- duced by great violence applied to any point in the length of the column, or at any point of the lower limbs, as in falls upon the feet or hips. However produced, fractures may occur in the bodies of the vertebrae; in the spinous processes, and in the oblique or trans- verse processes. The force producing these injuries is generally so great that they are most frequently complicated with injury of the contained organ, the spinal marrow. If any marked displacement should occur, the cavity of the spinal canal will be apt to be encroached on, and symptoms of derange- ments consequent upon pressure on the spinal marrow invariably result. (Fig. 105.) Symptoms.—The symptoms of these frac- tures will, of course, vary, according to the extent and character of the injury, and of the complication of the contained organs. If, for example, there be a fracture of the oblique processes of the second vertebra, the transverse ligament may be detached; there may be a partial dislocation between the atlas and the dentata; pressure may be made upon a view of a Fractured it. i i . ,i , • . j it. i- i Spine bisected so as to the spinal cord at that point, and the patient show how the spinal cord die suddenly in consequence of the interrup- is. passed on by the dis- . -1 \ placed bone. (After Lis- tion of respiration which results. There is ton.) no time for treatment in such a case as this, the death being instantaneous. If the fracture occurs lower down, and is of such a character that pressure is made upon the spinal cord, paralysis of the parts sup- plied by the nerves, given off from the cord below the seat of injury, will ensue; and this paralysis is very generally of one side only (paraplegia), owing to the pressure being made unequally upon the spinal cord. There being loss of power in the abdominal muscles, with paralysis of the lower extremities of one or both sides, more or less paralysis of the muscular coats of the stomach and bowels and consequent constipation, with paralysis of the muscles of the blad- 348 PRACTICE OF SURGERY. der, and consequent retention of urine, are also frequently noticed in this class of fractures. Prognosis.—A fracture of a vertebra is sometimes limited to a simple fissure, under which circumstances it will be difficult to recognize it, and such fractures occasionally recover. Much more serious are those which are accompanied by displacement, and by consequent paralysis of the lower extremities; yet, even after such injuries, patients have lived for months, and bony union has in some cases occurred before death. The prognosis of fractures of the vertebras, therefore, though very serious, is not invariably fatal. They are, however, as a general rule, followed by more or less paralysis of the lower extre- mities, which is very apt to be permanent. Treatment.—The treatment of these injuries will be rather that required by inflammation of or injury to the spinal marrow, than by the fracture itself; the latter being inaccessible to direct me- chanical agents, except the knife. Though one or two operations have been performed for the removal of depressed portions of the spinous processes, the dangers to life from such a plan of treatment will probably preclude its repetition. In the examination of the spine of a patient supposed to labor under fracture of the vertebral column, with the view of ascertain- ing the existence and seat of the fracture, the extent of the inj nry, &c, the surgeon should carefully avoid turning him upon his face, as serious consequences may thence result; because, as the injury to the vertebral column generally produces more or less injury of the spinal cord, there may be paralysis of the abdominal muscles consequent upon this cause. Hence, if the patient be rolled over upon his belly while the examination is being made, the abdominal muscles no longer by their contraction offer a resistance to the weight of the body, and the cavity of the abdomen is en- croached upon, particularly if the patient be a heavy man. The descent of the diaphragm then becomes imperfect, in consequence of the upward pressure of the bowels, and the patient, in his weakened condition, may be almost asphyxiated before the surgeon is aware that he is in danger. In making the examination, therefore, turn the patient simply on his side, when quite as efficient an investiga- tion can be made, and the dangers alluded to entirely removed. As the patient may be compelled to lie for some time upon his back, even under the most favorable circumstances, everything like SPINAL CONCUSSION AND MENINGITIS. 349 blisters or counter-irritants to the spine should be carefully avoided, either in connection with the injury itself, or with the treatment of the spinal meningitis, to which it may give rise. Neglect of this precaution may result in the formation of bed-sores, or cause sloughing, which will very much annoy the patient, give rise to considerable suffering, and seriously complicate the probability of a cure. During the treatment, the patient ought to lie as^much as possible on his side at perfect rest, any complications which may arise, as meningitis, &c, being actively treated by leeches, cups, and purging. As the muscular coat of the bladder participates in the muscular debility consequent on the injury, it should be carefully watched from the first, and all accumulations of urine prevented by the frequent use of the catheter. The action of the bowels, which is always sluggish in these injuries, in consequence of the paralysis of the muscular coat of the intestine, should also be watched, and constipation prevented by the free use of laxatives. § 3.—SPINAL CONCUSSION AND MENINGITIS. In all cases of spinal fracture, as already remarked, the symptoms of the consequent compression or concussion of the spinal marrow will be much more marked than the symptoms of the fracture itself. In fact, concussion of the spinal marrow, like concussion of the brain, is often met with independently of fracture, in consequence of the jarring of this structure in the spinal canal being much more frequent than fracture itself. This injury is a common occurrence, in consequence of collisions of opposing trains and other railway accidents; because when an individual is seated in a car, with his back resting against the hard back of the seat, and a collision takes place, the back of the patient is brought violently in contact with the back of the seat, and a concussion of the spinal marrow results. Many of the sudden deaths, without any apparent external injury, which have been reported as having occurred during or after rail- road accidents, as well as after amputations for fractures of the leg from such injuries, may doubtless be attributed to this cause. Concussion of the spinal marrow without fracture occurs also from other causes. Often it is combined with more or less concussion of the brain. Thus, a man falling from a height upon his feet or sacrum, 350 PRACTICE OF SURGERY. becomes paralyzed, falls back, and, striking his head violently against the ground, receives also a concussion of the brain. Symptoms.—The symptoms of concussion of the spinal marrow consist in a loss of innervation to all the parts supplied by its nerves, this loss of innervation in some instances being soon fol- lowed by death; thus, the respiration may be feeble, the heart con- tract with little power, the bowels and bladder act tardily, &c, whilst if more marked, it will be followed by such loss of action in the heart and lungs as will soon terminate in death. When spinal meningitis is established after a concussion, all the symptoms will appear which might be expected to accompany the development of meningitis from any other cause; thus, there will be pain, fever, paralysis, &c. &c. The occurrence of spinal meningitis, resulting in effusions often of a limited character, also explains many of those obscure cases of partial paralysis, especially in children, which have been so imper- fectly understood, or at least so imperfectly described by writers. A child sits down upon a damp cold step, and there is, as a con- sequence, more or less congestion of the lower part of the spinal cord, or of its membranes; this congestion resulting in inflammation, in effusion, or in thickening of the cord and its membrane. This child may suffer little or no pain in the back at the moment, but after a time will be observed to be stiff in his movements and to have lost the power, to a greater or less extent, of his lower limbs; and in such a case as the surgeon can naturally trace the connec- tion between cause and effect, he should regulate his treatment ac- cordingly. Sometimes it happens that after some such exposure, or after a slight fall, a limited effusion of blood, of serum, or of lymph, has taken place into the cavity of the spinal canal, causing the patient to suffer from a local and limited paralysis, as in the bladder and organs of generation or in the organs of generation alone; and there Can be no doubt, I think, of the above rationale of such cases, as this view of their pathology is confirmed by the mode of treatment found most efficacious. This consists in the use of such means, as mercu- rials, &c, as are calculated to produce the absorption of effusion and the breaking down of the plasticity of the lymph. In one instance of this local paralysis which came to my notice, a married man entirely lost his virility after a fall upon his sacrum on shipboard. For the first few days after the accident he felt no inconvenience, but FRACTURE OF THE RIBS. 351 after a time noticed that his venereal desire had totally left him, and that he had become almost impotent. This man, after being gently salivated and cupped on the spine as well as steadily purged, re- covered his powers entirely, so much so, indeed, that his desires became a source of annoyance to him. SECTION II. FRACTURE OF THE BONES OF THE TRUNK. § 1.—FRACTURES OF THE RIBS. When the ribs are broken by a direct force, the fracture is gene- rally a transverse one, and presents comparatively little displacement; or, when such does exist, it is generally due to the immediate action of the force producing the injury and not to muscular violence. In an oblique fracture there may be angular deformity, the points of the fragments presenting forwards or backwards. This fracture may be complicated with lacerations of the pleura costalis, or even of the lung itself, or with laceration of the intercostal muscles and injury to the intercostal artery and nerves. As a result of these injuries various morbid conditions may occur complicating the more simple symptoms of fracture, such as pleurisy, or pneumonia, or congestion of the lung, or hemorrhage from the intercostal artery; a small aneurismal tumor being sometimes formed in the course of the artery after the injury; or the inflammation set up at the point of fracture, may assume an unhealthy character and result in caries of the rib. Symptoms.—The symptoms of fracture of the ribs consist in such modifications of the ordinary symptoms of fracture as result from the relations of parts. In the first place the functions of the ribs are interfered with; they are no longer properly elevated, and, con- sequently, a proper expansion of the cavity of the chest no longer occurs; more or less crepitus, moreover, is to be felt at the seat of fracture, and can sometimes be heard by the patient, though often it is not so distinct. When the patient takes a long breath he is also apt to be checked by a violent pain at a point corresponding with the seat of fracture, this being due either to the sharp fragments pricking against the pleura, or to injury of the intercostal nerve. 352 PRACTICE OF SURGERY. By passing a finger along the course of the ribs the seat of fracture can also very generally be accurately recognized. Should the fragments happen to have been driven in so as to wound the lung, emphysema, to a greater or less extent, will usually ensue; but this will seldom be developed to any degree, until from twenty-four to forty-eight hours after the injury. Prognosis.—As in all other cases, the prognosis of fractured ribs will depend upon the nature and extent of the injury, and upon the character of the complications. Thus, if a violent pneumonia ensue, the case will be much more serious than one accompanied by no graver symptom than a slight sticking pain in the side. So the prognosis of a fracture of one or two ribs, without displacement, will be favorable when compared with a case where several ribs are broken, and perhaps driven much out of their natural line, and when the injury is accompanied by pleurisy or emphysema, the prognosis, as with the pneumonic complication, will be much more serious than in the simpler cases. But fractures of the ribs, except when accompanied by violent thoracic inflammation, seldom prove fatal. Treatment.—The indications for the treatment of this fracture are, to prevent the rising of the ribs and compel the patient to breathe by his diaphragm, so as to retain the parts at rest until the bone has united, or at least until sufficient lymph has been thrown out and organized to round the sharp fragments, and thus obviate in- jury to the thoracic contents. On account of the practical difficulties experienced in keeping the ribs at rest there is generally a proportionably larger amount of callus formed in the union of these bones than in fractures else- where, sharp projections of bone, like exostoses, sometimes be- coming permanent, and interfering during the remainder of the patient's life with the perfect motion of this side of the chest. The indications for the treatment, as above laid down, are to be carried out by means of the ordinary spiral bandage of the chest ap- plied tightly around the thorax, which, in the case of a female, may sometimes be replaced by a pair of corsets tightly laced. Before applying it compresses should be placed on the ribs, so as to obviate deformity, should any exist. If the fragments project out- wardly, the compress should be laid directly over the seat of frac- ture, that the turns of the roller may more directly force them back to their proper line; but, if they project inwards, two com- presses should be applied, one at each extremity of the rib, in FRACTURES OF THE STERNUM. 353 order that by their means the broken fragments may be canted out. Then commencing at the waist, apply the ordinary spiral bandage of the chest, as stated in the account of the first roller of Dessault's bandage for the treatment of fracture of the clavicle. The necessity of beginning this bandage at the waist, and ascending, will be understood by a slight reference to the shape of the body; this portion of it, together with that part of the trunk which joins the pelvis, resembling two truncated cones, the apices of which present to each other. If the bandage is not com- menced at the apex of the upper cone, and carried toward the base—that is, from the waist to the shoulder—its turns will be apt to slip down soon after their application. When a single rib only is broken, so forcible a bandage is not required, and for convenience a broad piece of muslin, with straps and buckles, applied to the chest as described in the treatment of cancer of the breast (see Fig. 48, p. 200), and properly tightened, may be used, and will answer the purpose quite as well. Very good cures may also be accomplished in these cases simply by the use of a piece of muslin, so torn as to make a slit and tailed bandage, or by applying long strips of adhesive plaster obliquely around the ribs, and over the seat of fracture. After the use of any of these modes of treatment for three or four weeks, sufficient union will generally be obtained to render further bandaging unne- cessary. The symptoms of the injury should always be carefully watched for the first seventy-two hours after the accident; and any pneumonia, pleurisy, &c, which may arise, be combated upon pre- cisely the same principles as would guide a physician in his treat- ment of these diseases had they arisen from any other cause. | 2.—FRACTURES OF THE STERNUM. Fractures of the sternum are sometimes, though rarely seen, and generally result from very great violence. Hence, the most serious sjrmptoms are rather those of the concomitant injuries to the in- ternal organs, than of the fracture itself. Seat.—The sternum is generally broken at the junction between the first and second of the three bones of which it consists, because the lower two pieces being attached only to the cartilages of the ribs, which are quite elastic, give under a force much more readily 23 354 PRACTICE OF SURGERY. than the upper one does, the latter being firmly supported by its attachments to the clavicles. Treatment.—The treatment of fracture of the sternum is chiefly constitutional, consisting of rest, opiates, and careful watching for inflammation in any of the internal organs; the latter being promptly met by an active antiphlogistic treatment; but, as the great majority of these accidents are caused by extreme violence, they are often accompanied by complications which result in death. If, after the inflammatory symptoms caused by the injury have sub- sided, the fragments are observed to play much upon each other during respiration, a compressing bandage will become necessary, and this should be applied as in the case of fracture of the ribs. As a consequence of fracture of the sternum, suppuration may be developed behind the bone, and travel down and open at the side of the ensiform cartilage, so as to point at the insertion of the rectus muscle; or caries of the bone may result, which will present all the symptoms of caries elsewhere, and require to be treated upon the same general principles. CHAPTEE IV. FRACTURES OF THE UPPER EXTREMITY. SECTION I. FRACTURES OF THE CLAVICLE. Fractures of the clavicle are usually regarded as of importance, because they are of frequent occurrence, and result, if not properly treated, in a deformity of the shoulders, besides limiting somewhat the subsequent elevation of the arm of the affected side. They may occur at any portion of the length of the bone, as at its sternal third, in its middle, or at its acromial extremity. To understand the manner in which this injury is produced, it is necessary to bear in mind the function of the clavicle. Situated between the acromion process of the scapula and the end of the sternum, its function is the just preservation of the pectoral space. It acts, therefore, as a stay, by keeping the shoulders apart', whilst it also steadies the motions of the glenoid cavity of the scapula, FRACTURE OF THE CLAVICLE. 355 against which the head of the humerus plays in the motions of the arm. Etiology.—Any direct force may cause fracture of this bone, either at the point to which the force is applied, or as in counter-stroke,' by the application of a force to its humeral extremity, whilst the other, by its attachments to the sternum, furnishes the resistance. In the latter case, it is readily seen that if the force be applied to the shoulder, so as to drive it towards the sternum, that force will be transmitted through the clavicle, and the sternum will resist it, whilst the clavicle will be broken at some point between these two forces. When a force is thus applied at one end, whilst the resistance is at the other, the fracture will be oblique; and this is by far the most frequent variety of the injury. The direct violence producing the fracture may be the kick of a heavy gun, the blow of a bludgeon, or any similar cause, and this acting on the body of the clavicle, and not on its ends, produces a transverse fracture, with contusion of the soft parts around the bone. In order to understand the deformities which will ensue upon the occurrence of a fracture of the clavicle, the action of the various muscles attached to the bone must be noted. Thus, at the sternal end of the clavicle is the insertion of the sterno-cleido-mastoid muscle, which has a tendency to hold the sternal fragment up- ward ; it being, moreover, supported in its position by the liga- ments at its articulation with the sternum. The outer fragment is chiefly acted on by the pectoralis major muscle; the contraction of which, by drawing the humerus towards the body, tends, when the clavicle is broken, to draw the shoulder or scapula with it, thus producing shortening of the entire bone and a diminution of the pectoral space. Deformity, after a fracture of this bone, will also be produced to a slight extent by the action of the subclavius muscle, causing one fragment to approach the chest, and thus aiding in destroying the level of the clavicle. At the same time, the weight of the arm causes the shoulder, which is no longer supported in the normal manner, to descend, and a deformity is thus created by the prominence of the fragments which can be recognized at a glance. The shoulder is also now evidently closer to the body, whilst the arm is more upon the pectoral space and lower than it ought to be, the forces acting upon it having caused it to fall down- wards, forwards, and inwards, from its normal position. Besides which, if the surgeon's finger be passed along the clavicle, it will 356 PRACTICE OF SURGERY. be readily observed that its continuity is destroyed at the seat of fracture; and when great swelling is not present, one fragment will be felt riding the other. In consequence of the false position of the shoulder, the action of the humerus is generally more or less imperfect; it has no longer a firm support, and the muscles cannot therefore cause it to execute its natural movements, as the arm cannot now be elevated, or the hand made to touch the opposite shoulder. Symptoms.—The symptoms of fracture of the clavicle are gene- rally easily recognized. Thus the patient, after a fall, or a blow upon the arm or shoulder, feels that he has suddenly lost part of the power of the arm of that side as the shoulder descends, the weight of the limb becomes painful, and he is disposed to support it by putting the sound hand under the elbow of the injured side. When a finger is now passed along the clavicle, it will be observed that the proper line of this bone in front is destroyed. The mobility of the limb is also very much impaired, and he suffers great pain both at the seat of fracture and in the axilla from pressure upon the axillary nerves, being from the same cause often annoyed by tingling of the fingers. In consequence of this pressure of the injured bone upon the arteries and nerves of this region, there may be various complications, some of which are very marked. Thus, from pressure upon the axillary nerves, as they pass under the clavicle from their origin in the neck, more or less complete para- lysis of the. injured arm may ensue, whilst from rupture of the bloodvessels there may be violent hemorrhage, or such an accumu- lation of blood as will form quite a tumor in the axilla. Diagnosis.—The diagnosis of fracture of the clavicle is usually easily made, provided the patient is seen soon after the occurrence of the injury, as the superficial position of the bone readily shows its condition. But when swelling has taken place, and especially if the force of the injury has also affected the shoulder-joint, it is some- times very difficult to recognize its existence. By placing a finger close to the sternal end of the clavicle, and having an assistant to force up the shoulder by pressing on the patient's elbow, the fact of the continuity of the clavicle may, however, generally be made apparent, because, if there is no fracture, the sternal end will move when the humeral extremity is elevated, which it will not do when a fracture exists. Prognosis.—The prognosis of the fracture of this bone is gene- rally favorable, if proper means are employed to keep the fragments FRACTURE OF THE CLAVICLE. 357 in position, and perfect cures without deformity of the level of the shoulders can generally be obtained by proper attention. Such results have been so frequently noticed as to leave no doubt on this point in the minds of many, though sometimes such good cures have not been made. Treatment.—The principles upon which the treatment of a fractur- ed clavicle is to be conducted, and indeed the only principles upon which the injury can be treated so as to obtain a perfect cure, are those suggested long since by Dessault. In investigating^this frac- ture, this accurate observer recognized the fact that the shortening of the bone was chiefly due to the action of the pectoralis major and subclavius muscles, and proposed, therefore, to overcome it, and reduce the shortening by carrying the shoulder outwards, whilst he overcame the deformity caused by the weight of the arm and other causes, which depressed the humeral end of the bone, by so acting under the elbow as to push the shoulder upwards. As, by the giving way of the clavicle, the shoulder had also been drawn forwards as well as inwards by the pectoralis muscle, he proposed in the treatment to carry it backwards. In other words, as the de- formity had been produced in consequence of the shoulder being drawn forwards, downwards, and inwards, he proposed the reduc- tion of the fracture by the use of forces calculated to carry it upwards, outwards, and backwards. In fulfilling these indications, Dessault invented a mode of dress- ing which is still frequently used. His treatment has, however, been much modified in various hands, and several new dress- ings have been invented since his day, any of which may be em- ployed, but all of which act upon precisely the same three indica- tions which wrere suggested by him. Dessault1 s Bandage.—This dressing requires the preparation of three long and wide rollers, each 8 yards long and 2\ inches wide; of a wedge-shaped pad nearly as long as the humerus; and of a sling and splint-cloth to surround the body; all of which are applied as follows: The arm of the injured side being held out at right angles from the body by an assistant, and that on the sound side held by the patient or an assistant, a little off from the body, so as to give room to pass the bandage, the surgeon should place the pad in the axilla of the injured side, and taking a roller commence at the pad and make a few circular turns of the thorax to steady it; after which the ordinary spiral turns of the chest should be applied until the bandage reaches the edge of the 358 PRACTICE OF SURGERY. axilla, when it is to be finished by one or two oblique turns of the opposite shoulder in order to keep the previous thoracic turns from slipping down. This bandage, as thus applied, is usually desig- nated as the first roller of Dessault, and its object is simply to hold the pad in the axilla. Then, in order to draw the shoulder out- ward so as to overcome the shortening of the bone, the surgeon should lower the arm and carry it against the pad so as to cause the humerus to act as a lever, and elongate the clavicle, the broad end of the pad being the fulcrum. Whilst the arm is thus held by an assistant, it should be secured to the side by a second roller. The second roller of Dessault begins in the axilla of the sound side, and is applied by making oblique turns from this axilla around the arm and body so as to bind the arm to the pad. The turns around the head of the humerus should be loosely made, or they will defeat the object of this bandage, which is to draw the shoulder outwards; but, as the roller descends towards the elbow, the turns should be more tightly drawn in order to force the arm in towards the side, these turns being continued until the point of the elbow is reached, when the bandage should be fastened by a pin. The third roller has for its object the carrying of the shoulder upwards and backwards, and its turns are perhaps more difficult to remember than the others. It constitutes, in fact, the chief diffi- culty with those who are inexperienced in the application of Des- sault's apparatus, though it is really very simple. Commencing at the axilla of the sound side, this bandage passes up over the seat of fracture, where a little compress should be laid in order to pre- vent undue prominence of the fragments. Thence it passes over the injured shoulder, down the back of this arm to the elbow, under this, and then back to the axilla whence it started, by pass- ing over the front of the chest; this last turn drawing the elbow upward, if applied with sufficient force. From this axilla the roller is now to be passed across the back to the injured shoulder, and over the front of this shoulder and arm to the elbow, from whence it passes across the back to the axilla whence it started: this turn drawing the shoulder backward. Having reached the axilla, the roller, which is represented as free in Fig. 106, should be passed over its previous course, the turns just described being re- peated again and again until the bandage is exhausted, when it should be fastened by a pin. When this last bandage is thus applied, it will be perceived that two triangles are made, one upon the anterior and FRACTURE OF THE CLAVICLE. 359 one upon the posterior side of the chest, the base of the triangles being at the arm of the injured side, and the apex at the axilla of the sound side. In applying this third roller, a very simple rule will prevent the possibility of any mistake in its course, and this is as Fig. A view of the Bandage op Dessault as applied foe the treatment op Frac- ture of the Clavicle.—1. The oblique turns of the first roller, which holds the pad in the axilla, as carried around the sound shoulder in order to secure the previous turns from slipping downwards. 2, 2. The turns of the second roller, which binds the arm against the pad, carries the shoulder outwards, and overcomes the shortening of the broken bone. 3, 3. The third roller, as applied in order to carry the shoulder upwards and backwards by acting on the point of the elbow. 4. The short sling, to support the hand after the band- age is applied. The splint cloth, which covers all these bandages, is not represented, as it would conceal the figure, whilst the roller which forms the third bandage is represented as coming from the back under the sound axilla, or point whence it started, in order to re- sume its previous course. (After Nature.) follows: Pass always from the axilla of the sound side across the front or back of the chest to the elbow of the opposite side, and from the elbow to the axilla whence you started. To prevent the last turns from slipping, Dessault generally finished this third roller by one or two circular turns around the body; and, to support the hand, made a sling out of a short piece of roller, which he fastened with a pin to the previous turns of the bandage. Several pins were then put in to secure the dressing, and over the whole a broad piece of muslin was applied to render it still more secure. This dressing is very firm, and answers an admirable purpose in many cases. It is a capital dressing for children, for lunatics, for those laboring under mania a potu, or others who are likely to 360 PRACTICE OF SURGERY. require a very firm bandage, as a patient thus enveloped can hardly, by any possibility, move the broken fragments. But, though firm, and carrying out fully the indications, this dressing is liable to several objections. One of these, and by no means the least important, is its warmth, the patient being enveloped in a great number of coverings, as there are over him three rollers, each eight yards long, besides the outer cloth. This therefore constitutes a serious objection to the dressing in warm weather, especially in the case of patients with a delicate skin; as the perspiration readily accumulates, the skin becomes sodden, and is therefore soon disposed to ulceration under the axilla. A se- rious objection to the dressing in females, especially those with large breasts, is the pressure which it makes upon the mammary gland. Then, again, inconvenience sometimes.of a grave nature will arise from the pressure of the pad in the axilla against the axillary nerves; this having sometimes paralyzed the fingers when the dressing has been tightly applied over a large pad. These objec- tions, and the fact that the same indications can be carried out by simpler and more comfortable means, lead me to regard some of the other bandages as preferable to Dessault's in the majority of instances. Brasdor's Bandage.—Another dressing is that of Brasdor, which does not carry out the -indications, however, as well as that of Des- sault, yet answers a good purpose in cases which demand from any reason a very light dressing. It consists of a triangular back piece, which laces down the middle, and to which-are attached two padded straps to surround the shoulders, and draw them backward pre- cisely like the posterior 8 of the chest. Of course, in causing the shoulders to move backward, it throws them more or less outward, though by no means so perfectly as is done by Dessault's apparatus. To the above apparatus a sling is added, which fulfils the third indication, by carrying the shoulder upwards and backwards. This sling may be made of various materials. A very excellent one is that manufactured of gutta percha, lined with cotton velvet, and supported by means of a silk band neatly padded, which passes around the neck, though* a handkerchief will readily supply its place. Such a dressing answers well when the fracture is com- plicated with a wound, as in gunshot wounds of the shoulder, a class of cases for which Dessault's apparatus is manifestly unfit. Mayor's Handkerchief.—The handkerchief bandage of Mayor for FRACTURE OF THE CLAVICLE. 361 this injury is a mode of dressing which answers an excellent pur- pose as a provisional application; but it by no means carries out Des- sault's indications, though it is well adapted to cases of railroad or stage-coach accidents, or any other emergency where, after the receipt of the injury, it is probable that the patient will have to be moved some distance before a more permanent dressing can be obtained. It is applied as follows:— Make an extemporaneous pad by properly folding two soft towels, or two large pocket-handkerchiefs, and place it in the axilla pre- cisely like the pad of Dessault. Then fold a large pocket-handker- chief triangularly, and apply it so as to support the arm by envelop- ing the wrist in its base, bringing its apex around the elbow, and carrying the two points up and round the neck, the one passing under the sound axilla behind the back to the opposite shoulder, and the other going from between the arm and the body over the front of the chest to meet it on the neck. A second handkerchief, folded into a cravat, should then be made to encircle the whole chest, and bind the arm to the side. Fox's Apparatus.—A dressing which is very light, and which answers the purpose better than most others, is the bandage of Dr. Fox, of Philadelphia. It consists of a pad like that of Dessault, but shorter, and consequently enables the elbow to be more readily drawn in to the side of the body, thus carrying the shoulder more strongly outwards. This pad is supported by means of two tapes, the latter being attached to a padded collar, which should be made to encircle the opposite shoulder. This collar may be formed by taking a roller about 2\ inches wide, and twenty-four inches long, folding it upon itself, and stitching the edges together so as to form a narrow sack or tube, which may then be stuffed with cotton or filled with bran, and its two ends sewed together so as to make it circular. To complete the dressing, a sling is added, which con- sists of a piece of muslin cut like a coat sleeve, but open in front, and which, by three tapes, one at the elbow, passing behind the body, and two at the wrist, is fastened to the collar which encircles the sound shoulder (Figs. 107, 108). Figures 107, 108 show so clearly the simplicity and action of this bandage, that no derailed description of its application is re- quired. By means of this dressing, very perfect cures have been accom- 362 PRACTICE OF SURGERY. Fie:. 107. A front view of Fox's Apparatus for Fracture of the Clavicle.—1. The Stuffed Collar applied to the sound shoulder. 2. The Sling, as applied to the injured arm. The tapes at the wrist being tied to the collar, draw the elbow into the side and throw the shoul- der outwards, thus elongating the broken bone. The tapes which are attached to the elbow and upper end of the sling pass across the back and also tie to the collar on the sound shoulder, thus drawing the injured shoulder upwards and backwards, as shown in Fig. 108. 3. The Pad, which is held in the axilla by two tapes, one of which passes across the front, the other across the back of the chest to tie on the collar of the sound shoulder. As the broken clavicle is thus left uncovered, it is easy to recognize the presence of deformity, and overcome it by tightening the proper tape. (After Nature.) plished. By very perfect cures are meant not only perfect union of the fragments, but union without angularity or any deformity. Fig. 108. A posterior view of Fox's Apparatus as applied, showing the course of the tapes which are attached to the Sling at the elbow, and also at its upper posterior end ; these taps traverse the back to the collar on the sound shoulder, and thus carry that of the injured one upwards and backwards, (After Nature.) FRACTURE OF THE CLAVICLE. 363 Objections have been raised to this apparatus on account of the chafing likely to result from the collar, from the sling, &c, which, however, are equally true of every apparatus by which any amount of pressure is made. Still, these may with care be entirely ob- viated, and if the surgeon sees that ulceration is likely to occur at any point, he should protect the skin with a piece of soap plaster spread on kid, which will often save it. Apparatus of Levis.—Another apparatus, which admirably fulfils Dessault's indications, and which for neatness and simplicity is fully equal, if not superior to all the others, is one to which the attention of the profession has been lately called by Dr. Eichard Levis, of Philadelphia.1 " It consists of a short, firm pad in the axilla, by which the shoulder is kept from the side, and over which, as a fulcrum, the elbow is drawn to the side. To the front and back of the axillary pad are fastened straps, which pass directly upwards, and are buckled to a wide main supporting band, which, passing from the shoulder across the upper part of the back, and over the shoulder of the sound side, terminates on the front of the chest, as in Fig. 109. "By this means the shoulder is supported, and the pad immovably held high in the axilla, where its pressure can be more conveniently borne than when its widest part compresses the brachial nerves and vessels lower down; besides, a better leverage is thus given to the arm over the pad. " To the front end of the wide supporting band is suspended a sling, by which the elbow is supported (Fig. 110). On the back of the sling, at a short distance from the point of the elbow, a strap is attached, which passes obliquely around the back, and, coming in front, is buckled to the main supporting band (Fig. 111). The A view of the Pad, Sling and Collar describ- ed in the text. (After Levis.) 1 See Am. Journ. Med. Sciences, vol. xxxi., Jan., 1856. 364 PRACTICE OF SURGERY. Fig. 110. A front view of the Apparatus, as applied to a Patient. (After Levis.) Fig. 111. A back view of the Apparatus. (After Levis.) action of this strap is to draw the elbow to the side, at the same time supporting it, whilst its opposite attachment in front prevents the tendency of the wide band to ride upward and press uncom- fortably on the superficial vessels of the neck. " By this combination, united so as to form one continuous piece, requiring no extra bandage over it, the shoulder is firmly held in the proper direction without any risk of the yielding or slipping of the apparatus, and so secure, that the most restless patient cannot disarrange it. "In adjusting the apparatus, the arm should be passed through the opening above the pad, the wide band thrown across the oppo- site shoulder, the elbow placed in the sling, and the long strap attached to the back of the sling brought round in front. . " In removing it from the patient, it is only requisite to loosen the long back strap which draws in the elbow, by unbuckling it at its front attachment. The other straps need never be removed from the buckles. " The extra buckle, which will be noticed at the front end of the wide supporting band (Fig. 110), comes into use when the appa- ratus is reversed for the opposite shoulder. " The apparatus may be made of any strong material, as webbing, drilling, or soft leather. The width of the wide band should be FRACTURES OF THE SCAPULA. 365 from two to four inches. The straps which press upon the surface were slightly padded in the apparatus as the writer has used it (Dr. Levis), but this may not always be essential, and temporary pads might be placed if the pressure should become anywhere uncom- fortable. Thus constructed, it can be very speedily prepared at an emergency, and buttons and button-holes might even take the place of buckles." This dressing, which has been too recently proposed to enable its inventor to report many cases of its trial, is one which has been applied to several persons, who described it as being quite easy in all respects. I regard it therefore as an improvement in the means of treatment heretofore suggested, and as admirably adapted to the wealthier class of patients, among whom neatness as well as efficiency is desirable, being satisfied from a careful examination of its action that it fulfils perfectly all the indications required in the treatment of this fracture. SECTION II. FRACTURES OF THE SCAPULA. When we notice the position of the scapula, the character of the muscles which surround it, and the nature of its connections with the body, it will readily be seen that this bone can very seldom be the seat of fracture. When a man falls so as to strike the point of his shoulder with considerable violence, the scapula being held on the upper back part of the thorax, chiefly by muscular attachments, yields to the force, and slips back towards the spine, instead of resisting the blow and being fractured, as might be the case if it was a fixed point. Hence it happens that dislocations of the head of the humerus, or of the clavicular articulations of the scapula, or fractures of the head of the humerus, are much more common than fractures of the neck of the scapula. Still, there are cases in which the scapula is broken by the application of great violence, as when a man is caught in machinery, or is knocked down and run over by a heavy wagon, or gunshot wounds may create it; such cases having been reported. Under these circumstances, the scapula may be broken at any point, as at the coracoid process, in or below the spine, at its inferior angle, in its body and in its neck. Of these, fracture of the acromion pro- 366 PRACTICE OF SURGERY. Fig. 112. A representation of the Seat of Fracture of the Neck of the Scapula. (After Fergusson.) cess is the most frequent, and may be produced by direct violence, or by indirect force transmitted through the head of the humerus. Fractures of the neck of the bone, except as a result of gunshot wounds, or as complicated with other fractures, are extremely rare, a very few being alluded to by Eu- ropean writers. There are, I believe, only two in the extensive museum of Dupuytren in Paris, and these were accompanied by fractures of other portions of the bone, or with# dislo- cation of the head of the humerus,1 but I am not aware of there being any well authenticated dried speci- men of it in this country. So with fracture of the coracoid process, which is extremely rare, sel- dom occurring as a distinct accident. When it exists, the deformity is produced by the action of the muscles inserted into it, as the coraco-brachialis, pectoralis minor, and short head of the biceps, which draw it out of line, and by removing the resistance to the forward motion of the head of the humerus facilitate a partial luxa- tion of this bone. Fracture of the acromion process is not so rare; but, from the point at which it occurs, it is doubtful whether some of the specimens of it which have been preserved are not due rather to a failure in the production of ossific union be- tween the epiphysis which consti- tutes the extremity of the process than to a true fracture, though the latter is sometimes met with; the A representation of the condition of the v . ,i o r parts in fracture of the Coracoid Process Um0n between the fragments be- lt^.CTA%efFTrgu^on?Ction °f ** inS generally ligamentous. Fig. 113. fc£ 1 See Malgaigne, Traite des Fractures, tome i: p. 498, Paris, 1847. FRACTURES OF THE HUMERUS. 367 When fracture of the acromion process is produced by any force, such as a fall upon the shoulder, or the blow of a bludgeon, a deformity results, which consists in drooping of the arm and de- struction of the proper configuration of the shoulder. Treatment.—Fracture of any portion of the scapula is to be treated by acting upon the elbow in such a manner as to press the arm upward, so as to bring the head of the humerus in contact with the broken extremity of the scapula, if broken near the glenoid cavity, or by holding it in the same position so as to keep the scapula at rest, when the fracture is seated in the body of the bone; after which no elevation of the humerus should be permitted until union has had time to become firm, owing to the thin flat character of this bone. These indications are best carried out by means of the same dressing as would be adapted to fracture of the clavicle, omitting the pad, as described in connection with that injury. SECTION III. FRACTURES OF THE HUMERUS. Fractures of the humerus are much more common than the pre- ceding, and may occur in any portion of the bone; thus there may be fractures of its head, these being generally the result of gunshot wounds or of extraordinary violence; fractures of the anatomical neck, which are more common in young persons than in adults, in consequence of the want of close union between the head, which is an epiphysis in early life and the shaft of the bone; and fractures of the surgical neck. By the surgical neck of the humerus is meant all that portion between the anatomical neck and the insertions of the pectoralis major and latissimus dorsi muscles. Fractures may also occur in the shaft, or that part of the bone above the condyles, and below the surgical neck and through the condyles either by passing directly through the epitrochlea, so as to involve the articulating surface—the latter exposing the patient to the risk of inflammation of the elbow-joint, and consequent anchylosis—or by simply split- ting off the projection of the internal or external condyle without involving the joint; but the fracture through the epitrochlea is perhaps, that most frequently alluded to as fracture of the condyles. Etiology.—Fractures of the humerus at any point may result from falls, from blows, from violence of any character; or may be due to muscular action. 368 PRACTICE OF SURGERY. § 1. FRACTURE OF THE SURGICAL NECK OF THE HUMERUS. Symptoms.—Fracture of the neck of this bone will present a somewhat complicated train of symptoms, the deformity consisting both in angular displacement as well as rotation of the fragments. Thus, in a fracture of the surgical neck or part above the insertion of the pectoralis major and latissimus dorsi, the action of these two large and powerful muscles will draw the upper end of the lower fragment in towards the axilla (Fig. 114); while the action of the Fig. 114. A front view of the Relation of the Parts concerned in a Fracture of the Surgical Neck of the Humerus.—1. Deltoid muscle. 2. Pectoralis major disseoted off from its origin and turned over the humerus so as to show its insertion. 3. Insertion of the latissimus dorsi muscle. 4. The subscapularis muscle. &. The supra-spinatus, as seen behind the clavicle. (After Hines.) supra and infra-spinatus muscles, which serve, in the normal con- dition of parts, to aid in the extreme elevation of the arm, act, when the continuity of the bone is destroyed, to cant the lower end of the upper fragment outwards. In consequence of the action of the pectoralis major and latissi- mus dorsi drawing the upper end of the lower fragment inward s FRACTURE OF THE SURGICAL NECK OF THE HUMERUS. 369 the elbow will generally project somewhat from the side. The prominence of the lower end of the upper fragment can therefore be distinctly felt, and, as the head of the bone still retains its posi- tion, there is usually no flattening of the shoulder. The upper fragment is not only canted out by the action of the supra and infra-spinatus muscles, but is moreover rotated by the subscapularis and pectoralis minor, so that there is often more or less displacement as regards the circumference of the bones, whilst the lower fragment is forced up towards the axilla by the contraction of the flexor muscles of the arm. The deformity, therefore, in fractures of the surgical neck of the humerus, is threefold: first, there is angular displacement; secondly, displacement as regards the circumference; and thirdly, more or less shortening, due to the action of the deltoid, biceps, triceps, and coraco-brachialis muscles which, arising from the scapula, are in- serted into the radius and ulna. The danger of shortening in frac- tures of the humerus is very apt to be overlooked, but it deserves the greatest care on the part of the surgeon, although the shorten- ing of this limb is not so important as it is in fractures of the lower extremities. In order to prove that the bone has been accurately reduced, its length should be measured, as may be readily done by means of a tape extended from the acromion process of the scapula to the ex- ternal condyle of the injured side, this being subsequently com- pared with a similar measurement made upon the sound limb. Prognosis.—The prognosis in simple fractures of the surgical neck of the humerus is highly favorable as regards union, but if appropriate treatment be not employed the deformity will be quite marked. Treatment.—In the treatment, such forces should be applied as will counteract the action of those muscles which have been described as tending to produce deformity. Thus, it will be necessary, to counteract the tendency of the pectoralis and latissimus dorsi, to draw the upper end of the lower fragment in towards the axilla; to overcome the tendency of the supra-spinatus and other scapular muscles, to throw the lower end of the upper fragment outwards and the disposition of the triceps, biceps, deltoid and coracoid bra- chialis to produce shortening. These indications may be answered by Boyer's dressing, which consists of three splints and a pad. (Fig. 115.) The pad resembles that used by Dessault for fracture 24 370 PRACTICE OF SURGERY. of the clavicle, whilst of the three splints one is for the front of the arm, extending from the rotundity of the shoulder to the bend of the elbow (4),°but not long enough to interfere with the flexing of the forearm upon the arm; the two remaining splints (3, 2) Fig. 115. A view of the Pad and three Splints required for the treatment of a Fracture of the Surgical Neck of the Humerus, as well as of the angular Splint used with the three shorter Splints in the treatment of Fracture of the shaft of the bone.—A. The wedge- shaped pad of Dessault. 1. The angular inside splint for fracture of the shaft, (as here- after described.) 2, 3, 4. The three splints for the outside, back, and front of the arm in fracture of the surgical neck, the pad acting as a splint for the inner side. (After Nature.) being intended one for the outside and the other for the back of the arm. These splints should be of pasteboard, or of light wood, carved to suit the convexity of the arm. Before proceeding to apply these splints, a bandage should be carried from the fingers up to the shoulder, in order to prevent capillary congestion and the consequent cedema which would other- wise arise from the necessary pressure made about the seat of the fracture, as well as to compress the muscles. This bandage should be the ordinary spiral of the upper extremity (see page 128). After applying it carefully, let one assistant keep up extension and counter-extension, whilst another applies the three splints, having first guarded the extremity of each by a little pad of carded cotton to prevent them from exercising undue pressure on the skin. After thus arranging the splints, secure them on the back, front, and outside of the arm, by simple spiral turns of a roller; then placing the pad in the axilla, with its thick end up, when the lower fragment is drawn inwards, bring the arm down to the side, and bind it to the pad and the body by means of circular FRACTURE OF THE SHAFT OF THE HUMERUS. 371 turns around the chest (Fig. 116); these circular turns being ter- minated at the elbow, beneath which none should be made, lest, Fig. 116. A view of the Dressing for Fracture of the Surgical Neck of the Humerus as applied to the body. The dotted lines show the apparatus inside the turns of the roller which binds the arm to the body. A. The pad in the axilla. 2, 3, 4. The splints in posi- tion, as previously seen in Fig. 115. The hand is supported by a sling. (After Nature.) by pressing upwards, shortening be induced. The dressing is then to be completed by a sling, which should merely support the wrist, and allow the arm to hang, so that its weight may aid in pre- serving its length, and thus prevent the occurrence of shortening. Boyer's dressing for fracture of the neck may be modified when the upper end of the lower fragment projects outwards, and the lower end of the upper fragment is drawn inwards, by simply in- verting the pad, and putting the thin end upwards. But this de- formity is much more apt to occur in fractures just below the surgi- cal neck in which the deltoid muscle draws the upper end of the lower fragment outward, while the pectoralis and latissimus dorsi draw the lower end of the upper fragment inwards, than in frac- tures of the true surgical neck of the bone. § 2. FRACTURE OF THE SHAFT OF THE HUMERUS. Fracture of the shaft of the humerus is often followed both by an- gular deformity and shortening of the limb, in consequence of the 372 PRACTICE OF SURGERY. action of the muscles, especially the biceps and triceps, which aris- ing from the scapula are inserted into the radius and ulna. The forces, therefore, to be resisted are these muscles, whilst the flexion and extension of the forearm, or any motion of the elbow-joint, must be prevented, owing to its con- Fig. 117. nection with the lower fragment. Symptoms.?—The symptoms are those of fractures generally, as pain, deformity, and increased mobility at the seat of fracture, with loss of the proper motions of the arm. Diagnosis. — The increased mo- bility, the crepitus, deformity, and history of the case generally, suffice to make the diagnosis of this injury quite easy. Prognosis.—The prognosis of this injury is very favorable in a sim- ple fracture correctly treated; but it should be remembered that false joint is very frequently met with after fractures of this bone, this re- sult being created either by want of rest, or by the fracture occurring A view of a Fracture of the Shaft of near ^0 ^he point of entrance of the the Humerus, showing the action of the . . r Biceps andTriceps Muscles in producing nutritious artery. shortening and displacement. (After Treaimmt_The treatment 0f fraC- tures of the shaft of the humerus requires four splints, one of which is angular and long enough to reach from the axilla to the ends of the fingers, and is to be applied to the inner side of the arm (see (1) Fig. 115); another (2) of the length of the arm is to be applied to the back of the humerus; (3) one for the outside, and (4) one for the front of the arm, all of: which should be made of light wood and well padded with cotton. Then, whilst an assistant keeps up extension by drawing on the forearm near the elbow, and counter-extension is made at the shoulder, commence at the wrist and apply the spiral reversed bandage of the upper extremity (page 128), continuing its turns up to the shoulder, making several extra turns on the arm at the seat of fracture, so as to compress its muscles with moderate 145 FRACTURE OF THE SHAFT OF THE HUMERUS. 373 firmness. Next place the arm and forearm upon the angular splint, the latter being well padded, especially at the elbow, and bind the arm and forearm to this splint with another roller, com- mencing at the wrist and continuing the bandage as far as the elbow. Then apply the three short splints, padding them well at Fig. 118. A View of the Dressing applied to a Fracture of the Shaft op the Humerus. 1. The inside angular splint. 2, 2. The splint on the back of the arm. 3, 3. That on the outside. 4. That on the front of the arm, the position of the arm across the chest making it appear to be placed towards its inner side, but this is the seat of the angular splint which keeps the elbow at rest. (After Nature.) the ends, and, resuming the roller, bind them all to the arm as in Fig. 118. After which the forearm should be carried across the chest and supported by a sling around the neck. The advantages of the use of an angular splint, which extends from the finger to the shoulder on the inner side of the arm, over the inside short splint, as advised by Boyer, will be found in the per- • manency of the dressing, and the perfect rest of the fragments in- sured by its application. After employing this dressing for two or three days, it should be taken off and the arm well washed with whiskey, when, on reapplying it, modify the angle of the splint or substitute another, so as to prevent the stiffness of the elbow which may ensue from the joint being kept constantly in one position. 374 PRACTICE OF SURGERY. 3. FRACTURE OF THE CONDYLES OF THE HUMERUS. Fig. 119. Fracture of the condyles of the humerus is a more serious injury, so far as the probability of the perfect motion of the extremity is concerned, than the fracture of the shaft of the bone just described. As before remarked, the external or internal condyle may be simply split off without involving the joint, but most frequently the fracture of the lower part of the humerus, known as fracture of the condyle, is a fracture directly through the epitrochlea and involving the articulat- ing surface of the bone, the consequences of which are serious, because the continuity of the cartilage covering the articulating surface of the bone and the synovial membrane which lines the joint is destroyed. Hence inflammation results, lymph is effused and organized, adhesions form, and the injury almost always results in an anchylosis, which is more or less complete, and which subsequently prevents the per- fect extension and flexion of the forearm that existed prior to the accident, though it will not entirely de- stroy the use of the joint. The articulating surface of the bones being thus involved, the condyles no longer retain their ordinary shape and position, dislocation of both bones of the forearm backward ensuing on the fracture, in con- sequence of the action of the triceps muscle, the in- jury being thus liable to be mistaken for dislocation. From this, however, it is important to distinguish it, as may be readily done by attention to the circum- stances which will be pointed out in connection with the diagnosis- Etiology.—Fracture of the condyles of the humerus is generally. seen in young persons or children, and due to a force applied either directly upon the elbow or indirectly to it through the bones of the forearm. Thus, it may result from a fall upon the point of the elbow, in which the olecranon, striking violently against the ground, is driven forwards against the condyles, which give way, and de- velop the fracture. Sometimes the bone is broken transversely across, through its articulating surface, creating a separation of its epiphysis from the shaft at this point; or it may be broken by in- A view of the ordinary seat of fracture through the epitrochlea of the humerus. (After Nature.) FRACTURE OF THE CONDYLES OF THE HUMERUS. 875 direct violence, as when the patient falls forwards upon his hands, the force being transmitted along the bones of the forearm to the condyle whilst the resistance is made by the weight of the shoulder. Symptoms.—The symptoms of this fracture are as follows: After the receipt of an injury upon the elbow, or a fall upon the hand, the patient suffers great pain in the neighborhood of the joint, which increases whenever he attempts to flex the forearm upon the arm; the mobility of the joint being also always impaired, and, in marked cases, almost completely destroyed. Combined with the above symptoms there is generally more or less deformity, which consists, in some cases, in complete dislo- cation of both bones of the forearm backwards, thus causing the injury to be confounded with the latter accident. Diagnosis.—A fracture of the condyles of the humerus can rea- dily be diagnosed from dislocation backward of both bones of the forearm, by the fact that the deformity in fracture is very readily reduced by moderate extension and counter-extension, which is not the case in a dislocation; and also by the fact that a fracture, un- like a dislocation, reproduces the deformity so soon as the extend- ing and counter-extending force is intermitted. Crepitus and the ordinary symptoms of fracture are also present in fracture, whilst, if these circumstances are insufficient for a diagnosis, the injury may be recognized by the following rule: If, in health, the fore- arm be flexed upon the arm, and a circular line drawn around the elbow-joint from the external to the internal condyle, it will touch the point of the olecranon, as well as the two condyles; but if a fracture has occurred which involves either the condyle or the ole- cranon, these points will no longer be within the line. Prognosis.—The prognosis of fractures of the condyles of the humerus should always be very guarded, compound fractures often demanding amputation, and simple fractures resulting in deformity, and partial anchylosis of the elbow, as well as loss of pronation and supination in the hand. The patient should, therefore, always be told that in all probability there will be more or less loss of motion in the joint, as well as imperfect pronation of the hand. Treatment.—In treating fracture of the condyles, it is necessary to overcome the action of the triceps, and thus prevent the dislo- cation of the bones of the forearm backward, whilst the arm should be kept at perfect rest in order to reduce the inflammation of the joint; passive motion being carefully made, after the first twelve days, in order to pfevent anchylosis. 376 PRACTICE OF SURGERY. These indications can be best carried out by means of an angular splint made to fit the front of the arm, and jointed with a hinge at the elbow, so that, by means of a wire properly applied, the splint can be placed at any angle desired; or several splints, like those in Fig. 120, 2, 3,4, may be prepared of different angles. -Then having, A representation of the Splints required in the treatment of Fracture or the Condyles of the Humerus.—1. The curved splint for compound fractures, or sim- ple fractures when accompanied by much inflammation. 2, 3, 4. Angular splints of dif- ferent angles, to be applied to the front of the arm, as described in the text. (After Nature.) by extension and counter-extension, with flexion of the forearm on the arm, reduced the fracture and applied the spiral bandage of the upper extremity from the fingers up to the shoulder, place a wad of cotton in the bend of the elbow to avoid injury from the pres- sure of the splint, and fasten the latter to the arm by means of a roller, beginning at the wrist and regularly ascending the arm up to the shoulder. The pressure made in the bend of the elbow by this splint will certainly prevent dislocation backward, whilst it obviates the dan- gers consequent on ulceration of the integuments over the internal condjde, as made by the side angular splint that was formerly placed on the inner side of the arm, in accordance with the sug- gestion of Dr. Physick. A compound fracture of the condyles of the humerus some- times occurs, with accompanying laceration of considerable extent. Under these circumstances, it would be worse than useless to attempt to apply one of these splints. The arm should therefore be simply placed upon a pillow in a semi-flexed position, while leeches, cold cloths, and other measures proper for the treatment of inflammation FRACTURES OF THE BONES OF THE FOREARM. 377 of the soft parts are employed; as the injury to the soft tissues, with the consequent inflammation, is here often the most serious part of the accident, the patient being very fortunate if his surgeon is able to save the limb. When the injury is not quite so extensive, and is so situated in regard to the joint as to permit it, advantage will be found from the use of the carved splint (Fig. 120,1), or one of paste-board or gutta-percha, either simple or supported on the outside by strips of tin. In employing the carved splint, the arm may be laid within it, and supported by the bandage of Scultet; but if the splint be properly applied, this bandage may be laid aside, as the limb can be raised and the wound dressed daily when a few turns of the ordinary spiral roller are loosely applied around it, without de- ranging the fragments, or removing the arm from the splint. Of the splints required in compound fractures, that carved out of . wood is infinitely preferable, and may be readily made by the fol- lowing process:— Having selected a piece of soft poplar or white pine about two inches thick, lay the injured arm upon it, and mark its outline with a lead-pencil. Then, with a penknife, if nothing better can be obtained, or with a gouge, hollow out the wood so as to make it correspond with the shape of the arm. Having thus worked it out in such a manner as to fit the arm as nearly as possible, shave down the outside so as to leave the splint as light and thin as would be consistent with firmness, after which a piece of buckskin may be glued over the inside to protect the.skin, and a piece of muslin or linen placed on the outside to prevent the thin wood from splitting or warping. Of course, if a finished article is required, it must be procured from a carver; but a splint like the above, which will answer a very good purpose, can be made under the direction of the surgeon by any workman. SECTION IV. FRACTURES OF THE FOREARM. § 1.—FRACTURES OF BOTH BONES OF THE FOREARM. The bones of the forearm may be broken at any point in their length, but most frequently the injury will be found at some point below the upper third, and in one bone rather than both. The reason why the upper third of these bones is so seldom broken is O I o PRACTICE OF SURGERY. to be found in the protection afforded by the bellies of the muscles of the forearm, which envelop them so that a simple fracture at this point is of rare occurrence. Etiology.—The causes of these fractures are blows, falls in which the weight of the body is caught upon the hands, or in which the arm is caught under the body, railroad accidents, etc. When a fracture of both bones occurs, it happens, as a general rule, at one point in the radius and at another in the ulna, particularly if the injury has been caused by a fall upon the hands. Still, cases occur in which a fracture of both bones is found at the same point, as when the arm is thrown up to fend off a blow. Such fractures may also be caused by catching the hand or forearm in a wheel, &c. Besides fractures of both bones, either the radius or the ulna alone may be broken at any point in their length without a frac- ture of the other bone. In this case there will be no shortening, the sound bone acting as a splint, and preserving the normal length of the arm. Indeed, there is seldom any shortening in fractures of the forearm, even where both bones are broken, in consequence of the character of the muscular attachments of the part, and of the interosseous ligament. The displacement, therefore, in fractures of the forearm is rather an angular deformity than shortening, besides which there is frequently more or less displacement in the circumference caused by the action of the pronator or supinator muscles. Whether the fracture affect both bones or but one, the symptoms and the treatment are very similar. A view of the Muscles of the Forearm as connected with the deformity created by a fracture of the Shaft of the Radius.—1. Biceps flexor cubiti. 2. Pronator radii longus. 3. Pronator radii teres. 4. Pronator quadratus. (After Hines.) Symptoms.—The symptoms in either case will be pain, swelling, inability to execute the functions of the forearm, more or less con- FRACTURES OF THE BONES OF THE FOREARM. 379 Fig. 122. tusion of the soft parts, and consequent infiltration of the cellular tissue with blood. These general symptoms will be found without much change in all fractures of the bones of the forearm, whether the radius, ulna, or both bones be involved. Sometimes there is a disposition towards partial fracture, com- bined with bent bones, of which there are two specimens in the Wistar and Horner Museum of the University of Pennsylvania,1 but the symptoms are then complicated with the ordinary symptoms of bent bones, and the deformity which results would hardly be mistaken for that of fracture. Treatment.—The object of the treatment is to keep up such an amount of extension and coun- ter-extension as will retain the fragments in po- sition, and prevent such angular deformity as might encroach upon the interosseous space; for it will readily be understood that, if there is an angular displacement in either bone so as to en- croach upon this space, it will interfere with the free pronation and supination of the hand. A very moderate amount of extension and counter- extension will usually suffice to effect this object, and it may be accomplished by seizing the pa- tient's hand with one hand, and his elbow with the other, and then drawing with moderate force until the fragments are brought into the proper line. The surgeon, then giving the limb in charge of an assistant, should coaptate the fragments, carefully observing that the inter- osseous space is preserved. The importance of this latter point in the treatment of fractures of the forearm cannot be over-esti- mated; as, even if the deformity in the bones themselves does not interfere with the pronation and supination of the hand, it should be borne in mind that the ensheathing callus which is thrown out will extend beyond the bones, and thus limit their motions; hence this fracture should be kept at perfect rest, not only because motion is liable to displace the fragments, but because the quantity of ensheathing callus thrown out is liable to be increased by the frequent action of the part. A representation of a partial Fracture of the Radius in a young patient, accompanied with the bending of the fragments. (After Fergusson.) 1 At Philadelphia. 380 PRACTICE OF SURGERY. The dressing best adapted for the treatment of fracture of both bones of the forearm is as follows: the forearm should be semi- flexed upon the arm, the thumb pointing upwards, and two splints, carefully padded, be placed one upon the front and the other upon the back of the arm, these splints being padded so as to make pressure on the interosseous space, and preserve the parallelism of the bones. Then, whilst they are held in position, fasten them to the forearm by a roller, beginning at the wrist and moving up to the elbow. Fig. 123. A view of the Splints, i with a side view of the position of the foot, the periods for the treatment of ugersi(AfLer mntf by *" leverase °f the this fracture in the extended position; almost all being lia- ble to the objection that extension and counter-extension are so made as to produce excoriation, ulceration, and sloughing of the integuments at the points most pressed on. Among the earliest plans was that of Dessault, which consisted in the use of a splint for the outside and one for the inside of the thigh of the length of the entire limb; in junk-bags, to prevent the splints from pressing against the limb, and in a splint-cloth to keep them in contact with it. But, owing to the shortness of the outside splint, this apparatus was liable to the objection that any inclination of the body from the injured side allowed the fragments to slide by each other, and thus permitted a degree of deformity which se- riously interfered with the subsequent usefulness of the member. Physick's Modification of DessauWs Splint.—Dessault's apparatus FRACTURE OF THE SHAFT OF THE FEMUR. 413 was, therefore, modified by Dr. Physick, of Philadelphia, his modi- fication consisting in extending the splint as high up as the axilla, and binding it to the side by a handker- Fig'145, chief around the chest, in order to prevent the incli- nation of the body. A small block was also added at his suggestion, by Dr. Hutchinson, to the lower end of the splint so as to make the extending band act more directly in the line of the limb than it did in the splint of Dessault. (See Fig. 145.) This dressing, after having been tested for many years, still retains a large share of professional confidence, and, having been variously modified, now consists of the following articles: A long splint, with holes in each end, and a block at the lower extremity, as seen in the figure; of another plain splint, long enough to reach from the perineum to the sole of the foot; of a splint-cloth one yard and a half long by one yard in width, in which the splints are to be rolled, so that they shall be about three inches wider apart than the width of the limb; of two muslin bags called junk-bags, one of which should be of the length and width of the inside splint, and the other about six inches longer, both being filled with bran to about two-thirds of their length. A soft silk handker- chief folded into a cravat of about two inches in width or a padded band, is also required to make the counter- extension. The means recommended for the purpose of preserving the extension have been very varied, the great difficulty being to find something which, while supplying sufficient power, would not cause excoria- tion of the heel. The best plan of keeping up exten- sion, no matter what form of the straight splint is employed, is as follows: A strip of adhesive plaster two inches wide, and long enough to reach from the outer side of the knee to two inches below and around the foot up to the inner side of the knee, should be warmed, and made to adhere to the limb- a thin block of wood of the width of the sole of the foot being placed in the loop formed below the foot, so as to keep the strips from pressing against the sides of the ankle, the side straps being also secured by three transverse pieces carried across the front of the leg. This plan has proved so efficient in the treatment of all cases 414 PRACTICE OF SURGERY. of fractures of the lower extremities that the suggestion of it has been claimed by various surgeons in the United States, each of whom seems to have been unaware of its previous employment. (See Fig. 146.) A SIDE VIEW OF THE EXTENDING BAND AS MADE OF ADHESIVE PLASTER, AND APPLIED TO THE LEG IN ALL FRACTURES OF THE FEMUR AND LEG WHICH DEMAND THE EMPLOY- MENT of AN extending force.—A. The broad outside strip which is retained by the cross strips 1, 2, 3 passing over to a similar wide strip on the inner side of the leg—this strip being one entire piece. B. The little block placed in the loop of the side strfp where it passes beneath the foot, thus furnishing a firm support to the tape which is to be attached to the lower end of the splint, whilst it also keeps the pressure of the extending band off the sides of the foot. (After Nature.) The plaster having been thus applied, and a strip of bandage or strong tape attached to the block below the foot, the cravat which forms the counter-extending band is to be slipped beneath the but- tock of the injured side, and carried across the edge of the perineum and groin, so that it may tie to the upper end of the outside splint. Then, whilst the limb is extended and slightly elevated by the hands of the surgeon at the ankle, let an assistant pass the splint cloth as wrapped around the two splints, underneath the limb, until the upper end of the inside splint reaches the perineum. The splints being then laid down as thus placed, on each side of the lirnb, the junk-bags should be arranged upon them in such a manner that their stuffing may correspond with the inequalities of the lirnb. Let an assistant now hold the outside splint with its bag up against the limb until the extremities of the counter-extending cravat are passed through the holes at its upper end and securely tied. Then, whilst the surgeon draws the limb gently, but firmly, downwards, so as to make extension, let another assistant tie the strip of band- age attached to the block below the sole of the foot to the lower end of the outside splint, thus preserving, by means of the adhesive plaster, the extension previously made by the hands of the surgeon. The inner splint, with its junk-bag, being now brought up against the limb, the two splints should be secured in position by three strips of bandage, gently introduced beneath the knee, and slid FRACTURE OF THE SHAFT OF THE FEMUR. 415 into position. Two crossed hoops should then be applied over the foot so as to protect the toes from the weight of the bedclothes. It will be seen that the short splint in this apparatus has nothing to do with the extension and counter-extension, its object being merely to make pressure upon the inside of the limb, and thus pre- venting muscular contraction, undue projection of the lower frag- ment backwards being prevented by the firm hard mattress on which the patient should be placed, as well as by the splint-cloth which surrounds the splints and binds them to the sides of the limb. Should the patient complain of pain in the perineum after wearing this apparatus for a few days, the dressing should be loosened, as indeed it should be every two or three days during the first fortnight after the injury, and the points pressed on rubbed with soap liniment, to obviate that capillary congestion which gives rise to the inconvenience, and, if unchecked, will result in ulcera- tion. But if the pain reappears after the dressing is reapplied, the apparatus must be laid aside and some other resorted to. When from this cause, or from any complication, a different dressing seems desirable, resort may be had to the modification of the above splint suggested by the late Dr. Horner, of Philadelphia, a short time before his death, but of which no account has yet been published. Horner's Splint.—This modification of Dessault's splint consists of two splints similar in length to those just described, but padded throughout their length so as to supersede the necessity of junk- bags. The outside splint is otherwise precisely like that of Phy- sick's, but the upper extremity of the inside splint is so shaped as to supersede the necessity of a perineal band (see Fig. 147), being slightly carved out like a crutch-head and having stretched across it a soft leather strap. On the inside of the upper portion of this splint, two leather loops are nailed to serve for the attachment of the counter-extending band. This inside splint, therefore, makes the counter extension by being drawn up against the perineum, pres- sure being thus made upon a different point from that which bore the counter-extending band in Physick's dressing. The apparatus thus prepared is applied as follows: Four or five strips of bandage being laid down transversely on the bed, the patient should be placed on them (no splint-cloth being required), and the splints laid one on each side of the limb, a piece of bandage being passed through the leather loops on the side and near the upper end of the inside splint, 416 PRACTICE OF SURGERY. one portion of which should be carried beneath the buttock whilst the other passes in the line of the groin to the top of the outside Fig. 147. A FROXT VIEW OF HORNER'S SpUITTS. —a. Bottom of outside splint, b, b. Block for extending band to pass over, so as to keep the extension in the line of the body. c. Perforation for the passage of one end of the extending band, which1 cab thus be tied on the bottom end of the splint at A. D. The two perforations at the top of the splint through which the counter-extending bands are to be passed. This splint is to be padded, as shown in the cut, so as to do away with the junk- bags, e. Excavation of upper end of in- side splint. F. Strip of leather stretched across it to serve as the point of counter- extension. G, a. In the magnified view of the upper end of the inside splint are the two loops of leather as tacked to the outer side of the inner splint to receive the counter-extending tape. H, H. The tape or bandage as passed through these loops. The width of this tape is of no consequence if it is strong enough, as it does not press on the body; the only point pressed on being the perineum, and here the pressure i» made by the soft leather, which is stretched across the excavated end of the inside splint. Phy- sick's Splint may therefore be readily con- verted into Horner's when it is desired to vary the seat of pressure from the counter-extending band. (After Nature.) splint where they are tied, so as to make the counter extension. Extension being then made by means of sticking-plaster, as already described, the bandage should be attached to the block below the foot, and be made fast to the lower end of the outside splint as in the previous dressing. The counter-extension is thus made on the lower part of the perineum by means of the loops fastened near the inner side of the inside splint acting on the strap stretched across the upper end of this same splint whilst the extension is made in the middle line of the limb, as in Physick's splint. The dressing is completed by tying the strips of bandage, previ- ously laid on the bed, around the two splints, and fastening each strip to the two splints by means of a carpet-tack, which firmly secures them to the limb and obviates the necessity for a splint cloth. This dressing is particularly adapted to cases in FRACTURE OF THE CONDYLES OF THE FEMUR. 417 which ulceration has resulted from the use of any other apparatus. As in the preceding dressing, it is necessary to protect the foot from the weight of the bedclothes, for so tender does the heel become Fig. 148. A side view of Horner's Splint as applied to the patient. As the cross strips are tacked fast to the splints, as represented by the black dots in the figure, they act in supporting the splints laterally against the limb with much greater certainty than the splint-cloth of Des- sault, this being liable to slip, and also difficult to apply so as to obtain the proper width for the limb between the splints. (After Nature.) that the mere weight of the clothes, forcing it back against the mat- tress, is often quite sufficient to produce ulceration, particularly if the heel becomes moistened by perspiration, and thus has its cuticle softened. Another apparatus admirably adapted to severe cases of com- pound fracture, and which makes the counter-extension by the upper end of the inside splint pressing on the perineum, is that of the late Dr. Hartshorne, of Philadelphia. Hartshorne's Splint.—This consists of an inside and outside splint, Fig. 149. A side view of Hartshorne's Splint, as applied to the patient, the extension being made at the foot by fastening it to the footboard and turning the screw, whilst the counter-exten- sion is made by a pad on the upper end of the inside splint. The upper end of the outside splint is also represented as padded, but this is merely to protect the edge of the axilla, and has no connection with either the extension or counter-extension. In compound fractures this outside splint may be removed and the wound dressed, without affecting the extension of the limb. (After Nature.) 27 418 PRACTICE OF SURGERY. Fig. 150. which are fastened together at the bottom, where there is a movable footboard which can be shifted up and down by means of a screw. (See Fig. 150, 7.) Extension is made by this screw, acting on the footboard, whilst the counter-extension is made by the padded head of the inside splint in the perineum. (See Fig. 150, 3.) Neither padding nor junk-bags are required, as no lateral pressure is made upon the sides of the limb by the splint, owing to its being kept in position laterally by little pegs, which are inserted into the tenons where they play in the lower mortise. 3. Fracture of the Condyles of the Femur.—When a fracture of the femur oc- curs through the condyles, an injury is pro- duced which involves the knee-joint, and which, therefore, besides the dangers incident to fracture, exposes the patient to all those likely to result from the inflammation of so important an articulation. Symptoms.—The symptoms of this injury are generally quite marked; thus, there is increased width of the joint, with great pain and swelling; crepitus, as a general rule, being readily perceptible. As there is usually some effusion into the joint, the accident, if the patient recovers without amputation, can hardly result in anything but anchylosis. Treatment.—In the treatment of such a case the remedies are to be addressed rather to the prevention of inflammation of a high grade than to the mere injury of the bone; extension and counter-extension not being demanded, nor could they be borne. A long fracture-box, long enough to reach from the foot to above the middle of the thigh (see Fig. 151) should, therefore, be selected, a pil- low placed upon it, and the limb laid on the pillow, when, the sides of the box being brought together, pressure can be made, and the parts kept at rest, whilst leeches, cold Aviewof Hartshorne's Splint for Fracture of the Shaft of the Femur. —1. Upper end of the out- side splint. 2. The inside splint. 3. Its padded end by which counter-extension is made. 4. The movable footboard. 5, 5. Two mov- able tenons to which the footboard is attached. 6,6. Two fixed tenons in which a screw plays so as to ap- proximate 5, 5. 7. The screw which passes through 6, 6 is fastened on 5, 5. (Af- ter Nature.) FRACTURES OF THE PATELLA. 419 cloths, lead-water, &c, are applied to check the rising inflamma- tion. After continuing this treatment for several weeks, or until the inflammatory action has diminished, passive motion should be gently tried with the view of limiting the extent of the anchylosis. Fig. 151. A side view of the Lono Fracture-Box for the Treatment of Injuries of th_e Knee-Joint.—1. Outer side. 2. Inner side. 3. The footboard. 4. Bottom piece. 5,5. Hinges which attach the side pieces to the bottom and enable them to shut against the sides of the footboard, thus making lateral pressure on the limb when placed within the box on a pillow. (After Nature.) It should, however, be commenced very carefully, the knee being raised at first only half an inch or so from its position in the box and set down again; when, in a day or two, it may be flexed a little more. Compound fracture of the condyles of the femur is best treated by means of a fracture-box prepared as for Dr. Ehea Barton's bran dressing, the mode of employing which will be described in con- nection with compound fractures of the leg. SECTION II. FRACTURES OF THE PATELLA. Fracture of the patella resembles greatly fracture of the olecranon in the causes and effects of the fracture, as well as in the indications to be fulfilled in its treatment. Anatomical relations.—The patella is so situated that it is between two forces, one of which possesses great power, its attachment by 420 PRACTICE OF SURGERY. the ligament of the patella to the tuberosity of the tibia holding it firmly below, whilst superiorly it is acted on by the tendon of the quadriceps femoris, a muscle of considerable magnitude. The ten- don of this muscle being continued over and around the patella, unites at its inferior edge with the ligament as it passes towards its insertion into the tibia, the bone being thus made to act the part of a sesamoid bone and facilitate the play of the tendon over the condyles of the femur and the knee-joint. Etiology.—The patella is liable to fracture, not only from external forces, but also from muscular action, the contractions of the quad- riceps femoris muscle becoming, under certain circumstances, so powerful that the tendinous expansion over the face of the bone gives way, and the bone is fairly torn in half, the upper fragment being carried up towards the lower fifth of the shaft of the femur. (See Fig. 155.) Patients.—The class of individuals who suffer from this accident are, therefore, those who, from their calling, are in the habit of making violent muscular contractions of the lower extremities, such as ballet or tight-rope dancers, or circus-riders, in whom it some- times occurs whilst in the act of leaping. This fracture is also sometimes produced by mechanical violence, as when a person falls with his knee upon some sharp substance that cuts through the patella, the force being thus applied directly to the bone. However produced, this fracture, like that of the olecranon, diminishes to some extent the usefulness of the limb, bony union seldom occurring, the fragments, like those of the olecranon, being generally united by a ligamentous band, which, though ultimately very firm, yet destroys more or less of the power of the muscles inserted into the patella by adding to their length. In this, as well as in every fracture in the neighborhood of a joint, the inflammation set up by the fracture, or caused directly by the injury, may also extend itself to the joint, synovitis and par- tial anchylosis sometimes complicating the injury. Symptoms.—When a fracture of the patella occurs, the following train of symptoms supervene: If the patient is in the erect position at the time of the occurrence, especially in those cases in which the bone is broken, by muscular violence, he drops to the ground suddenly, as if he had been shot, and finds himself unable to FRACTURES OF THE PATELLA. 421 rise upon his feet. Soon afterwards a considerable amount of swelling will be observed about the knee, and, as the fracture is generally transverse, an apparent increased length of the patella can be no- ticed. When the fingers are passed along the sides of the fragment, a deficiency in the correct outline of the bone will also be observed, and, if the swelling has not become too great, the fingers can depress the front of the soft parts between the two fragments, and thus show- distinctly the nature of the case. Some modifications of these symptoms will sometimes occur, owing to circumstances; thus, if the fracture is oblique, there will be a difference in the character of the deformity; and, if the tendinous expansion over the bone be not entirely ruptured, the separation between the fragments will not be so complete as if it had happened. Diagnosis.—When there is much swelling, the diagnosis of the fracture may be difficult at first, but generally the mobility of the upper fragment establishes the character of the injury. Prognosis.—The result of a simple fracture of the patella is favor- able, as regards the ability to walk, though there will probably be some loss of power in the extension of the leg, the union in these cases, as before stated, being so generally ligamentous that the pos- sibility of osseous union has been denied. Several cases of osseous union have, however, been met with, and there is in my cabinet a specimen, the history of which is unknown, in which the union is very complete. (C, Fig. 152.) The fact that such union may occur Fig. 152. B A C A view of the condition of the Patella after A Fracture.—A. An oblique com- minuted fracture of the patella. B. A transverse fracture showing the union by ligament- ous matter, and the manner in which it adds to the length of the quadriceps femoris muscle and thus diminishes its power. 1. Intervening ligament between the fragments. 2, 2. The upper and lower fragments. C. Represents a case of osseous union of the patella. After Nature.) 422 PRACTICE OF SURGERY. renders it, therefore, exceedingly important that, in the treatment of these cases, the fragments should be kept accurately adjusted, so as to present the most favorable circumstances for this desirable termination, or, if the surgeon fail in procuring osseous union, that such an apposition of the fragments may at least cause the liga- mentous band between them to be as short as possible. Treatment.—The treatment in fractures of the patella, as in frac- tures of the olecranon, will consist in keeping the limb at rest in the extended position, and in the use of such apparatus as can retain them in position, and is calculated to counteract the power of the muscles which act in separating the fragments. This appa- ratus may consist in any of the following dressings:— The dressing of Dessault for fractured patella is applied as fol- lows: Take a strip of muslin 2J inches wide and long enough to go from the ankle to the groin, and lay it along the front of the limb; then, commencing at the ankle, bind it in position by the ordinary spiral bandage of the lower extremity, covering in the heel lest the swelling which may ensue from the compression of the skin should predispose that point to take on ulcerative action. After covering the heel, continue the turns of the roller regularly up the limb until the knee is reached; when two slits should be cut in the band first laid upon the front of the limb in such a manner as to permit the surgeon's fingers to pass through and draw the upper fragment down. Then, regaining the fragments in apposi- tion, cover in the knee with the ordinary figure of 8 turns so as to bind the upper and lower fragments in nearly accurate juxta- position, and fastening this roller with a pin, take another roller and proceed with the ordinary spiral reversed turns to cover in the thigh, drawing these turns with considerable firmness in order to prevent the contraction of the great muscles which act upon the upper fragment. After fastening the end of this bandage with a pin, the dressing is to be completed by the application of a straight splint on the back of the limb long enough to reach from the tuber ischii to the heel, the entire splint being carefully padded, especially under the heel and knee. The limb may now be elevated upon a single inclined plane (Fig. 153) of sufficient length to flex the femur upon the pelvis and thus diminish still further the power of the muscles upon the front of the thigh. Besides which, this inclined plane, by elevating the limb and draining it of blood, does FRACTURES OF THE PATELLA. 423 Fig. 153. A side view of the simple inclined plane for elevating the lower extremity. (After Nature.) away with the tendency towards the swelling and inflammation which might ensue upon the ap- plication of the roller or the cause producing the injury. Another dressing is that of Boyer for fractures of the ole- cranon, which is equally adapted to fractures of the patella, and is as follows: Having applied the ordinary spiral bandage of the lower- extremity, and carried it up as high as the knee, a long compress of muslin should be folded, and applied in the form of a figure of 8, so as to draw the upper fragment down, after which the fragments should be held in position by another bandage, which, commencing at the knee and covering in the joint by figure of 8 turns, should be car- ried to the groin, a long splint being applied to the back of the limb, precisely as was done in Dessault's dressing. Another dressing, by means of which a considerable amount of power can be obtained, and one which can generally be made upon the spur of the moment, is that of Dr. Dorsey, formerly Pro- fessor of Surgery in the University of Pennsylvania. It consists of a straight splint for the back of the limb, long enough to go from the tuberosity of the ischium to the heel, upon which two strips of bandage are nailed with carpet-tacks, one a little above and the other a little below a point corresponding with the back of the knee-joint. Then the splint being carefully padded and a bandage applied to the limb, from the toes to the groin, place the splint on the back of the limb, and carry the upper strip (1, 1, Fig. 154), as attached to the splint, round the knee so as to tie, on a compress, below the lower fragment, whilst the lower strip (2, 2, Fig. 154) is in like manner to be carried round and tied on a com- press above the upper fragment. These two strips, thus acting on the compresses, will hold the fragments accurately in position, while the splint will keep the limb extended and prevent the contraction of the muscles. After arranging these, bandage the leg fast to the splint by the ordinary spiral bandage of the lower extremities. This dressing is one of very great power, and in some cases will 424 PRACTICE OF SURGERY. Fig. 154. be very well, borne, but in the early stages of the majority of cases its employment would expose the pa- tient to great risk of inflammation and ulceration. There is perhaps only one mode by which the fracture can be kept more thoroughly in position than by this apparatus of Dorsey, and that is the plan of Malgaigne, the French surgeon. This gentleman hooks two little iron clamps into the fragments and ap- proximates them by means of a screw; a very painful method, but one which he says is exceedingly successful, being not unfre- quently followed by bony union. It is, however, a plan which seems objectionable not only from its rude character, but from the liability of the ulceration produced by the hooking of the iron clamps through the skin into the bone to result in erysipelas. The same apparatus which was described as Sir Astley Cooper's apparatus for fracture of the olecranon may also, with very trifling modification, be adapted to fractures of the patella. Its application need not be repeated in this place, having been described under the head of Fracture of the Olecranon. Very good cures have also been accomplished in these cases by the use of strips of adhesive plaster, a dressing which was many years since considered particularly applicable to compound fractures, or to fractures combined with wounds in the region of the knee, as it at the same time served as a dressing to the fracture and as a means of closing the wound. In its application, cut the sticking-plaster into strips about twelve inches long, and about three-quarters of an inch wide, and apply the ordinary spiral bandage of the lower ex- tremity as high as the tubercle of the tibia. Having reached this, whilst an assistant holds the fragments in apposition, let a strip well warmed be applied with considerable firmness around the joint, starting from the outer side of the head of the fibula, passing up over the front of the knee above the upper fragment and down upon the inner side of the joint and of the head of the tibia, to terminate at a point opposite that from which it started. A second A VIEW OF THE MIDDLE PORTION OF THE SPLINT AS- ARRANGED by Dorsey for THE TREATMENT OF FRAC- TURE of the Patella.— 1, 1. The lower strip nailed on to the splint so that it can be carried over a compress which is to be placed above the upper fragment. 2, 2. A similar strip as arranged to pass below the lower frag- ment. (After Nature.) 3315�99557 FRACTURES OF THE PATELLA. 425 strip, having been also well warmed, should then be applied by commencing at the posterior part of the external condyle of the femur, and descending across the front of the limb be tightly drawn beneath the lower fragment so as to keep it in firm juxtaposition with the upper, which is drawn down by the first strip, this second strip being made to ascend on the inner side of the joint along the inner condyle to a point opposite that from which it started. A sufficient number of strips being thus applied, each covering one-half of the preceding strip, until the whole joint is covered, the fragments will be held accurately in position, when the roller should be continued up the limb to the groin, and the dressing completed by means of a splint, or the single inclined plane if it be deemed essential. This dressing may be retained for a week, when it should be taken off and reapplied, the fragments being carefully held in posi- tion by an assistant during the change, and may be continued for five or six weeks, by which time passive motion or flexion of the joint may cautiously be made. In the Pennsylvania Hospital, of Philadelphia, it has been frequently applied to simple fracture with satisfactory results—attention having been recalled to it by Dr. John Neill. Another dressing is by means of the uniting bandage of Gerdy. In this dressing two strips of muslin about two and a half inches wide are prepared by making three slits in one and tearing the end of the other into three tails; then the ordinary spiral bandage being applied to the leg and thigh, but without covering in the knee, the first piece of muslin is to be laid so that the slits will corre- spond with the edge of the lower fragment, when it should be bound upon the leg by the circular turns of a roller applied below the knee. The piece with the tails being then laid upon the front of the thigh should be fastened in like manner above the upper fragment by the spiral turns of a roller, which commences above the knee and extends to the groin. Two compresses being then placed, one below the lower fragment, and one above the upper, the tails should be passed through the slits, and the two fragments be closely approximated. After which the whole limb should be bandaged with a second spiral roller, the object of which is to fasten the strips and retain the uniting bandage in its position. The after-treatment and general directions of this dressing are the same as those stated in connection with the others. 426 PRACTICE OF SURGERY. A neat and convenient apparatus is now made by the cutlers for the after-treatment of these cases. It consists of a piece of padded leather, which buckles round the limb above and below the frag- ments, and the two parts being approximated by means of straps, the fragments are held accurately adjusted. Such^ a dressing is very neat, well suited to the better class of patients, and particu- larly adapted to those persons who are obliged to travel after a fracture of the patella before the bond of union is sufficiently firm to justify the omission of all dressings. SECTION III. FRACTURES OF THE BONES OF THE LEG. The bones of the leg may be broken at any part of their length, the accident being sufficiently common. A fracture high up through the tubercle of the tibia sometimes occurs, and is very troublesome, not only because it is liable to involve the knee-joint, but also because it is apt to be followed by gangrene of the integuments, the latter being due to injury of the branches of the tibial artery. When both bones of the leg are broken, it rarely happens that the fracture occurs at the same point in both; thus, if a fracture of the tibia has occurred at the junction of the middle and lower third of the bone, the fracture of the fibula accompanying it will be apt to happen at the junction of the middle and upper third of the bone, and vice versa. Still it sometimes occurs, as when a person has been run over by a wagon or railroad car, that both bones are broken in the same line. Fractures of the bones of the leg may be transverse or oblique, simple, compound, or comminuted. Displacement.—Various deformities result from these fractures, which differ in accordance with the character of the force produc- ing the injury, and with the point at which the fracture occurs. Perhaps the most common deformity is a disposition in the upper part of the lower fragment to project forwards (see Fig. 155), the gastrocnemius and soleus muscles which are inserted into the os calcis contracting so as to approximate the heel to the back of the thigh, in consequence of which the foot is pulled backward, and the upper end of the lower fragment thrown forward. Shortening, when it exists, is generally due to the action of the extensor mus- FRACTURES OF THE BONES OF THE LEG. 427 cles; it is, however, seldom marked in these fractures, on account of the insertion of the interosseus ligament. ity, it should be remembered, is more marked when the fracture is transverse than when it is oblique; but in an oblique fracture, al- though the deformity is not so great, there is risk of the fragments wounding the ante- rior or posterior tibial artery. Sometimes, when great force has been used, the frag- ments become impacted, or may be driven through the skin so as to cause a compound fracture. There is still another displacement, which must be guarded against in the treat- ment of fracture of both bones of the leg, and that is a displacement in the circumfer- ence of the limb, as shown by a rotation of the foot causing the toes to turn inwards or outwards, though most frequently the latter. In fracture of either the tibia or fibula alone, there is generally little or no displacement, the unbroken bone acting as a splint to support the injured one, so that there can be no shortening of the limb. Treatment.—The means by which the indi- cations which should be fulfilled in fractures of these bones are to be carried out are vari- ous. In hospital practice, and in the army and navy, where the patient can be con- trolled, perhaps the best means of treating them is by the fracture- box (see Fig. 157), but it is a mode of treatment against which patients in the better ranks of life will often rebel. It is also often complained of in consequence of the, pressure of the point of the heel against the bottom of the box, causing pain and ulceration, even when the heel is well supported by a pillow, this point of the foot being usually very intolerant of pressure. The fracture-box is made by cutting a piece of board, a little wider than the limb, of such a length that it will reach from the sole of the foot to the knee; a foot-board should be attached to its inferior extremity at right angles—not obliquely, as is sometimes The angular deform- Fig. 155. A side view of the angu- lar deformity of the tibia, often seen after fractures of the leg, showing the action of the gastrocnemius and soleus muscles. The draw- ing also shows the action of the quadriceps femoris mus- cle in producing a separa- tion of the fragments in a fracture of the patella. (Af- ter Hines.) 428 PRACTICE OF SURGERY. done—as this elevates the heel and consequently does not allow of the accurate reduction of the displacement, the box being then com- pleted by two side pieces which are fastened on to the bottom by hinges. Fig. 156. lil 1 A representation of the Fracture-Box for the treatment of fractures of one or both bones of the leg. (After Nature.) In applying this apparatus two strips of bandage of sufficient length should be laid down transversely to the length of the limb, on which the box is to be placed and a pillow laid in the box. The limb being then laid upon the pillow and a proper degree of extension and counter-extension made by the hands of the surgeon, the foot should be fastened to the footboard by the simple turn of a roller, the sides of the box being closed upon the pillow and then tied so as to make late- ral pressure on the limb. If the inflammatory action of the soft parts Fig. 157. runs high, leeches, cold cloths, or cloths wrung out of lead-water, &c, can conveniently be applied without removing the dressings, though in this case the pillow must be covered with a piece of oiled silk, in order to protect it. This treatment may be continued during the first eight or ten days after the accident, after which it becomes necessary to pay special attention to the situation of the limb with reference to the deformity. Lymph is now beginning to be effused, granulations to form, and organization to take place around the FRACTURES OF THE BONES OF THE LEG. 429 seat of fracture, and it becomes therefore a matter of importance that the union should be accomplished in such a manner as will give the patient a limb that will correspond in shape with that upon the other side of his body, and thus enable him to walk with as much facility after as he did before the accident. Thus, if the patient is bow-legged, the surgeon should not treat the injured limb in such a manner that when united it will be perfectly straight, as this would make the deformity in the other leg apparent and interfere with the patient's gait. A very good rule for telling whether the foot has been brought properly into line, even without examining the limb on the opposite side, is to. notice that the inner side of the ball of the great toe is in a line with the inner side of the head of the tibia. If this is the case, the sur- geon can say with great confidence that the limb will be in its normal line. If in making the dressings at this period a tendency is noticed in the heel to sink down, and in the upper end of the lower frag- ment to project forwards, as in Fig. 155, a pad of cotton, or some similar substance, should be placed under the heel, but beneath the pillow, to prevent it. If the toes have a tendency to fall inward, it may be counteracted by tying a piece of bandage around them, drawing them outwards as much as necessary, and fastening the strip with a pin to the side of the pillow. Although the fracture-box is a good dressing for the treatment of fracture of the leg, when the patient is entirely under the sur- geon's control, as in the instances above alluded to, yet its useful- ness will be found to be very much impaired when it comes to be applied to the limbs of those in the better condition of society.' These individuals, being more or less accustomed to independence of action, often fail to give to the commands of the surgeon that prompt obedience which can be exacted in the wards of a hospital, but have their heads propped up with pillows until they commence to slip down, owing to their being thus placed, as it were, on an inclined plane. As the weight of the fracture-box retains the foot in position, the upper fragment is therefore pushed past the lower and shortening is thus induced. Or, if the pressure of the apparatus proves uncomfortable, and produces pain, the whole will be loosened by a friend, and tied up again in such a manner that its utility is destroyed. For this class of patients, therefore, another mode of 430 PRACTICE OF SURGERY. dressing becomes desirable, and resort may be had to the beautiful apparatus of Salter, of England. Fig. 158. A view of Salter's apparatus for the treatment of fracture of both bones of the leg. The limb being bandaged and a carved or tin splint applied beneath the calf, it should be placed in the sling, which, being attached to a little wheel which runs on the centre bar in the top of the frame, the sling moves with the motion of the patient; the latter being able to move the limb up and down with the motion of his body without deranging the frag- ments. (After Fergusson.) Salter's apparatus consists of a tin splint hollowed out at its inferior extremity, to receive the heel without making pressure upon it. This splint reposes in a sling, attached to wheels which play up and down the centre-piece of an iron cradle, somewhat similar to that sometimes used to prevent the weight of the bed- clothes from pressing upon the toes, and enables the patient to sit up or lie down in bed without displacing the fragments, as there is no point of resistance connected with the foot so as to create shorten- ing. The heel also is not pressed on, and the patient is thus saved a great source of annoyance. The lightness of the bandage which surrounds the limb will usually be well borne by patients in good circumstances, as in the accidents of the better classes of society we have seldom those extensive and terrible injuries to the soft parts which are met with among the laboring classes. A laboring man has his leg broken by being crushed under a gravel bank, whilst the gentleman breaks his by slipping and falling down upon the ice; and it is to such injuries as the latter, that is, injuries un- FRACTURES OF THE BONES OF THE LEG. 431 accompanied by severe contusion or laceration of the soft parts, that Salter's apparatus is particularly applicable. But in the treatment of contused cases, the limb should be sim- ply laid upon a pillow for the first few days and supported by light turns of a roller, the foot being steadied by a band fastened to the pillow. When inflammation has subsided, extension and counter- extension to the requisite degree may be made, the spiral of the lower extremity loosely applied, the tin splint padded and laid upon the back of the limb, and then retained by a bandage, when it may be laid in the sling of Salter's apparatus, the patient being no longer obliged to confine himself to one position. He may therefore move about in bed to a reasonable degree, or even sit up, the sling sliding along on its rollers, and adapting the position of the limb to the motion of the body, so that no danger of displacement is incurred. Salter's apparatus is, therefore, a neat and convenient dressing for such cases, being very useful where expense is not an object, being highly lauded for its comfort by those to whom I have applied it. Where, however, it cannot be obtained, and some sim- pler dressing is desirable, its place may easily be supplied by a ruder contrivance of wood. Another very excellent mode of treatment is by means of the old dressing of Boyer. It is applied as follows: Three strips of bandage are laid down transversely to the course of the limb, precisely as the two strips were laid down in the dressing with the fracture-box. Upon these Fig. 159. should be laid a splint cloth of appropriate dimensions, say half a yard by a yard; on the splint cloth a pillow, and upon the pillow an 18-tailed bandage; by which is meant a bandage of strips formed upon precisely the same principles as the bandage of Scul- tet, but each piece, as it is laid down, being sewed fast to a Ion en- 432 PRACTICE OF SURGERY. tudinal strip, in order to give greater strength to the bandage. A proper degree of extension and counter-extension being made, the 18 tailed bandage should be firmly applied and fastened by a pin. The splints should then be taken of such a length as to reach from the knee to a few inches below the foot, and be rolled in the splint cloth so as to make firm pressure on each side against the pillow, and through that against the limb; after which, the three strips of band- age should be firmly tied to hold it in that position. (Fig. 159.) The dressing is then completed by tying another strip of bandage in a loop about the toes, and fasteuing it so as to prevent inversion or eversion of the foot, and by placing a cradle properly made for the purpose, or two hoops tied crosswise over the limb, to prevent the pressure of the bedclothes. This dressing is preferable to the ordinary fracture-box, because, when the patient slips down in bed, the apparatus which is attached to his leg slips before him, and the upper fragment does not ride past the lower, as was shown to occur sometimes in the case of the fracture-box, which is only pre- ferable, as above detailed, in hospitals, in the army and navy, and under circumstances generally where the patient can be completely controlled. It sometimes happens that the force which produces the fracture drives the fragments into each other, or into the soft parts, so as to wound and irritate the muscles, produce spasm, and not only create shortening, but reproduce it after it has been reduced. Under such circumstances an apparatus will be required by means of which a suitable degree of extension and counter-extension can be kept up, though this is not generally required in injuries of the leg. Such an apparatus is that of Hutchinson. Hutchinson's Splints.—These consist of two splints long enough to go from the knee to some little distance below the foot. Near the bottom of each a mortise is cut, into which a tenon can be inserted for the reception of the counter-extending tape; this tenon being drilled with holes, so that the distance of the splints apart can be regulated by means of pegs of wood inserted into the holes. At the top of each splint four perforations are made at equal distances so as to form the corners of a square. (Fig. 161.) In applying this apparatus, Barton's handkerchief (see Fig. 160) may be employed as a means of making extension. This handkerchief is to be ap- plied as follows: A good soft handkerchief being folded into a cravat, its body should be laid against the point of the heel of the injured limb in such a manner that two-thirds of the handkerchief FRACTURES OF THE BONES OF THE LEG. 433 may be on one side of the heel and one-third on the other, after which the longest side should be carried round across the instep to the opposite side, where it is to take a turn around the other ex- tremity of the handkerchief, which is then carried under the sole Fig. 160. of the foot to be turned around the first turn, and form a knot at the opposite side of the foot from the first; both ends of the hand- kerchief being then carried off perpendicularly from the limb, and extension made by fastening them to the tenon at the foot of the apparatus. The counter-extension is made by means of four tapes, applied two on the inside and two on the outside of the limb, these tapes being laid lengthwise upon the limb, and fastened in position Fig. 161. Hutchinson's Splints.-1 The splints applied to the leg as covered by Scultet's band age, the tapes being fastened by circular turns below the knee, and then tied throu«rb^hP batd.at(ih«rrL;n)d °f ^ SPliDt-2- ^ Splint-3' The *"« "e^a^g by circular turns of a bandage. Previous to the application of this part of the dressing, however, the limb should be covered bv 28 327�412�254�368773662� 434 PRACTICE OF SURGERY. the bandage of Scultet, or some similar means to prevent the swell- in & which would otherwise ensue from the constriction of its ves- sels by the circular turns of the bandage that secures the tapes. The tapes being now passed through the holes in the upper extremity of the splints and securely tied, counter-extension will thus be kept up while extension is made by means of the handkerchief around the foot. As a precautionary measure the splints may be padded to any necessary degree before they are applied, by means of cotton and a bandage in the manner described in connection with fractures of the forearm. After this dressing has been applied for three, four, or five days, it will generally be found that the spasm of the muscles has been overcome, so that there is no longer any occasion to maintain so powerful a degree of extension and counter-extension as is secured by these splints, and if the patient begins to suffer from the pres- sure of the extending and counter-extending bands, the apparatus may now be laid aside. But there is a much graver reason for laying it aside, and that is that the constriction of the limb necessary to secure the counter-extending tapes, interferes with the circulation. The fragments are therefore not as freely supplied with blood as in the other dressings, and this diminution in the quantity of the supply of nutritive material may become so serious as to interfere with the formation of callus, and cause the case to result in non-union, and in the production of that state of affairs which will be described under the head of Pseudarthrosis. So soon, therefore, as the spasm of the muscles is thoroughly over- come, the splints of Hutchinson should be removed, and the limb dressed by the fracture-box, or by the more secure and elegant dressings of Salter, or by that of Boyer. The treatment of a fracture of the leg by any of the means above detailed, requires that the patient should be confined to bed during a period varying from six to eight weeks, or even longer. Circum- stances will however occur which will render it extremely desirable that he should be able to sit up and attend to his business during the treatment, or, as in the case of a soldier, it may become necessary for him to be removed to a considerable distance a few days after the accident. Under such circumstances, resort may be had to some immovable apparatus, such as the starch bandage, or the dressing of Laugier, which is composed of brown paper and glue. FRACTURES OF THE BONES OF THE LEG. 435 The Starch bandage has been repeatedly applied by me with advantage, having used it first as early as 1838,1 upon a lawyer of Philadelphia, to whom it was applied with great benefit, per- mitting him to return to his office duties within two weeks after the occurrence of the injury. This, and some other patients to whom I applied it, were the first cases thus treated in the United States. The starch bandage, though an excellent dressing, should not, however, be resorted to, in the treatment of even simple fractures of the leg, until all active inflammation has subsided; that is to say, not until the third or fourth day of the treatment at the very earliest, and seldom before the tenth. In its application, a washed roller should be placed upon the limb, so as to cover in the foot and leg and ex- tend as high as the knee, leaving the heel and toes exposed so as to enable the surgeon to judge of the state of the circulation in the limb. If this precaution be not observed, serious injury may ensue. The roller thus applied is then to be well smeared on its outer side with ordinary starch, or dextrine if it can be obtained, and a second washed roller applied over the first in the same manner. This roller having also been well coated with starch, two splints of binders'boards, cut. to suit the size of the limb, are to be applied one to the inside and the other to the outside of the leg, they having been previously rendered flexible by being well soaked in boiling water. These splints should be cut so as to cover the sides of the foot, as in Fig. 165, but yet leave the heel and toes exposed. A third roller being then carried round the limb, and well starched to keep the splints in position; a fourth applied over the whole, completes the dressing. The limb should then be laid in an empty fracture-box, the foot made fast to the foot-board, and the whole kept at perfect rest until the starch becomes firm, which it does in the course of two or three days, dextrine harden- ing more readily than starch. Should the patient complain of the above apparatus after it has hardened, or should the condition of the skin of the toes and heel present evidence that the bandage has been too tightly applied, or that it has shrunk, it should be slit down in front with a pair of scissors to relieve the constriction, and another starched bandage applied over the whole to secure it at the proper point, and prevent it from becoming too loose. On the other hand, should shrinking of the muscles, or a diminution of the swelling leave the bandage too loose, as will not unfre- 1 See Phila. Med. Examiner, vol. ii., 1838. 436 PRACTICE OF SURGERY. quently be the case, another well starched bandage may be applied over the whole to make the requisite degree of compression. Another immovable apparatus, which, with the same precautions as the above, may be used in similar cases, is the apparatus of Lau- gier. Having applied the French spiral of the lower extremities as described in connection with the starched bandage, coat it well with common glue; and cutting a number of strips of coarse brown paper of the proper length, apply them regularly up the limb like the bandage of Scultet. This being done, coat them also with glue, and apply another set in the same manner; repeating this operation four times, till the limb is securely supported by a coating of inter- mingled paper and glue, which when dry will make a solid splint and answer the same indications as the starch bandage. Various other dressings have been suggested to enable the patient to leave his bed by the second or third week of his confinement. One is the splint known as the perforated splint, which is made of tin or flexible metal, perforated so as to ren- der it light. This hav- ing been moulded to fit the limb (see Fig. 162), is fastened in place by means of straps and buckles. Two of these splints are required, one (a, Fig. 162) having a continuation along the side of the foot to keep the ankle-joint at rest, and both having orifices corresponding in posi- tion with the malleoli. Before putting them on, the bandage of Scultet should be applied, and wadding interposed at points between the splint and the limb if it chafes anywhere. Another apparatus for fractures of the leg consists of two simi- larly shaped wooden splints, one carved to fit the shape of the foot, and the other extending merely from the knee to the malleolus, View op the Perforated Tin Splint.—a, the inner splint, being a little shorter in the foot, the two fasten- ing together by means of straps, b is the splint for the outside of the left leg. (After Nature.) FRACTURE OF THE FIBULA. 437 which answers the same purpose as the perforated splint, though not so well adapted to warm weather. It should, however, be borne in mind that neither of these splints is intended for the earlier stages of the treatment, but for a later period when a certain amount of consolidation has already taken place, or when the first inflammatory action has been overcome, and callus begun to form. Splints or frames made of wire to fit the leg, as well as the other limbs, have also been recommended by Mr. Mayor, of Lausanne,1 whilst " wove wire" has recently been ad- vised for the same purpose by Dr. Nott, of Mobile. A very admirable splint, although one adapted like the perforated and carved splint rather for the latter than for the early stages of the treat- ment, is made of the ordinary felt from the hat-makers. A sheet of this article may be cut into a shape approximating that of the limb, and having been soaked in boiling water till rendered perfectly flexible, and cooled sufficiently to avoid vesicat- ing the cuticle, applied to the limb, carefully moulded to suit all inequalities, and held in position by means of a roller. After having been allowed to harden, it may be taken off, coated three or four times with copal varnish, which will give it a firmness almost equal to that of the carved wooden splint, and then being carefully padded with cotton wad- ding, may be reapplied. § 1.—FRACTURE OF THE FIBULA. The Fibula, like the Tibia, may be broken at any point of its length. The symptoms of this fracture in the upper part of the bone are so readily recognizable, and the treatment is so similar to that laid 1 Bandages et Appareils, par Mathias Mayer. Paris, 1838. 438 PRACTICE OF SURGERY. down in connection with fracture of both bones, that further refer- ence may be omitted. But a fracture of this bone which deserves attention from the fact that it demands a special treatment, and presents a train of symptoms of a peculiar character, is that seated in the lower fifth of the bone, or within two inches of the external malleolus. Functions of the Malleoli.—The chief resistance to a lateral dislo- cation of the ankle-joint during flexion and extension of the foot is the two malleoli, and the external and internal lateral ligaments of the ankle which are attached to them. It will, therefore, be perceived that if, from any cause, there is a solution of conti- nuity in the fibres of the fibula, the functions of the external malleolus will be destroyed, and nothing can prevent a violent eversion, or even" dislocation outwards of the foot, and the pro- duction of such a strain upon the internal lateral ligament as may rupture it entire, or break at least a part of it. Or the force thus brought to play through the ligaments upon the bone may rupture the fibres of the latter, and split off the internal malleolus from the tibia, so that both malleoli may be simultaneously fractured, a con- dition of which there are numerous specimens. It will be easily conceived that the inflammation accompanying such an injury, attended as it very frequently is by laceration of the capsular ligament and of the synovial membrane lining the joint, may result in effusion into the articular cavity, and thus cre- ate more or less perfect anchylosis, thus interfering with the patient's motions, and producing a well-marked and inconvenient deformity. Etiology.—The causes exciting this injury are often apparently slight; thus, a patient walking hastily, treads upon a stone, or upon uneven ground, and turns his foot, or falls from a moderate height upon an irregular surface, turning the foot and bringing such a force to bear upon the external malleolus as produces the fracture. Symptoms.—When the fracture occurs, great pain is experienced in the articulation, particularly when the foot is flexed or extended, but crepitation cannot readily be perceived in the majority of cases, because the firm character of the ligaments which bind the fibula to the tibia prevents that ready play of the fragments upon each other which would be likely to produce it. That a fracture exists, however, may, in the majority of instances, be ascertained by a simple manipulation; thus, pass the fingers carefully along the line of the fibula on the outside of the limb—in most patients it can readily be traced—and when the seat of fracture is reached, not only will FRACTURE OF THE FIBULA. 439 the patient complain of pain, but the bone maybe felt to give way under the finger. Diagnosis.—The diagnosis, however, is sometimes a point of con- siderable difficulty, and requires patience and attention in order to prevent mistakes. A surgeon, for example, may be called to attend a patient who has stepped suddenly off a curbstone, and struck the sole of the foot upon some inequality in the ground, as a pebble or some similar substance, and find him unable to walk, and complaining of a great deal of pain in the joint, which is increased by flexion and ex- tension of the foot. The ankle being also much swollen, especially laterally and anteriorly, the injury may readily be mistaken for a sprain or for a rupture of some of the fibres of the internal or external lateral ligaments; but knowing the probability under the circumstances of a fracture of the lower fifth of the fibula, he at once proceeds to a more minute examination with special reference to this injury, and finds that the function of the external malleolus is destroyed, that the foot can readily be made to fall preter- naturally outward, and then passing his fingers carefully along the line of the fibula as above directed, feels the bones give way, and thus recognizes the existence of the fracture. There is, however, in some cases, considerable and characteristic deformity; the upper end of the lower fragment being thrown into the interosseous space, leaving, as a general rule, the lower end of the upper fragment very nearly in position. If this deformity is not produced by the force which caused the fracture, it will often occur a short time afterwards as the result of the contraction of the peronei muscles, whose tendons pass immediately behind the exter- nal malleolus. As a consequence of these changes, the foot falls outwards, or may even be partially dislocated laterally, producing changes in the appearance of the limb which are quite characteristic. Prognosis.—The prognosis will generally be favorable if the sur- geon recognizes the injury and treats it properly. Treatment.—In the treatment the first step is to guard against inflammatory action. The limb should therefore be laid on a pillow in a fracture-box and leeches freely applied; cloths wrung out of warm water, or the cold water dressing if preferred, lead-water, and other antiphlogistic measures being resorted to; and it is not until the third or fourth day, when inflammatory action has much abated that the surgeon should proceed to set the fracture. This may be done simply by coaptation, and turning the toes inward, more so 440 PRACTICE OF SURGERY. indeed, than in their normal position, they being then held by means'of a roller attached to the end of the box. After four or four and a half weeks the limb may then be taken out of the box, and some supporting splint applied, as the carved splint, the perforated, or the felt splint (Fig. 163), the patient being allowed to sit up or to walk about his room with a crutch. In about five weeks passive motion should be commenced by the surgeon, to guard against anchylosis, and the limb be gradually brought into use. It will often, however, be seven weeks before a patient can walk upon it without the use of a cane. There is, moreover, a class of fractures of the fibula at this point which are not so simple as those above laid down; in which, owing to the fact that greater force has been employed in the creation of the injury, the deviation of the foot outwards is more marked, and in which, therefore, a more decided force is necessary to draw the foot inwards to its proper line and keep it in position. It is in such cases that the dressing known as Dupuytren's splint for fractures of the lower part of the fibula is particularly applicable. This apparatus consists of a long wedge- shaped pad, Fig. 164, long enough to go from the knee to the internal malleolus, and of a splint long enough to go from the knee to some three or four inches below the foot. The pad being applied with its thick end downwards on the inner side of the limb, the splint is to be laid upon the pad, so that, by means of this apparatus, and of the turns of a roller, the foot may be drawn much more powerfully inwards than with the fracture-box, as above described; the thick end of the pad acting as a fulcrum, while the roller around the foot supplies the power. In applying this roller, the rule is precisely the reverse of that ordinarily obeyed in applying a roller to the lower extremities. Instead of beginning below and going upwards, this roller begins above and comes downward. The initial extremity of it is there- fore to be laid upon the limb just below the knee, and two or three circular turns made to fix it; then, with spiral turns—reverses being seldom desirable or necessary—the bandage should be made to descend towards the foot with moderately firm turns. When the seat of fracture is reached, it should be left uncovered, so as not to cause the fragments to encroach upon the interosseous space, and thus counteract the very purpose for which the apparatus was intended, and when the foot is reached the turns of the bandage should be more firmly applied, in order to draw it forcibly in- FRACTURES OF THE TARSUS. 441 wards. By means of this dressing, the tendency of the peronei muscles to draw the foot outwards is completely overcome. Still, there are objections to this dressing of Dupuytren. The firm pressure made upon the internal malleolus is not well borne, ulceration and sloughing may result if it be too long persevered in, and the patient, moreover, generally complains so much of it, that it is often necessary to take it off, rub the parts with liniment and reapply it, or abandon it altogether within twenty-four hours after Fig. 164. A side of Dupuytren's Pad and Splint for the treatment of fracture of the lower fifth of the fibula as applied to the right limb. (After Nature.) its first application. Fortunately, however, even twenty-four hours' use of the apparatus is generally sufficient to overcome the great tendency to eversion of the foot for which it was required, and the dressing, with the fracture-box given above, will afterwards be sufficient. SECTION IV. FRACTURES OF THE TARSUS. The bones of the tarsus are sometimes the seat of fracture, and any of them may be broken. Generally, however, the force produc- ing the injury is so great as to create extensive laceration of the soft parts, and the fracture is therefore usually a compound one. Still, simple fractures of the bones of the tarsus sometimes occur: thus the Astragalus is occasionally broken by falls upon the foot, the force being transmitted from the os calcis to it, and meeting with the resistance offered by the articulating surface of the tibia, it gives way, thus increasing the apparent width of the joint, and lacerating the articular cartilage and the synovial membrane. The results of such an injury are apt to be synovitis, effusion of lymph, and par- tial or complete anchylosis. 442 PRACTICE OF SURGERY. The injury can generally be recognized by the tendency to dis- placement when the foot is flexed or extended, and but little can be done towards repairing the mischief by setting the fragments. The treatment will, therefore, rather consist in the employment of leeches and antiphlogistic measures to combat the inflammation, than in the means calculated to keep the fragments in position. Fracture of the Os Calcis.—The os calcis is occasionally the seat of fracture, generally the result of falls in which the feet of the patient strike the ground. The most frequent point at which the fracture occurs is through the posterior third of the bone, at some point intermediate between the articulation with the astragalus and the insertion of the tendo-Achillis. When such a fracture takes place the deformity which ensues is marked and easily recognizable, the contraction of the gastrocnemius and soleus muscles acting through the tendo-Achillis inserted into the fragment, causing it to be drawn up to a position posterior to the articulation of the tibia with the astragalus. Symptoms.—The symptoms will be pain, swelling, and all the ordinary symptoms of fracture elsewhere; besides which there will be loss of motion in the foot, destruction of the natural prominence of the tendo-Achillis, and the deformity consequent upon the eleva- tion of the fragment which has been described. Treatment—In the treatment it will be necessary to extend the foot upon the leg as much as possible, and to apply force in such a manner as to overcome the resistance of the gastrocnemius and soleus muscles, so as to bring the fragment down into position. The dressings by which these indications can be carried out are varied; perhaps the best, however, is that suggested by Boyer. A Fig. 165. A side view of Boyer's Dressing for Fracture of the Os Calcis, the splint on the top of the foot and leg keeping the foot extended, and thus approximating the body of the os calcis to the fragment which is drawn up by the action of the muscles of the calf. (After Nature.) wad of lint, charpie, or raw cotton, being laid over the toes to pro- tect them from the pressure, a strip of broad bandage or of muslin is carried from the instep down over the toes, up along the sole of the foot and back of the leg, and retained in position by an assistant. FRACTURES OF THE TARSUS. 443 The upper fragment of the bone being then drawn down and held in. position as well as possible, two or three circular turns should be made around the ankle with a view of fixing the bandage, which is then to be carried over the front of the instep to the toes, and made to ascend the foot by the ordinary spiral turns. When the heel is reached a number of figure of 8 turns should be made to retain the fragment in position, and as soon as it is sufficiently secure the roller may ascend the leg as in the ordinary spiral reversed bandage of the lower extremity. This latter part of the bandage not only serves to fix more securely the muslin strip which was car- ried down over the toes, but by compressing the muscles on the back of the leg diminishes the probability of their contracting in such a manner as to reproduce the displacement of the upper fragment. The dressing is completed by placing a straight splint well padded along the front of the limb, and retaining it in place by means of a roller so as to keep the foot firmly in the extended position in which it was placed. (Fig. 165.) It will be observed in this connection that the principles carried out in the treatment above described, are precisely the same as those laid down in connection with fractures of the olecranon process of the ulna and fractures of the patella. In both these cases, as well as in fracture of the calcis, the figure of 8 turns, or some modifica: tion of them, are required to draw the fragments down into posi- tion; in all, compression is required to counteract the action of those muscles whose contraction would produce separation of the fragments and reproduction of the deformity, and in all the use of a splint or some substitute is necessary to give-greater firmness to the dressings. After this dressing has remained upon the limb for two or three days, it should be removed, and the fragments carefully held in position while the limb is rubbed with soap liniment to obviate any evil effects from compression or from obstruction of the capillaries, after which the whole dressing may be reapplied as before. After six weeks this apparatus may be laid aside, and a simple and lighter dressing substituted, which may consist in a slipper such as that used for a side-saddle, or an ordinary slipper cut down so as to resemble it (see Fig. 169), which being put upon the toes, and a piece of bandage fastened to it and brought up over the heel, the band should be attached to a handkerchief made fast around the calf so as to keep the foot in position. In a week or two more, passive motion 444 PRACTICE OF SURGERY. Fig. 166. may be practised, and the limb cautiously and gradually brought into use. Fractures of the other bones of the tarsus or of the metatarsus and phalanges sometimes occur; and are generally due to some great violence of a crushing character, as the passage of a wagon-wheel or railroad car. In consequence of the character of the causes these fractures are, there- fore, most generally of the compound class: tendons being torn and lacer- ated, ligaments ruptured, inflammation set up, and the patient fortunate should union occur with anchylosis. Besides which it should not be overlooked that the injury thus done to these bones often results in necrosis or caries, which gives trouble for many months, and not unfrequently necessitates amputation. All that can be done, therefore, in such cases, is to coaptate the parts as accu- rately as possible, to put the limb in a fracture box, and to combat inflamma- tory action by the use of the cold water dressing. There is one point, however, in con- nection with fractures of the phalanges of the foot which demands attention. It will be seen by reference to the sub- ject of the treatment of fractures of the phalanges of the superior extremities, that it was recommended in that place to endeavor, when anchylosis between the phalanges seemed inevitable, to cause it to occur in a flexed position, so as to obtain the greatest amount of usefulness that circumstances would permit. Now the rule to be laid down with regard to the phalanges of the foot is precisely the reverse. Should anchylosis occur in this case in the flexed position, the prominent knuckle presented by the bent phalanx would soon, from the pressure of the boot or shoe when the patient began to walk about, become the seat of a painful corn; or ulceration would occur, and the toe become such a source of suffering and annoyance that more than one case has occurred in which the patient has submitted to amputation rather than endure A view of the Apparatus applica- ble to the treatment of Fracture of the Os Calcis, as well as to Rupture of the Fibres of the Gastrocnemius Muscle. (After Miller.) COMPOUND FRACTURES. 445 it any longer. To avoid this, the rule laid down in the case of fractures of the phalanges of the foot is, to endeavor to induce anchylosis in the extended position, by which all such inconve- niences are avoided. SECTION V. COMPOUND FRACTURES. A compound fracture is one in which there is a wound commu- nicating with the ends of the fractured bones. This wound may be caused either by the force which originally produced the fracture, or by the sharp ends of the fragments themselves. The presence of the wound alone distinguishes it from simple fracture, and any bone which may be the point of simple, may therefore become the seat of a compound one. Thus, a pa- tient may fall from a height and break Fig-167. his thigh; whilst the same force which produced the fracture may drive the sharp ends of the fragments through the skin, so as to cause them to protrude externally; a compound fracture being thus created. In such a case, in ad- dition to the ordinary dangers of the fracture we must note those resulting from the wound of the soft parts, from the probable injury to great blood- vessels and nerves, and from the fact that the contact of atmospheric air with the fractured bone produces certain changes highly unfavorable to speedy union. These various inconveniences and dangers are to be combated upon those general principles which have been heretofore laid down. To prevent the injurious effects of the contact of atmospheric air with the cavity of the wound, the parts should be closed as Speedily as possible. If View of a Compound and Commi the muscles have spasmodically con- ^^^ture oftheLeg. (After 446 PRACTICE OF SURGERY. tracted around the protruded fragments, the patient may be ether- ized, in order that the muscular relaxation thus induced may per- mit the fragments to be restored to their place. If this is not suffi- cient, the orifice through which the bone has protruded should then be judiciously enlarged by the surgeon; and if that fiiils to secure the desired object, the ends of the fragments may be sawed off, an operation from which the surgeon should not shrink, as nature will perform the same process, though more slowly, and with more danger to the patient, by exfoliation, if the parts are let alone. Having reduced the fracture, and coaptated the fragments as well as possible, the entrance of the atmosphere may be prevented by means of the artificial scab of Sir Astley Cooper. This is sim- ply a piece of lint well soaked in the albumen of an egg, and laid over the wound; it dries speedily, and effectually excludes the atmosphere. An admirable dressing for compound fractures, especially of the leg, is the bran dressing of Dr. J. Rhea Barton, of Philadelphia. This excellent plan of treatment consists of a fracture box with fixed sides, at the superior extremity of which a piece of bandage is fast- ened with tacks to prevent the bran from escaping; a little bran being placed in the box so as to form a bed for the limb, which is laid upon it, and the fracture carefully coaptated, after which bran is poured into the box so as to cover the limb completely. No other dressing is required. The discharges from the wound are absorbed by the bran, and can be removed from day to day, the soiled bran being1 replaced with fresh. This dressing is very com- fortable and easily obtained, and at the same time serves to ex- clude the atmosphere. It will be found very useful in hospitals, and especially where there is a tendency towards the production of erysipelas. SECTION VI. PSEUDARTHROSIS, OR UNUNITED FRACTURE. When a fracture fails to unite, a condition results which is desig- nated as pseudarthrosis, or false-joint, but which is better indicated by the appellation of ununited fracture. Ununited fracture is the condition of parts found when the PSEUDARTHROSIS, OR UNUNITED FRACTURE. 447 natural process fails to accomplish union between the extremities of a broken bone. Etiology—-The causes of this condition may be classified as con- stitutional and local. Among the constitutional causes will be ob- served certain depraved conditions of the system, such as that found in scorbutus, in purpura, in certain low forms of fever, preg- nancy, secondary syphilis, &c. The local causes are varied. Thus, it may result from improper treatment on the part of the surgeon, who, by too frequent dressings, or by the use of such means as do not keep the fragments at rest, may cause or allow such a degree of motion in the part as will break up the newly-formed vessels of the effused lymph, destroy the organizing granulations, and finally prevent the formation of callus. Or, the pressure of a band- age or a splint may be made in such a manner as to interrupt the circulation of the limb, and cut off the supply of blood from the fragments. Another cause may be the introduction of a fibre of muscle or tendon between the ends of the bone, these acting, in such situations, as foreign matter. Or, it may be caused by the manner in which the extremities of the fragments present towards each other; as when an external periosteal surface is presented to the internal periosteum, or two external periosteal surfaces are presented to each other. It will be understood, therefore, that the condition called false-joint, is simply that condition in which, from want of action, or from over-action, the lymph effused for the repair of a fracture is not sufficiently organized to result in osseous union. Condition of the part.—Under these circumstances, the ends of the bones will be rounded off and covered by a dense fibrous or osseous strata, which is sometimes polished upon its surface, so as to re- semble the articular cartilage of a true joint, although, in fact, no true cartilage or true synovial membrane exists. At the same time, from the irritation caused by the rubbing together of the fragments of bone, a quantity of watery lymph is sometimes effused, which, being changed by the absorption of its more liquid portions, finally simulates somewhat the synovia of a true joint. The inflammatory action set up in the surrounding tissues, moreover, not unfrequently develops an amount of thickening in the neighboring cellular sub- stance which causes it to resemble a capsular ligament, and a condi- tion of parts is thus created which is analogous to the appearances of a joint. At other times the bones- are simply united by liga- 448 PRACTICE OF SURGERY. ment, or changed in their shape, and without any appearance of fibrous tissue. (Fig. 168.) Treatment.—In accordance with the various views taken by dif- ferent surgeons of the pathology of the complaint, different plans Fig. 168. A VIEW OF THE DIFFERENT CONDITIONS OF THE BONE IN UNUNITED FRACTURE.—1. Ununited fracture of the tibia, with increased thickness of the fibula, the ends of the frac- tured bones being coated with a compact layer and surrounded by some irregular callus. 2. Ununited fracture of the ulna, showing the ligamentous union between the ends of the fracture. 3. Ununited fracture of the radius, showing the great enlargement of one frag- ment and the wasting of the other. (After Hines.) of treatment have been proposed, all having for their object the creation of such an amount of inflammatory action as would result in the effusion of lymph, in its organization, and in the final development of osseous matter. Thus where, from any circum- stance, compact matter has been presented to compact matter, and false-joint has resulted from such a relation of parts, it has been recommended to cut down upon the seat of fracture, saw off the ends of the bone, bring the two fresh surfaces into contact, and then treat the case as one of compound fracture. The same prac- tice has also been recommended in cases where ligamentous union has occurred, surgeons having cut down upon the ends of the bone, excised the new ligamentous matter, brought the fresh surr faces together, and then treated the case as one of compound fracture. Where a certain amount of callus has been thrown out, but not enough to produce complete union, they have also sometimes tried PSEUDARTHROSIS, OR UNUNITED FRACTURE. 449 counter-irritants, near the seat of the injury, as blistering the limb, forming issues, &c, as was suggested by the late Dr. Hartshorne, of Philadelphia, with a view of stimulating the parts into completing the action they had begun. Yet another plan was that originally suggested and practised successfully, by Dr. Physick, of passing a seton between the ends of the bone, and retaining it there as long as was necessary to develop such an amount of inflammatory action as should result in the formation of callus. Another method is that of Dieffenbach, who drilled holes in the extremity of the bones, and, inserting little pegs of ivory, kept them there until such an amount of inflammatory action was developed as resulted in union. Dr. Brainard, of Chicago, has also proposed to drill a "number of holes in the end of the bone with an awl, with the same view. But in order to make use of any of these modes of treatment, it becomes necessary that the patient should for a long time retain the recum- bent position; whilst he is exposed to the risks of the creation of a compound fracture, in which suppuration may take place, and where the pus travelling up and down the limb in the intermuscu- lar cellular substance, will establish a drain upon his vital energies, which may cost him his life. Or, if these dangers are escaped, ery- sipelas may be set up, and he will be exposed to all its evils. It has also happened more than once, that, after submitting to one of these painful operations and perilling his life, he has subsequently" been obliged to submit to amputation. With a view of avoiding these dangers, I some time since called the attention of the profession1 to an apparatus, consisting of an artificial limb (Figs. 169,170), which formed a complete casing for the affected member, and by means of which union was hastened, and a tolerable amount of usefulness at once obtained in any limb affected with false-joint. These limbs, to act well, should be varied in their length and circumference, so as to fit accurately the part on which they are to be applied, the patient being carefully measured, whilst a mode- rate degree of extension and counter-extension is kept up in order that any subsequent shortening during the use of the apparatus may be guarded against. In ununited fracture of the femur, the chief point of support in these limbs will be the conical shaped piece which surrounds the 1 Am. Journ. Med. Sci., vol. xxix.,N. S., p. 102, Jan. 1855. 29 450 PRACTICE OF SURGERY. thigh, and which also makes pressure at the seat of the false-joint, the weight of the body being also sustained by the belt which sur- rounds the pelvis and is united to the thin bars of steel which go down under the foot. (Fig. 169.) In order to protect the knee, the Fig. 169. Fig. 170. Fig. 169.—A view of Smith's Apparatus for the treatment of ununited fracture in the femur of the right leg—the inside piece terminating in a little padded head, I, which rests against the perineum. (After Nature.) Fig. 170.—A side view of the Apparatus for the treatment of ununited fracture in the bones of the leg. (After Nature.) splint is guarded by a padded plate on the side of the joint, whilst a padded band surrounding the head of the tibia tends to distribute the weight of the patient, and strengthen the supports. The shoe should be made to lace all the way down the front, so as to facili- tate the introduction of the foot. With such an apparatus, a patient even with an ununited fracture will be enabled to walk—after a little practice—almost as well as with a sound limb, and much bet- ter than he could do with an artificial one. When the ununited fracture is in the leg, there is no occasion for PSEUDARTHROSIS, OR UNUNITED FRACTURE. 451 the pelvic band, the apparatus being made like Fig. 170, the sup- port in this case being chiefly furnished by the conical-shaped leg piece which buckles around the calf and the seat of fracture, the band around the middle of the thigh being merely intended to add to the steadiness of the, patient in walking. In the treatment of false joint in the Humerus, the same prin- ciples are to be carried out by surrounding the arm at the seat of the disorder, as well as the forearm—with a similarly shaped splint, the two being united by means of a joint at the elbow. By the use of these limbs, a patient laboring under false joint in the femur can walk about immediately after their application, if not as well as in a state of perfect health, yet at least better than he could do with an artificial limb after amputation. In the paper just alluded to it was also shown, that by the motion and friction created in the bones through the use of this apparatus, such inflam- mation had been developed in several cases, as caused a large amount of ensheathing callus to be thrown out, several obsti- nate cases having thus eventuated in perfect cures. Since this pe- riod, various others embracing all the bones of the extremities have been similarly benefited. An additional advantage of this plan is to be found in the fact that if it fail in accomplishing union in any case, it will yet be less dangerous than other modes which are not more certain, and also expose the patient to the risk of amputation. Not the least recommendation of these limbs is that by means of them the patient can obtain plenty of fresh air and exercise, these adjuvants being most important in the treatment of such cases. In order to exhibit the results of such cases as have been al- ready treated, I add the following list, as published in the Journal.1 Case 1. Under the care of Dr. Wm. Waters, of Fredericktown, Md. False joint in both bones of the leg, of eighteen months' standing, cured in five months. Case 2. False joint of both bones of the leg, of four months' standing, cured in nineteen weeks, by Dr. Waters, of Maryland. Case 3. False joint in the femur, of five months' standing, cured in seventeen weeks, under my own care. Case 4. False joint in the femur, of six months' standing, cured in nine weeks, under my own, care. 1 For a full account of these cases, see Am. Journ. Med. Sciences, vol. xxix. N. S., p. 117. Also, vol. xxi., N. S., 1851, p. 108. 452 PRACTICE OF SURGERY. Case 5. False joint in the femur, of twenty weeks' standing, cured in six weeks, under the care of Dr. R. J. Levis, of Philadelphia. Case 6. False joint in the humerus, of six months' standing, under treatment, and at present relieved, by Dr. G. Dock, of Harris- burg. Case 7. False joint in the humerus, under the care of Dr. C. W. Ashby, of Alexandria. In addition to these, I had previously noted a case of false joint in the femur of a man of upwards of seventy years of age, which failed to unite, but which was made so firm by the apparatus that the patient walked only with the assistance of a cane. One case of false joint in the leg also failed, but though the bones did not unite, the patient is yet able to walk; and I have now from Mr. Rohrer, the cutler, reference to two other cases in the leg, cured by surgeons at a distance, who have failed to respond to my communication respecting them. We have, therefore, a total as follows:— Cases. Cured. Believed. Failed, but able to walk. False joint in the femur 4 3 1 " " " leg bones 8 7 1 " " " humerus 2 2 Total . 14 10 2 2 Experience, up to this date,1 has only tended to show me the per- fect success in numerous instances in all sections of the United States, of this plan of treatment, and the impropriety of amputating limbs for a condition which can under most circumstances be thus remedied sufficiently to give the patient the use of his limb even if union does not ensue upon the application of the apparatus. CHAPTER VI. DISEASES OF THE CONTINUITY OF THE BONES. The important influence of the periosteum in the repair of frac- tures having been already alluded to, it is unnecessary now to recapitulate what was then said, in order to show that the bone chiefly owes its vitality to its connection with this membrane. • July, 1856. PERIOSTITIS. 453 When the periosteum takes on diseased action, the result will be exhibited not only in the change of structure noticeable in the membrane itself, but also in that portion of the bone which it nourishes, whilst, as this membrane is a fibrous tissue, we can trace in its changes the general character of diseased action noted in the fibrous structures elsewhere. SECTION I. PERIOSTITIS. Etiology.—Inflammation of the periosteum, or periostitis, is a suf- ficiently common disorder, which is due to the ordinary causes of inflammation, and is in its earliest stages very difficult to recognize. These causes may be local mechanical injuries, as blows and wounds, or the extension of ulcers, or it may result from constitutional dis- ease, as rheumatism and gout, syphilis, tubercles, cancer, &c. Seat.—Periostitis may occur in all the bones of the body, but is most common in such as are superficial, and therefore more di- rectly exposed to local causes; such as the tibia, clavicle, femur, sternum, and cranial bones. Result.—Periostitis, like all other inflammations, may terminate by resolution, or by effusions of lymph or pus, or in ulceration, mortification, or sloughing. It may also, like other inflammations, be either acute or chronic in its character. When examined at different periods, an inflamed periosteum will be found to offer at first all the usual appearances consequent on inflammatory action elsewhere, as increased vascularity or redness, and exquisite sensi- bility, whilst subsequently we can note such results of inflamma- tion as create effusion and organization of lymph, or the formation of pus with ulceration and other degenerations of tissue. Symptoms.—The existence of acute periostitis is first shown by pain in the course of the bone, this being generally increased on pressure. In its earlier stages, it is, however, difficult to distin- guish periostitis from inflammation of the bone itself. After the development of pain, the part soon becomes swollen and hot, the swelling being circumscribed, firm, and resisting, seldom attainino- any size, but softening slowly and suppurating, though it gives little evidence of fluctuation. As suppuration is developed, the pain 454 PRACTICE OF SURGERY. becomes more severe, owing to the effusions being circumscribed, and stretching the inflamed and closely-adherent membrane. Fever is, therefore, often present at this period, and accompanied with great restlessness, insomnia, and the other signs of sympathetic excitement. In chronic periostitis, the progress of the disorder is less rapid, the tendency of the inflammation being rather to an effusion and organization of lymph than to suppuration. Conse- quently, chronic periostitis more frequently results in thickening of* the membrane and hypertrophy of the bone, than in abscesses. Prognosis.—The result .of periostitis is usually favorable if promptly and properly treated, but otherwise, it is very apt to be followed by such a diseased action in the proper bony tissue as may result in ostitis, caries, or necrosis. Treatment.—The indications for the treatment of periostitis are the same as those required in other inflammations, the means being varied occasionally, in accordance with the peculiar action of the cause which produces it. In the acute variety, the ordinary local antiphlogistic measures will usually be demanded, as leeches, cups, the warm water dressing, with anodyne frictions, such as those made with aconite and lard in the form of ointment, or with the saturated tincture of aconite, belladonna, or opium. At the same time, free purging, combined with the moderate use of mercurials, will prove useful. When there is reason to think that pus has formed beneath the periosteum, this membrane should be incised by cutting directly down to the bone, so as to give free vent to the matter, and prevent its accumulation from elevating the membrane from the bone, and thus impairing the vitality of the latter. In these cases, the pain will also be promptly relieved by the incision permitting the expansion of the previously confined liquid effusions, and so great has been this relief, that Yelpeau, Malgaigne, and others have advised that it should be made in all cases of acute perios- titis at an early period, or before there is evidence of suppuration. After the evacuation of the matter which has formed beneath the periosteum, the wound should be treated on the general princi- ples already detailed in connection with abscesses. In chronic periostitis, there is a marked tendency to an effusion of lymph, which, becoming organized, soon results in a permanent thickening of the part, which is designated as a node. It is also apt to result in hypertrophy of the bone, and thus serves as one of the exciting causes of certain bony tumors, as exostoses, osteophytes, OSTITIS. 455 &c. In the early stages of chronic periostitis, the application of repeated blisters is sometimes exceedingly useful, anodynes being also required for the relief of pain. But, as the chief source of the trouble is the effusion of lymph, nothing serves so good a purpose as the use of mercurials both internally and externally, pushing them far enough to induce moderate ptyalism. This treatment, by destroying the plasticity of the effusion, will often check the pro- gress of the disorder, and prevent the development of bony tumors, by bringing about a more healthy condition. The treatment of chronic periostitis, when the result of syphilitic disease, will be again alluded to in connection with syphilis. SECTION II. OSTITIS. Ostitis, or inflammation of the proper structure of the bone, is a disorder which is generally found in the young or middle-aged, and in the long bones, especially the tibia. At its commencement it is difficult to recognize ostitis as a distinct disorder, and as it sometimes results in ulceration, it has not unfrequently been alluded to as identical with caries. But every inflammation of a bone does not result in ulceration, and there are therefore certain changes which can only be justly regarded as the effects of the inflammatory pro- cess as modified by the bony structures. Thus, inflammation of a bone by creating increased vascularity, may result in a deposit of osseous matter exterior to the true compact layer of the bone, so as to create spiculae and great deformity as well as loss of motion in a joint (Fig. 171), or in hypertrophy of either its compact or cancel- lated tissue or both, rendering them more dilated, and expanding the lamellae of the compact as well as the cancellated tissue, so as to pro- duce a marked augmentation, either in a part or in the entire volume of the bone. (Fig. 172.) Or suppuration and a true abscess of the cancellated tissue may ensue (Fig. 173), and be followed by the ordinary results of abscesses elsewhere; but as the tissue which becomes distended under the influence of an abscess in a bone, is hard and unyielding, the sides of the cavity do not collapse when the pus is evacuated, as was the case in abscess of the soft tissues. In examining by section, a bone which has been acutely inflamed, 456 PRACTICE OF SURGERY. there will generally be seen a certain amount of bloody serum 1 its cancellated tissue with a diminution of its natural hardness, th Fig. 171. Fi8-172- Fig'173- Fig. 171.—Chronic Ostitis, marked changes in the exterior of the tibia and fibula. (After Liston.) Fig. 172.—A view of the ordinary enlargement of both the compact and cancellated Tissue of a Tibia as the result of ostitis. (After Liston.) Fig. 173.—A representation of the condition of the Head of the Tibia after the forma- tion of a chronic abscess, the bone being much thickened as well as enlarged around the cavity. (After Miller.) structure being soft and somewhat pulpy, whilst after the develop- ment of an abscess, a circumscribed cavity surrounded by increased vascularity will often be found. Etiology.—The causes of ostitis may be the extension of inflam- mation from the periosteum, or the direct application of irritants, as blows, caustics, &c, or it may ensue upon the deposition of tuber- culous or carcinomatous matter, which passes through the stages of these deposits elsewhere, thus inducing inflammation of the bony tissue in the progress of the deposit towards the surface. Tertiary syphilis, by developing an internal periostitis, is not unfrequently a prominent cause of ostitis. Symptoms.—At the commencement of ostitis, the patient may OSTITIS. 457 Fig. 174. complain of deep-seated and indescribable pain, which is increased by jars or violent movements of the bone; this pain being often permanent for many days or weeks without its source being recog-- nized. Then the pain becomes marked on pressure; the part swells; the integuments become livid, hot, and swollen, and there is an evident extension of the inflammatory action from the cancellated tissue of the bone to the periosteum and the other tissues around it, the case being subsequently characterized by the symptoms just mentioned in connection with periostitis. Diagnosis.—The diagnosis of ostitis is usually very difficult, but its presence may be suspected from the deep character of the pain, the slow progress of the disorder, the absence of the circumscribed swelling of periostitis and the peculiar seat of the suffering, as described by the patient. Prognosis.—The ordinary result of ostitis is the formation of an abscess, with caries or necrosis, and the prognosis is therefore favorable as regards life, the disorder resulting in the evils which ensue upon the evac- uation of the abscess, or the existence of caries or necrosis, as will be subsequently alluded to. Sometimes it develops such an hypertrophy of the bone as creates a marked elongation of the limb, the bone becoming convex forwards in the efforts of nature to obviate the evil. (Fig. 174.) Treatment.—The treatment at first should con- sist in the use of local and general anodynes, with the application of counter-irritants to the part, or the free use of warm emollient dressings; after which mercurial plasters, and the means directed for the relief of periostitis will be demanded. When the symptoms of an abscess in the long bones, especially the tibia, are so marked (as intense pain, swelling, fever, &c), as to justify it, the surgeon should cut down and expose the bone at or near the seat of the pain, and perforate the compact tis- sue as far as the medullary canal by means of a trephine, so as to give vent to the pus, a mode of treatment which has sometimes proved most use- ful, and is not followed by any serious consequences in the event Enlargement and convexitt op the Tibia from Ostitis.—In this patient this limb was half an inch longer than the other. (After Nat.) 458 PRACTICE OF SURGERY. of an error of. diagnosis, though caution should, of course, be ex- ercised in the examination of the case before resorting to the ope- ration. SECTION III. CARIES. Caries (**tp», to abrade) is a peculiar condition of a bone, which may be defined as that solution of continuity in this tissue which is the result of unhealthy inflammatory action and interstitial ab- sorption. It is especially characterized by the destruction and soft- ening of the cancellated tissue, resembling in this respect the slough- ing of the cellular structure, and the condition of the soft parts described under the head of the Irritable Ulcer. Caries differs from ulceration of bone in the same way that the simple healthy ulcer differs from the irritable. In ulceration of bone, there may be a partial loss of substance as the result of an abscess, but the tendency of this ulcer is to heal by the deposit of lymph and the formation of healthy granulations; whilst in caries the tend- ency of the diseased action is to spread, the dead portions being thrown off in scales or particles like the minute shreds or sloughs of the soft tissues, whilst the reparative effort is unable to check the disorder for some time, the progress of the disease being cha- racterized by very much the same symptoms as were described in connection with the irritable ulcer of the soft parts. Symptoms.—Caries, like ulceration of bone, is usually preceded by an inflammation of the bony substance, and is shown by the same symptoms as were detailed in connection with ostitis, such as deep-seated pain, inability to sleep, enlargement of the part, tender- ness on heavy pressure, loss of appetite, and fever; whilst the skin, which at first preserves its natural color, subsequently becomes hot, swollen, livid, and ulcerated in various points, these ulcers being accompanied with depression of the edges from the loss of the subcutaneous cellular tissue. As soon as the integuments give way, there escapes through these ulcerated points a thin grayish sanies, mingled with shreds of the subcutaneous cellular tissue, as well as with little scales of the cancellated tissue of the bone. On passing a probe into this opening, it will prove to be the orifice of CARIES. 459 a fistulous canal, at the end of which the bone will be felt, soft, porous, and broken down into a semi-pulpy, or lardaceous struc- ture, from which dark venous blood will escape under the action of the probe, this examination being often exquisitely painful to the patient. As the disease progresses, the matter becomes more brown or greenish in its tint, has a peculiarly offensive odor, and is so irritating that it develops inflammatory action on that part of the integuments over which it flows; hence it is not unusual to find eczema scattered around the neighborhood of the integuments which cover a carious bone. When the caries attacks deep-seated bones, as those of the vertebrae and pelvis, its course is much more tardy, the matter escapes with difficulty through the superimposed soft parts—travels, therefore, along the sheaths of muscles, and is apt to discharge in the line of the groin or loins, creating such symp- toms as have been alluded to in connection with the subject of cold abscesses, hectic, or the typhoid condition there alluded to, often becoming established. The constitutional disturbance is also very marked when caries invades the articulating surfaces of bones, as in the ankle and tarsal or carpal articulations. Etiology.—Caries may be created by any cause which will develop unhealthy inflammation in the cancellated tissue of a bone: thus it may ensue on periostitis, ostitis, ulcers of the soft tissues which destroy the periosteum, as well as upon syphilitic or mercurial irritation of the fibrous structures when accompanied by a destruc- tion of the plasticity of the reparative lymph by which nature checks the progress of inflammatory action. Diagnosis.—The disease with which caries is most apt to be con- founded is Necrosis, and the distinctive signs between them will, therefore, be given hereafter. Prognosis.—The prognosis of caries is generally serious, the re- sult depending especially on the age and constitution of the patient. When developed by injury in the young and healthy, the progress of the destruction may be checked after a time by the simple efforts of nature, leaving a condition somewhat analogous to the indolent ulcer of the soft parts. But when it is the result of syphi- litic, tuberculous, or mercurial contamination, and when it is seated near, or in the bones of an articulation, as those of the tarsus or parpus, it will be very apt to exhaust the patient's strength, and cause death, unless arrested by amputation of the limb. When it is superficial, and in bones which have but a limited amount of 460 PRACTICE OF SURGERY. cancellated tissue, as those of the cranium, the prognosis would be less serious, the disorder being ultimately amenable to treatment. Treatment—The general indications in the treatment of caries are: 1st, to remove, if possible, the cause of the disorder; 2d, to brino- about a healthy condition in the diseased bone and favor the cicatrization of the carious ulcer. These indications are to be ful- filled on general principles; thus, if caries is the result of syphilitic or tuberculous contamination, administer such remedies as are appropriate to these conditions, whilst the local treatment should vary in accordance with the nature of the part affected. In all cases, the exterior inflammation should be checked as directed in the general and local treatment of inflammation, whilst the diseased bone should be removed by instruments, as scoops, gouges, &c, if it is so situated as to be anatomically safe.1 When the carious surface is exposed, and the reparative process is not readily esta- blished, some modification of the local action may be obtained through the action of topical applications, as alkaline ointments, which will sometimes modify in a marked manner the ichorous character of the discharge, or stimulants, as the tinctura ferri chlo- ridi or the nitric or muriatic acid carefully applied on lint for a few moments; or caustic solutions, as of potash or chloride of zinc; whilst the actual cautery has sometimes been freely used with ad- vantage, the separation of the eschar being followed by the deve- lopment of healthy granulations. In fact caries, like the irritable ulcer of the soft parts, requires that the destructive action should be checked and the reparative effort established; but whether this is to be effected by exciting or reducing the vascular action of the part, must depend on the peculiarity of the case. As a general rule, when caries is sufficiently superficial and limited in its extent, the best plan of treatment is resection of the diseased part either by scooping it out until sound healthy tissue is reached, or by cutting off the diseased end of the bone.3 | 1.—CARIES OF THE CRANIUM. Caries of the bones of the head may affect any part of the cranium, though most liable to be developed in the upper and 1 See Operative Surgery, vol. i. p. 244, and vol. ii. p. 379, 2d edit. 2 See Resections, in the Operative Surgery. CARIES OF THE CRANIUM. 461 lower portions, as the frontal, parietal, and occipital bones, the temporal and sphenoidal escaping. Etiology.—Caries in this locality is usually the result of syphi- litic or mercurial contamination, and ensues upon periostitis or pericranitis, which, by creating ostitis, gradually develops the un- healthy action of carious ulceration. Symptoms.—After the existence of the symptoms of nodes—as described under the head of periostitis—a soft fluctuating tumor forms in the scalp, which when opened either by ulceration or by puncture, gives exit to some healthy looking pus, but is soon followed by the sanies of carious bone, as previously described. This opening is now apt to spread until it creates an ulcer of the size of a shilling and upwards, and, owing to the peculiar character of the integuments, is liable to develop erysipelas. In the centre of this ulcer the outer table of the skull is usually found in a necrosed as well as a carious condition, until, as the compact lamina is thrown off, the diploe exhibits the ordinary condition of caries as seen in the cancellated tissue of other bones. If the disease progresses slowly, as it is apt to do, the edges of the ulcerated scalp may be- come thickened and inverted, sometimes also becoming closely adherent to the subjacent pericranium. At the same time the patient suffers pain and all the symptoms of inflammatory fever. Diagnosis.—The superficial character of the parts affected renders the diagnosis easy. Prognosis.—Caries of the bones of the cranium, when limited, is more readily susceptible of cure than any other seat of caries; but as it is generally the result of syphilitic ostitis or pericranitis, it is apt to invade a considerable portion of the bone, and to require either many months for its cure, or ultimately to exhaust the patient by the hectic fever which supervenes. The cicatrix that remains after the existence of caries of the cranium is always de- pressed, and deprived of hair, so that it generally creates a marked deformity. Treatment.—In the treatment of caries of the cranium constitu- tional remedies—especially the use of the iodide of potash—often exhibit considerable power in checking the phagedenic tendency of the disorder. When the disease is circumscribed, the best ap- plications are the mineral acids, painted on the diseased bone after the scalp has been shaved around the ulcer, and its edge protected from the action of the acid by covering it with simple cerate spread 462 PRACTICE OF SURGERY. directly on the scalp. The removal of the diseased portion, as far as the internal table, is also highly serviceable, the remaining ulcer of the integuments being treated on general principles or cured by a plastic operation.1 SECTION IV. CURVATURE OF THE SPINE FROM DISORDERED ACTION IN THE BONES AND MUSCLES. § 1.—DISEASE OF THE VERTEBRA. Under the name of caries of the vertebrae, the older surgical writers described such a condition of the vertebral column as re- Fig. 175. Fig. 176. Fig. 175.—A view of the Antero-posterior Deformity or Curvature of the Spine, often seen as the result of caries of the bodies of one or two vertebrae. (After Liston. f Fig. 176.—A view of the Deformity created by a Lateral Curvature of the Spine as caused by the excessive action of the muscles on the right side. (After Pirrie.) suited in giving way of the bodies of the bones, in an encroach- ment on the natural caliber and line of the spinal canal, and in 1 See Operative Surgery, vol. i. p. 319, 2d edit. DISEASE OF THE VERTEBRAE. 463 such a deviation from the natural line of the back as created a marked deformity, generally in an antero-posterior direction. This deformity, by causing a prominence of the spinous processes of the vertebra, creates a lump, and hence is popularly known as "hump-back," or "broken-back," the bones being supposed to be fractured. Another deviation of the line of the spinal column, which is here mentioned to point out the comparative deformity of the two, is that due to the excessive muscular action of one side, in conse- quence of which the spine is inclined to that side, this deformity being designated as " Lateral Curvature,11 as will be subsequently alluded to, the shoulder blade being raised up on one side, and the spine inclined, though the bones themselves are not diseased. As the direct local treatment of curvature from disease of the vertebrae cannot be accomplished, owing to its deep situation, it and lateral distortion may be advantageously studied together, as both present the common object of obviating or modifying the deformity. There are two varieties of diseases of the vertebrae which may result in curvature of the spine; these varieties being very often confounded with each other. The first is that due to a true caries of the bodies of the bones, in which we have all the symp- toms already stated as characteristic of caries elsewhere, whilst the second is created by the deposit softening, and changes of the bony tissue consequent on tubercular deposits in the cancellated tissue of the spinal column. This latter affection is ordinarily spoken of as " scrofulous disease of the spine," a vague term, which indicates nothing positive in regard to the pathology of the dis- order, and which is much better expressed by the title of tubercles of the vertebral column. In both the symptoms are at first some- what indefinite, whilst in both there may be such changes of struc- ture as will involve the spinal marrow. Thus, after a fall or some other accidental cause capable of developing inflammation, the patient will experience a constant deep aching pain in the part, which is subsequently followed by symptoms that are due to alterations in the cavity of the spinal canal and secondary disorder in the spinal marrow or its membranes, all of which may be created either by caries or tubercles in the vertebrae. 1. Caries oftJte Vertebrae.—Caries of the vertebrae generally affects the bodies of the bones, causing them to break down by their front faces, the pus which attends the progress of the disorder passing 464 PRACTICE OF SURGERY. either beneath the anterior vertebral ligament until it reaches the origin of the psoas magnus muscle, whence it travels beneath the sheath of this muscle towards its insertion, opening in the groin and constituting "psoas abscess;" or it follows the posterior line of the vertebras and the sacro-lumbalis muscle to a point just above the posterior edge of the brim of the pelvis, thus creating "lumbar ab- scess." Caries may affect the bodies of any of the vertebrae, but is most commonly met with in those of the dorsal or lumbar region, being rare in the neck. As the reparative effort is imperfect, the entire bodies of one or two vertebrae may be removed by the disease, in consequence of which the weight of the head and shoulders causes the approximation of the adjacent vertebrae, and creates a deformity like that shown in Fig. 180, nature subsequently solidifying the part by anchylosis, the inflammation of the periosteum leading to the deposit of new bony matter. 2. Tubercles of the Vertebrae.—This disease, consisting in a true tubercular deposit similar in all its characteristics to tuberculous de- posits in the lungs and elsewhere, is usually the result of the tuberculous, or as it was for- merly called, the scrofulous diathesis. Tuber- cles of the vertebrae are generally deposited in the cancellated structure of the bodies of the bones, where they may be found either as little distinct masses, or generally infil- trated throughout the cancellated tissue, the latter being of the miliary form, and analo- gous to miliary tubercles in the lungs, and when once deposited, pursuing a course which is similar to that seen in the lung. The subject of the deposit of tubercles in the cancellated tissue of these bones, as well as in others, has only been properly understood within the last twenty years; Nelaton, of Paris, having first called the attention of the profession to it, in a distinct treatise in 1837.1 In order to 1 Recherches sur PAffection Tuberculeuse des Os. Par A. Nelaton, D. M. Paris, 1837. Caries of the Vertebrae, showing the destruction of the bodies of two of the dor- sal vertebrae, the approxima- tion of the adjacent ones by the weight of the head and shoulders acting on the upper part of the column, and the prominence in the back caused by the spinous pro- cesses. (After Liston.) DISEASE OF THE VERTEBRAE. 465 understand the true course of this disorder, it is only necessary to recollect that an aggregation of tuberculous matter deposited in the centre of the body of one vertebra of a patient who previously has labored under the tuberculous diathesis, must find its way out when the tuberculous mass softens; but why this particular spot should have been selected for the deposit we are unable to state. Perhaps some local congestion may have preceded it, or the same causes which determine the deposit of tubercles in the glands or lungs, may also create it in the vertebrae. Once deposited, however, the morbid structure acts like any other foreign body, by inducing congestion, inflammation and sup- puration in the surrounding tissues, and as more or less of the cancellated structure of the bone is thus destroyed, little morsels of it loosen and are cast off mixed with the pus, and with the soft- ened tubercle, and is sometimes discharged externally, mingled with the purulent mass. The pus of the little abscess which forms around the softened tubercle, does not travel directly to the sur- face of the bone through the cartilage which covers its epiphyses or articulating surfaces, probably on account of the great vascu- larity of this part, allowing a free effusion of lymph to take place, so as to limit the extension of the abscess in that direction; but escapes by perforating the body of the vertebra anteriorly (Fig. 178), destroying a portion of the bone, which is quite limited as compared with the destruction created by caries. After passing out beneath the anterior vertebral ligament, it takes a course downward, as the matter from caries did, between the ligament and the vertebras, so as to point below in the form of psoas or lumbar abscess, though most frequently the discharge is not so profuse as that created by caries. Tubercles of the vertebrae, as thus briefly described, are to be re- garded rather as evidences of a peculiar diathesis, or as the result of peculiar constitutional disturbance, than as a complaint resulting from external violence or excited by it. And the recollection of this fact will often aid the surgeon materially in diagnosing them from caries, the latter being often—indeed, generally—the result of exter- nal violence. The tendency of caries, it should be remembered, is to spread—to involve neighboring parts, and gradually to destroy the whole bone; whilst the progress of a tuberculous abscess in the bone is to a discharge of its matter and the formation of a simple ulcer, the tendency of which is towards reparation, though this is 30 466 PRACTICE OF SURGERY. generally rendered of no effect by the fresh deposits of tuberculous matter in the neighborhood, which runs a similar course and thus keeps up and propagates the disease. Tuberculous deposits in the vertebras seldom, however, cause the destruction of substance or the deformity that follows caries, the upper and lower plates of the affected vertebra assisting in preventing the caving in of the bone as shown in Fig. 178. Symptoms of Spinal Curvature from either of these Disorders.—After the existence of caries or tuberculous disease of the vertebrae, the symptoms of spinal curva- ture may be arranged under two distinct heads, the first including those which precede the deformity, and are due to the extension of inflammatory action to the contents of the spinal canal; the second embracing those subsequent to its pro- duction, as the displacement of the spin- ous processes, compression of the spinal cord, &c. 1. Of the symptoms which precede the actual occurrence of any deviation from the proper line of the spine.—When the affec- tion of the spine is due to disease of its bones, the patient complains first of a certain amount of pain in the part, this pain being heavy, deep-seated, and ach- ing. There is, moreover, tenderness upon pressure, and this tenderness will very often be found to be limited to certain spots, which spots are generally noted in the dorsal or lumbar vertebrae, though oc- casionally seen in the case of the ver- tebras of the neck. Soon after this the patient begins to experience a sense of weariness in the back, with an indisposition to exercise, and after exercise suffers more severely from the dull, heavy, ach- ing pain already alluded to, especially when that exercise has been accompanied by some amount of accidental jarring of the spine, such, for example, as having made an incautious step when walking, or taken a long step in descending from a carriage, &c. Under these A VIEW OF THE APPEAKANCES created by the softening of Tu- bercles in the Bodies of the Ver- tebrae, showing the amount of the destruction of the bones, the epiphyses remaining perfect.— 1, 1, 1. Points where the tuber- cles have softened and created the death of the cancellated tissue. The bony spines which strengthen the parts after the escape of the tubercles is also shown. (After Nature.) DISEASE OF THE VERTEBRA. 467 circumstances, the patient soon assumes the horizontal position, as he obtains in this way temporary relief by taking the weight of the head off the spinal column. The pain, however, returns so soon as he again becomes erect; and as this condition may continue for many weeks, he is often said to have " a weak back." Thus far, the symptoms just detailed apply equally to disease of the bones arising from tubercles, as well as to that which is the result of caries. But certain differences can now be noted which will point out with more or less certainty the special character of each disease. Thus, if the .pain be due to a tuberculous deposit, there will be more or less evidence of the tuberculous diathesis in the general appearance of the patient and in the general symptoms of the case, with more or less tendency to diarrhoea, or to cough, according as the irritation also affects the mesenteric glands or the lungs, either of these being symptoms which are not usually present in caries of the spine. 2. Symptoms consequent on the yielding of the bodies of the vertebrae. —When the disease has gone so far as to break down the bodies of the vertebrae, whether due to tuberculous or carious disorder, such changes will be noticed as are directly connected with loss of sub- stance ; thus, the bodies of the vertebrae will give way, and the spinal column will fall forwards, producing more or less antero-posterior deformity, and the condition to which the term humpback is ordi- narily given. If deformity goes on to such an extent that the curva- ture results in more or less compression of the spinal cord, paralysis will ensue to a greater or less extent, and if the curvature be in the cervical vertebrae the termination will generally be death. As the yielding of the vertebrae progresses, more or less change will be noticed in the relative position of the ribs, with alteration in the cavity of the chest, the result of which will be difficulties in respiration, shortness of breath, dyspnoea, &c. At the same time there will be changes in the normal condition in the circulatory organs, as shown by palpitation of the heart, &c. The position which the patient most frequently assumes is also quite characteristic of disease of the bones; thus, when seated he sits doubled up with his knees towards his chest, and when he walks his motions generally indicate more or less loss of power in the lower extremities, tripping over the slightest obstacle, and becoming much fatigued after short walks. As the disease progresses, other sio-ns 468 PRACTICE OF SURGERY. connected with loss of nervous power become apparent, the patient losing his control over the sphincters of the bladder and anus, in consequence of which the urine and feces are passed involuntarily, precisely as happens in paraplegia from any other cause, whilst the functions of digestion are weakened, costiveness, flatulency, and eructations showing the disordered action of the muscular coat of the alimentary canal. Diagnosis.—It is a matter of some importance in regard to the treatment of the eomplaint, to be able to make a diagnosis between caries and tuberculous disease of the spine, as the treatment which is perfectly appropriate to the one will be useless if not injurious in the other, and attention to the signs above given as peculiar to tubercle and caries, will generally suffice. The symptoms just described are also liable to be confounded in females with an appa- rently similar condition, to wit, neuralgic irritation and spinal ten- derness, though this special disorder is usually the result of uterine disorder. This neuralgic irritation of the spinal column may, however, be diagnosed from the diseases under consideration, by the fact that pressure rather diminishes than increases the uncom- fortableness or pain in neuralgia, and in some cases affords posi- tive relief. The diagnosis from lateral curvature, or that due to muscular distortion, can be made with readiness, from the fact that, in muscular distortion the curvature is generally lateral instead of antero-posteriorly; whilst the symptoms described as due to tuber- cles or caries, are absent, such as tenderness upon pressure, pain, paraplegia, etc. etc. Prognosis.—The prognosis of spinal curvature, whether due to caries or tubercles, should be guarded, the disease being a slow one, and if its progress be not arrested, resulting in serious perma- nent organic changes of the bones of this portion of the body. The cure, when it can be accomplished, is only to be effected by means of anchylosis, a process always tedious and uncertain, but which sometimes occurs,post-mortem examination occasionally revealing the vertebrae fused together by true bony matter. The patient, there- fore, even under the most favorable circumstances, should not be encouraged to expect a cure before twelve or eighteen months— whilst the deformity, if well marked, will always continue, though it may be slightly modified by judicious treatment. Treatment.—In the treatment of spinal curvature, whether due to caries or tubercles, the indications are, first, to prevent displacement DISEASE OF THE VERTEBRAE. 469 and the formation of a curvature as much as possible. Secondly, to pay attention to the patient's general health, with a view of removing, if possible, the peculiar constitutional condition upon which the local disease often depends. But these indications are to be carried out in different ways, according to the character of the cause which ex- cites it. Thus, if the pathological condition is due to tuberculous deposit, the first duty of the surgeon is to employ, so far as it is in his power, such means as will tend to limit the further deposition of tuberculous matter. If, for example, in the earlier stages of the disease, some tenderness upon pressure be noticed in the bodies of any of the vertebrae indicating more or less irritation or inflamma- tion of the parts concerned, it should be treated precisely as we would treat irritation or inflammation elsewhere. Thus, local deple- tion may be employed with advantage, such as that by means of leeches, &c, but care must be taken not to carry these local deple- tory measures too far, lest, by inducing depression, they result in an augmentation instead of a diminution of the tuberculous deposit. If the signs of curvature have begun to show themselves, we may find it, in these tubercular cases, desirable to take the weight of the head and shoulders from off the spinal column, so as to prevent them from adding to the congestion in the bodies of the vertebrae at some point where they are most diminished in strength by disease. At the same time that this is desirable, fresh air and exercise are imperatively indicated. Now, these two indications may be well carried out, in the case of children—from whom every- thing is to be expected from exercise and fresh air—by means of a swing, the supports of which are of wood, instead of cords, and in which the patient can staud, the weight of the head and shoulders being taken off the column by means of a band which passes under the chin, or by means of "go carts," &c. If the disease is specially seated in the dorsal vertebrae, some such mechanical contrivance may be applied as that ordinarily sold by the cutlers, and which consists of a band of sheet-iron, padded, and covered with leather (Fig. 179), and made to surround the body just above the hips, whilst bands on each side present a crutch- shaped pad, which, passing under each shoulder, supports the weight o*f the arms. With such an apparatus, the patient may take gentle exercise in the open air, from time to time, and thus improve his general health. Meanwhile, the treatment proper for the tubercular diathesis is 470 PRACTICE OF SURGERY. to be adopted. Chalybeates, such as Yallet's carbonate of iron, or the ferri pulv., may be freely administered, the whole class of reme- dies being employed, with these patients, which are ordinarily given in cases of tu- bercular disease, in the lungs or else- where. Benefit is sometimes obtained in cases of tuberculous deposit in the bodies of the vertebrae, from the use of counter-irri- tants, and one of the best that can be em- ployed is a very simple one. Select an iron, such as that used for the application of the actual cautery, having ^, linear shape; dip it in boiling water, and then draw a line along both sides of the verte- bral spinous processes from one end of the column to the other. As thus applied the iron will not vesicate, but will tho- roughly redden the skin, and is a better application than a mustard plaster blis- ter, or any similar substance. The means thus briefly described em- brace most of these that will be found necessary in ordinary cases, and present the only plan from which good can be expected. In Caries, however, the treatment must be varied, as the con- dition of things is here entirely different, and it is to this class of patients that the plan laid down by Mr. Pott is especially appli- cable ; this disorder being due to a phagedenic ulceration of the bone, which is the result of inflammation. This inflammation should consequently be treated promptly, like inflammation else- where, by antiphlogistic measures, as depletion, purgation, and counter-irritants, these remedies being patiently combined with per- fect rest in the horizontal position. If possible, the patient should be made to lie upon his belly, and not be allowed to make the slightest exertion. He should also be briskly purged twice a week with the compound powder of jalap. By this plan of treatment, judi- ciously persevered in during a greater or less period, the disposi- tion to ulceration and breaking down of the bodies of the bones will often be checked, anchylosis will ensue, and the patient recover, though probably with some deformity. The mode recommended Fig. 179. , A FULL VIEW OP A "SHOUL- DER-BRACE," OR SPINAL SUP- PORT, adapted to the treatment of Curvature of the Spine, when due to disease of the bodies of the Dor- sal or Lumbar Vertebrae. The lower band fastens around the hips, whilst the crutch-like pieces pass under the armpits, and thus take the weight of the upper extremities off the spine. (After Nature.) MUSCULAR CURVATURE OF THE SPINE. 471 by Mr. Pott for the treatment of caries of the spine is, I fear, too often and thoughtlessly resorted to in all cases of disease of the bodies of the vertebrae, whether due to caries or to tuberculous deposit, and that is the active use of counter-irritation. According to his plan, a seton, or an issue or two, should be maintained upon the back, directly over or alongside any point of tenderness which may be noticed, but this plan is liable to one very serious ob- jection, to wit, that it increases to an inconvenient, if not to an injurious extent, the irritation of the integuments, caused by the pressure of the hump or angle of the deformity. The same ob- jection would also apply to moxae, but with more force. The only true way of employing counter-irritants, if they are to be made use of, either in caries or tubercles of the vertebras, is to apply them at a distance, say some four or five inches from the seat of the injury. But in tuberculous disease of the vertebras anything like a drain on the system is apt to prove inj urious by weakening the powers of life. In order to prevent the patient from suffering from the want of fresh air and exercise, during the treatment of caries, a little coach may be made for him, in which he should be dragged about, whilst he yet enjoys all the benefits arising from the horizontal posture. § 2.—MUSCULAR CURVATURE OF THE SPINE. Lateral curvature of the spine is a distortion of the vertebral column due to muscular action. It is generally seen in young girls and boys of from five to fifteen years of age, especially in girls who are improperly educated physically. Etiology.—The causes of this disorder are to be found in the relax- ing influences of luxurious beds and over-warmed houses; in the ridiculous rules of certain fashionable boarding-schools, such as those which require growing girls to stand for two or three hours during a recitation, or to use seats without backs, under the impres- sion that the little sufferer will thus acquire grace and an erect carriage; or in the absurd directions of certain writing masters, compelling the child to sit with one side to the table, thus en- couraging the use of one set of muscles. Another very common cause is dressing female children with low necked dresses, so as to cause them to hitch and turn themselves with a view of keeping 472 PRACTICE OF SURGERY. up their clothes, thus not unfrequently developing the muscles of one shoulder more rapidly than those of the other. It will also be sometimes found in growing boys, as in those who carry a strap full of school-books on one shoulder, or who work at some trade which compels them to use one side of the body more than the other, such as blacksmiths' apprentices, who blow the bellows, &c. In these cases, the muscles involved are most frequently those con- nected with the scapula, such as the trapezius, rhomboicleus, levator anguli scapulae, &c. muscles, the tendency of which is to draw the scapula towards the spine, or elevate it, but muscles, the action of which would serve equally—one scapula being made a fixed point— to draw the spine from the scapula. In some patients the creation of lateral curvature as the result of muscular action is also favored by a want of firmness in the bones, the latter presenting a tendency towards the condition described under the head of osteo-malaoia, or mollities ossium. Symptoms.—The presence of lateral curvature, from these causes, may generally be at once recognized by a simple inspection of the naked back; the true line of the spinous processes of the vertebrae being considered, under ordinary circumstances, so far at least as its lateral inclination is concerned, as a plumb-line. Inspection in the case of lateral curvature will at once show the deviations from this line, these deviations being greater or less in degree according to the point to which the disease has progressed. Usually, it is rare to find disease of the bones in connection with muscular distortion. As a consequence of the distortion of the vertebral column, changes may also be noticed in the position and relations of the ribs: the length of the chest being sometimes very much shortened on one side, and the distance between the lower rib and the top of the ilium occasionally diminished to such an extent that it may be spoken of as not existing; or the chest may be flattened in its shape, the con- dition of the " chicken-breasted" being not unfrequently created by muscular distortion. Prognosis.—The prognosis of curvature of the spine from the ex- cessive muscular action of one side should be guarded. If the case is seen early, it may be remedied by judicious exercise of the set of muscles opposite to those which have hitherto been called into play; but the process is a tedious one, and, if the disease has existed any length of time, will generally be but very partially successful. Treatment—The indications for the treatment are the development MUSCULAR CURVATURE OF THE SPINE. 473 by exercise, by frictions, etc., of the weaker set of muscles; thus, if the curvature has its convexity towards the right side, the muscles of the left are those the development of which should Fig. 180. Fig. 181. Fig. 180.—A view of the Deformity seen in Lateral Curvature from an inspection of the back. (After Miller.) Fig. 181.—A view of the Condition of the Vertebrae and Ribs in the same disorder. (After Miller.) be attempted. Besides exercise and frictions, electro-magnetism has also been recommended, and will often prove serviceable if judiciously applied, by increasing the circulation in the weakened muscles. An attempt was made some years ago to bring into credit a mode of treating these curvatures by section of the contracted mus- cles, Mr. Guerin, of Paris, having operated extensively in this man- ner upon all cases of spinal curvatures which presented themselves, but the result has never created any marked professional favor. As a general rule, the bones and ligaments of bad cases have accom- modated themselves to their new positions, and few, therefore, can be permanently benefited by such operations. 474 PRACTICE OF SURGERY. The same general remark will apply to mechanical contrivances, with which the stores are filled, and the power of which is lauded for the cure of this deformity. As a general rule, they are entirely useless if the disease has been of long standing. Something may, perhaps, be accomplished by gradual extension, but it must be very carefully applied, lest it result in evil rather than in good. SECTION V. SPINA BIFIDA. Spina Bifida, or Hydrorachis (v8«p, water, and pa^t$, the spine), is a congenital malformation of the spinous processes and posterior part of the vertebral column, in consequence of which an orifice is left, through which the spinal membranes protrude. Some- times, indeed, the spinal cord itself escapes, though this is by no means generally the case. The disease, as might be supposed from the fact that it is congenital, is generally seen in infants, and those cases upon record in which it is spoken of as first appearing one, two, or three months after birth are generally such as have escaped attention at an earlier period. As a general rule, the child in whom the disease occurs is in other respects well formed, and free from all other deformity except a marked predisposition to hydro- cephalus. The formation of the tumor is generally at some point in the lumbar region, and the symptoms are as follows:— Symptoms.—Soon after birth, there is noticed in the region men- tioned a tumor of variable size, which is thin and diaphanous, and evidently contains fluid (Fig. 182). Usually, it is uncovered by the ordinary integuments of the part, or if they cover it, they are some- times extremely attenuated. If gentle pressure is made upon the tumor, its contents will pass up into the spinal canal, and the swell- ing disappear more or less completely; but any such effort as this should be made with great caution, for if too violent or sudden pressure be made, the spinal marrow may become involved, and paralysis be induced. The disease is often combined with hydro- cephalus, and sometimes with idiocy. Diagnosis.—The diagnosis of this affection does not present much difficulty, the size of the tumor, its translucency, its position, the SPINA BIFIDA.—NECROSIS. 475 age of the patient, and the history of the case being quite sufficient to determine its nature. Prognosis.—With regard to the prognosis, it is unfavorable. Fig. 182. A full view of Spina Bifida of the lower part of the Lumbar Vertebrae. (After a cast from Nature.) The disease is not readily relieved, and generally terminates fatally, though occasionally cures have been obtained. Treatment.—The treatment consists in evacuating the contents of the tumor by means of acupuncture needles, after which various plans have been proposed for inducing the adhesion of the sides of the cavity, such as injecting the cavity of the spinal cord with tinct. of iodine in aqueous solution.1 SECTION VI. NECROSIS. Necrosis (from vsxpoa, to kill) is a mortification of the bony tissue, and corresponds in its general character and results with mor- tification—not sphacelus—of the soft tissues, there being generally ' For an account of various operations for the relief of spina bifida, see Operative Surgery, vol. ii. p. 183, 2d edit. 476 PRACTICE OF SURGERY. Fig. 183. 1% k6I sufficient vitality in the surrounding structures to separate the dead from the living portions. In mortification of the soft parts the dead portion, when of limited extent, was designated as a slough, this portion retaining enough of the elements of the dead structure to show that it had belonged to a soft tissue. In the bones the dead portion, if small, is designated as an "exfoliation,"—if larger as a "sequestrum," it also retaining enough of its original characteris- tics to show that it was once vital bony tissue; thus it will often preserve the original shape of the bone, its hardness, laminated character, and other peculiarities, though changed in color to a dead or tawny white. Etiology.—The causes of necrosis may be all placed under one head, to wit, such as impair the power of the circulation in the bone, and may be arranged as follows: 1. Separation, or division of the external periosteum; 2. The same lesions of the internal or medullary» membrane; and 3, mortification as the result of inflammation of the bone itself or the in- jury of its nutritious artery. Through all these causes one general process may be noted, to wit, the death of one portion, and increased vascularity oA^qulstrum of adjacent parts, this increase being in proportion from the inner sur- to tne ]oss 0f vitality or size of the dead portion. faceofalongbone, ^ L showing its sur- This increased action amounts often to true healthy ton6) ef 1S inflammation in both the internal and external pe- riosteal membranes. Symptoms.—In its commencement necrosis is generally pre- ceded by sufficient inflammation to create a change either in the action of the external or internal periosteum, or both; hence, the earliest symptoms are those of inflammation of the bone or its membranes, such as pain of a variable degree of intensity, which is often most marked during the night, with the other symptoms of periostitis. After the duration of these, for a longer or shorter period, a flattened uncircuinscribed enlargement will be noted at the painful spot, without any change being perceptible in the color of the skin, until fluctuation is more or less evident, when the skin will redden, ulcerate, and give vent to pus through one or more orifices, the pus often bringing away some particles of the sloughing peri- osteum. These ulcerated points in the integuments over a necrosed bone are nearly always elevated, with a minute orifice in the centre, NECROSIS. 477 and hence are designated as papillae. If the necrosis is superficial the bone will be readily felt denuded of its periosteum, the dead lamina will exfoliate and be thrown off by nature, healthy granula- tions and new bone will be formed, and over this the integuments will adhere and form a dense white but depressed cicatrix. If the diseased bone involves the greater part of the thickness or length of a long bone, as the tibia or femur, all the symptoms will be more marked, the swelling embracing most of the circumference of the limb. The ulcerations will also be numerous, the pus more thin, fetid, and ichorous, whilst a probe passed through the ulcerated inte- guments will enter a hypertrophied layer or shell of bone, and touch the denuded and necrosed portion within it. At first this fragment or sequestrum will be more or less firmly adherent to the new bone thrown out around it, but in the latter stages of the complaint it becomes loose and movable, yielding to the force which touches it, and sometimes becoming so loose as to move readily with the motions of the patient. The constitutional symptoms are those of irritative fever, this being due to the pain and discharge from the part, and the severity of the symptoms being in proportion to the extent of bone affected. Throughout necrosis of a flat or part of a long bone the continuity of the bone is often unimpaired, and its functions are, therefore, more or less perfectly performed. State of the Tissues during Necrosis.—It being admitted that necrosis is generally preceded by inflammatory action, and that this action creates the destruction of one portion of the structure that is involved, it will be seen that the death of the bone or a portion of it, is created by very much the same steps as the death of the soft parts when mortifying, the reparative effort in both instances being analogous. Without recapitulating what has been said in connection with the subject of mortification of the soft parts, or repeating the allusion previously made to the action of the periosteum in the repair of fractures, we may now simply note the condition of parts around the necrosed portion, and the manner in which it is thrown off by nature. From the extended observations of Mr. Stanley,1 as well as from those of Mr. Paget,2 it appears that the phenomena in ne- crosis which illustrate the process, are— 1. A permanent and increased vascularity of the structures ad- jacent to the necrosed bone, this being indicated not only by the 1 On Diseases of the Bones. 2 Lect. Surg. Pathol., p. 301, Phil. ed. 478 PRACTICE OF SURGERY. Fig. 184. condition of its vessels but by the numerous enlarged Haversian canals. 2. A reparative process, due, as in mortification of the soft parts, to a limiting effusion and organization of lymph, on the border of the living tissue, the latter, by interstitial deposit and absorption, forming "a line of demarcation," the groove around the dead bone being augmented until, as in mortification of the soft parts, it forms "a line of separation," the earthy matter being washed away in the pus, and not absorbed, as was thought by Mr. Hunter, whilst the animal matter retains its connection with the living bone, probably in consequence of its greater vitality. The removal of portions of the earthy matter, when followed by the subsequent destruction of the animal and cancellated tissue, generally gives to the necrosed portion or the sequestrum a porous, spiculated, irregular surface and margin, as shown in Fig. 184. 3. The inner surface of the periosteum is usually the agent of these changes, its face becoming covered by granulations, which, as in the ordinary growth of bone, creates the nucleated cells from which new bone is formed. Hence, whilst one portion of the bone is being separated by degeneration, another is being formed by the reparative effort, the new material being thrown out around the old so as to incase it and preserve the continuity of the member. 4. The shell of new bone formed by the exter- nal periosteum around the necrosed portion, is usually found perforated in numerous points, so as to give exit to the pus, without materially weakening the part. These perforations are, it is thought, the result of the death of limited points of the external periosteum in consequence of which there is no nidus for the growth of new bone in those openings which originally ulcerated through the periosteum. When the loss of peri- osteum is extensive, an orifice termed "cloaca,"" is formed, through which the necrosed bone may be withdrawn from its shell. ,5. The points of difference noted in the condition of parts be- tween necrosis and mortification of the soft tissues is found in the View of a Sequestrum as detached after an amputation of a femur, showing the character of its surface as well as its terminal con- nection with the liv- ing bone. (After Lis- ton.) NECROSIS. 479 duration of the process, necrosis being slow and often requiring six, twelve, or eighteen months for its completion. Fig. 185. Fig. 186. WW v \ Fig. 185.—Necrosis of the Tibia, showing the perforations in the shell of new bone, as alluded to in the text. (After Miller.) Fig. 186.—Necrosis of the Tibia, showing a large cloaca with the sequestrum protruding. (After Miller.) Diagnosis.—Necrosis, when once developed, may be readily re- cognized from caries by an examination with a probe, the necrosed bone being denuded, hard, rough, and often movable as a frag- ment, whilst caries is soft, porous, friable, and without distinct shape, seeming rather as a broken-down mass of tissue. Prognosis.—The prognosis of necrosis will vary with the position of the bone that is affected, but the disorder is seldom fatal to life; when the necrosis is circumscribed and superficial, the sequestrum will be thrown off more quickly than when the disease is more extensive and deep-seated. The prognosis, as regards the period of separation of the sequestrum, may be rendered more certain by examining the part carefully with a probe or director, in order to iudo-e of its mobility and the amount of its attachments to adjacent parts. When free, and so situated as to be amenable to an opera- 480 PRACTICE OF SURGERY. tion, the prognosis as to the time of cure will be more favorable than it would be under different circumstances. Treatment—Little can be done for the relief of necrosis until nature has accomplished the separation of the dead from the living portion, except to regulate the inflammatory action. AYhen the necrosis is the result of syphilitic periostitis, the constitutional remedies demanded in syphilis may prove useful, whilst in all cases the use of anodynes, with mild purgatives, will allay pain, and diminish the irritative fever. If a wound has denuded the bone of its periosteum, replacing the integuments and favoring their adhe- sion will often serve as a prophylactic measure, whilst the warm- water dressing, rest, &c, will aid in diminishing the inflammation of the soft parts. When the necrosed bone is loosened by the process of nature, its removal, if it is of limited extent, may be accomplished by drawing it out with strong forceps, and treating the wound as a simple ulcer. But when the sequestrum is larger, and the dead bone is inclosed in a thick casing of new bone, the latter must be cut away sufficiently to permit the removal of the necrosed portion. The details of the process belong to operative surgery, but may here be generally stated as consisting in per- forating the shell of new bone at two points with a trephine, and then chiselling out the intervening portion1 until an opening of sufficient size is obtained, the wound being subsequently made to heal by granulation. SECTION VII. BONY TUMORS. The bones, like the soft tissues, are liable to such changes in the process of growth and repair as create a modification of their natural condition, and result in the development of tumors, which may be classified as those due to hypertrophy, atrophy, and fatty degeneration of structure. 1 See Operative Surgery, 2d edit., vol. i p. 232, ut supra. EXOSTOSIS. 481 § 1.—EXOSTOSIS. By an exostosis (tf, out of, and ooaov, a bone) is meant a bony growth or tumor which is due to a true hypertrophy, and which may arise either from the compact or cancellated tissue of the bone. Varieties.—Various kinds of exostoses are met with, that which is hard and solid being designated as the "eburnated11 or ivory-like; that which is formed of superimposed layers, as the laminated; and that which is formed chiefly of cancellated structure, as the "spongy." Exostoses are also named from their shape, as the circumscribed, tuberculated, and spinous. A circumscribed exostosis is a mere projection from the bone of a limited extent; the tuber- culated or knotted is an irregular knob or excrescence; whilst the spinous resembles in shape the thorn of the rose-bush, or some similar blunt-pointed growth, all of which are more or less solid in their structure. Seat and Result.—Exostoses vary much in their position, all the bones being liable to them, but especially those which are superfi- cial, as the cranium, clavicle, tibia, lower jaw, sternum and ribs. The tuberculated and laminated varieties are chiefly found in the flat bones, as those of the head; whilst the spinous and circumscribed are seen in connection with the long bones. Exostoses are fol- lowed by results which vary in accordance with their position; thus an exostosis from the interior of the cranium would be liable to compress the brain, and an exostosis on the long bones of the extremities would create inconvenience by interfering with the play of tendons and muscles, or acting on the coats of the blood- vessels, or irritating the nerves. Pathological Changes.—In all exostoses the periosteum or endos- teum is liable to be more or less changed, the development of the growth being generally due to the action of these tissues either directly or indirectly. Generally, the periosteum is thickened, injected, or sometimes softened around the exostosis, especially in the tuberculated and spinous varieties, whilst in the spongy it may be unchanged, the chief action being at the expense of the cancel- lated tissue, which expands the compact layer without creating any marked change in the periosteum over it. The soft parts around an exostosis are often but slightly affected by it if it is small, whilst, when it is large, they may be so distended as to be very ol 482 PRACTICE OF SURGERY. much thinned, the muscles sometimes disappearing to such an ex- tent as to leave only a thin layer of muscular fibres. The color of an exostosis is usually that of healthy bone. Causes.—Exostoses may be produced by any cause which will induce increased action in the bone, or its investing membrane, and often follow the development of tubercles in the bone, or secondary or tertiarv syphilis, or rheumatism and gout. In the tibia they sometimes supervene on the long continued irritation of ulcers or nodes, or from repeated contusions of the skin. Symptoms.—The development of exostoses is characterized by various symptoms, especially in their commencement by those which have been detailed as due to. periostitis or ostitis. The symp- toms, after the growth attains a certain size, are those due to the compression of adjacent parts—as swelling, redness, lividity, heat, and inflammation, with ulceration of the skin; abscesses of the cellular tissues; neuralgia, from irritation of the nerves, and aneu- risms or obliteration of the arterial channels. When seated near ' joints, they may impair the motion of the articulation, or develop synovitis, with effusions within the joint, and subsequent anchy- losis. When seated on the vertebrae, they often impair the flexion and extension of the spinal column. When liable to press on the brain or spinal canal, they are also apt to be followed by general or local paralysis; whilst in the pelvis they may interfere with the birth of the foetus, or with the functions of the bladder and pelvic viscera. Diagnosis.—The diagnosis of exostoses may be readily made if ; superficial, by the sense of touch, as they present the characters of firm and hard tumors, of a shape which varies in accordance with the variety. Prognosis.—The prognosis of exostoses is generally very slow and tedious. They may disappear, or, after having reached a cer- tain point, cease to grow, and ultimately become somewhat dimin- ished, though they seldom disappear entirely. The result to life, or the usefulness of adjacent structures, will depend upon their position, as they are dangerous in accordance with the importance of the parts pressed on by their growth. Treatment—The treatment of these growths should consist both in local and constitutional measures, the internal remedies being addressed to the supposed cause of the disorder, and being such as are appropriate to the constitutional treatment of syphilis, rheuma- SPINA VENTOSA AND OSTEO-SARCOMA. 483 tism, or the tuberculous diathesis. As a general rule, the adminis- tration of mercurials is useful, whilst diaphoretics and purgatives are often demanded, with the free use of anodynes if neuralgic symptoms are developed. The local treatment may consist in the employment of blisters, in the neighborhood of the exostosis; in incisions on the tumor when it is superficial, the periosteum being divided around the base of the growth, so as to create a limited necrosis; or in a resection of the substance of the bone, or of a portion of the exostosis when it interferes with the play of the tendons. After the removal of an exostosis, by an operation, the wound should, if possible, be made to unite by the first intention, in order to prevent exfoliation of the adjacent bony tissue. SECTION VIII. SPINA VENTOSA AND OSTEO-SARCOMA. Spina ventosa is an old term, which was employed to designate a peculiar sharp tumor of bone, which resulted in a thin porous structure, that felt elastic and as if filled with air (spina, a thorn; and ventosa, windy). Osteosarcoma, or the bony and fleshy tumor, is another ancient term, sometimes indiscriminately applied to an analogous tumor. Both these tumors are malignant in their character, and would be better designated as Enchondromata, or as Cancer of bone, the growth being generally due to a deposit of carcinomatous matter in the bone, causing an expansion of both its cancellated and compact tissue. In spina ventosa, the greatest development is of the can- cellated structure; whilst in osteo-sarcoma it is rather the compact layer and the external periosteum that are involved, the cancellated tissue being filled with a fleshy carcinomatous structure, whilst the enlarged cells are sometimes also filled with limited effusions of blood, or a lardaceous, soft, and pulpy deposit. Seat—These tumors may affect any of the bones, but that of spina ventosa is most common in the long bones, as those of the extremities, whilst osteo-sarcoma especially attacks the jaw, clavicle, and pelvis. Symptoms.—These growths, when of any size, produce changes 484 PRACTICE OF SURGERY. in the integuments, covering them by impeding the circulation; hence they often present congestion of the veins, and pulsate or throb when the arteries are likewise involved. In the earlier stages, we have all the symptoms of deep-seated abscesses in bone as alluded to in connection with ostitis, accompanied by intense pain and difficulty in the performance of the ordinary functions of the affected bone. Sometimes these tumors acquire considerable volume, and ulti- mately pursue the course and give rise to the same symptoms as have been already described in connection with carcinomatous de- posits in the soft tissues. The tumor usually presents more or less rotundity, has an irregularly depressed and lobulated surface (Fig. 187), over which the venous congestion is very marked, and, when Fig. 187. the skin ulcerates, is accompanied by hemorrhage and the deve- lopment either of a cancerous ulcer or of a fungous growth. Diagnosis.—It is often very difficult to recognize the precise cha- racter of these tumors at their commencement, but at a more advanced period they may readily be distinguished from caries, necrosis, or exostosis, by the character of the swelling, its elastic and sometimes pulsating feeling, and by the absence of the peculiar symptoms which have been stated in connection with these disorders. Prognosis.—The prognosis of these tumors is always serious, the termination of the case being similar to the result of carcino- matous deposits elsewhere. When removed by amputation of the limb, or extirpation of the tumor, the constitutional disorder may be checked apparently for the time, but sooner or later it will carry MOLLITIES OSSIUM, OR OSTEO-MALACIA. 485 off the patient, the disorder showing itself elsewhere—hectic being the usual cause of death. Treatment.—Eesection of the bone, extirpation of the tumor, or amputation of the limb may retard the progress of the disease; whilst the constitutional treatment, as detailed under the head of Cancer, presents the best chances of prolonging the patient's life.1 SECTION IX. MOLLITIES AND FRAGILITAS OSSIUM. An examination of the general constituents of bones shows the presence of two principles to which they owe the proper perform- ance of their function—^one the lime, or earthy matter, giving them hardness, whilst the animal matter adds to their tenacity. Under certain congenital or acquired peculiarities, the proper proportion of one of these elements is sometimes wanting, and a diseased con- dition is established. When the earthy matter is deficient, the bones bend, and are incapable of supporting the patient, or sustain- ing the perfect action of the muscles; hence it has been designated as Mollities ossium, or softening of the bones. When, on the con- trary, there is a deficiency of the gelatinous or animal matter, or when the lime is in excess, the bones want their proper tenacity and become brittle, this condition being designated as Fragilitas ossium. § 1.—MOLLITIES OSSIUM, OR OSTEO-MALACIA. According to the more recent views of pathologists, as Virchow, Redfern, Goodsir, Paget, and others, mollities ossium is an example of that degeneration of tissue which has been designated as the "fatty degeneration," and is shown in the corpuscles of the bone, on the interior of which small fatty molecules appear. These gradually disintegrating, create a liquefaction and separation of the proper bone substance immediately surrounding and including each cor- puscle. 1 For the operations required by these tumors, see Operative Surgery, vol ii. p. 387, 2d edit., under Resection of the Bones and Amputations. 486 PRACTICE OF SURGERY. In examining the bones when thus disordered, they will be found to be more spongy than usual, the cancellated tissue being espe- cially enlarged, and filled with a pink or sanious liquid, which is sometimes almost pulpy, the medullary canal being also much enlarged and filled with this matter. The periosteum is usually thickened, softened, and as if infiltrated with a somewhat similar pulpy matter; the action of the surrounding muscles, or the weight of the body, causing the bones to bend in various degrees of curvature. Patient.—This condition is most common in females, being sometimes seen at puberty, but more frequently in adult life, or at the critical period. It is, however, a rare disorder. Causes.— The causes are not well known ; frequently the disorder has been hereditary, though often the patient has suffered for a long time from chronic diseases, which have weakened the powers of life, as the low forms of fever, or uterine hemorrhages; but little is positively known in regard to these points, the amount of our know- ledge of the true causes creating the condition being limited. Symptoms.—Mollities ossium generally shows itself by symptoms similar to those of rheumatism, especially when the patient has been exposed to cold and moisture ; thus there are pains in the joints, and vague pains often in all parts of the skeleton. After a period which varies, the bones which are affected swell around the articulations, and the movements of the patient become imperfect, each attempt at motion increasing the pain; after which the bones begin to yield to the muscular action, and become curved in various directions, the limbs being shortened, and the position of the patient strongly inclined to a stoop, which creates marked deformity; the legs showing a marked tendency to that curve, which is often designated as "bandy legs." The spine, ribs, and pelvis participating in the curvatures as the disease progresses, the whole figure of the patient becomes crooked and misshapen. Prognosis.—The prognosis is decidedly unfavorable, nearly all the cases recorded having died in a variable period of time, from the subsequent degeneration of other organs, especially the lungs, the function of the latter being sometimes impaired by the changes created in the cavity of the chest. Treatment.—Little can be done to arrest the progress of this dis- order ; the indications being to add to the powers of life by the FRAGILITAS OSSIUM. 487 administration of tonics and chalybeates. Phosphate of lime has been employed, but little benefit has been noticed from its use. § 2.—FRAGILITAS OSSIUM. Brittleness of the bones is the result of a degeneration of tissue consequent on the opposite condition to that seen in osteo-malacia or mollities, the animal matter being removed, and the lime thus left in excess. This condition predisposes the patient to fracture from the most trifling causes, and is generally the result of some congenital peculiarity which is not accurately known. The number of fractures in the same patient under this peculiarity of constitution is sometimes wonderful, one case having been reported of a woman who had twenty-three fractures in the course of two years and a half. One of a lady, who has suffered about eight fractures in as many years, is well known to me; and within three years I have had occasion to treat her for fracture of the humerus, of the radius, and of the femur, all created by trifling forces, she having been pre- viously treated for others in the same limbs. Treatment.—The treatment of the fractures created in these pa- tients is usually the same as is required by fractures arising in those of sound constitutions, though, as far as personal observation has gone, it has seemed to me that the union was much more rapid and perfect than under ordinary circumstances, requiring, in the case of the lady alluded to, about one-jfchird less time than that usually employed in the cure. The constitutional treatment should consist in the administration of chalybeates and tonics, aided by the cold bath and general hygienic measures to improve the patient's strength and powers of digestion. PART VI. INJURIES AND DISEASES OF THE JOINTS. CHAPTER I. LUXATIONS. Among the most important of the injuries which affect the articulating extremities or the contiguity of the bones is that due to their displacement, and designated as a Luxation or Dislocation. A Luxation (luxare, to put out of place) may be defined as the removal of a bone from its natural articulating surfaces. It is a frequent result of the application of certain forces to the parts adjacent to the joints, and has been variously classified for the purposes of study. Varieties.—Luxations may be classified either according to the position of the displaced bone, as primitive and consecutive; according to the nature of the injury, as simple, compound, and complicated; and, according to its duration, as old or recent. 1. A primitive luxation is one in which the articulating surface of a bone is driven out of its natural articulating cavity, to take up some new and false position. 2. A consecutive luxation is one in which the head of a bone leaves its new and abnormal position for some other unnatural one. 3. A complete luxation is one in which the articulating surface is driven entirely out of its natural position. 4. An incomplete luxation is one in which the bone is displaced, but not entirely so, some portion of its articulating surface still re- maining in the natural cavity or upon its edge. Under this variety would come a luxation of the humerus, where the head of the bone rested upon the edge of the glenoid cavity. 490 PRACTICE OF SURGERY. 5. A simple luxation is one in which there is merely a displace- ment, without any greater injury to the surrounding parts than is necessary to permit such an accident; the injury being accom- panied by no external wound. 6. A compound luxation is one in which there is a wound, com- municating with the articulating surfaces of the displaced bones. 7. A complicated luxation is one in which the patient suffers simultaneously from any disease or injury; thus, a dislocation may be complicated with fracture, with anemia, or with aneurism, &c. Etiology.—The causes of these injuries may be classified as^re- disposing and exciting, or as constitutional and local. Among the predisposing or constitutional causes, may be enu- merated diseases of the articulating surfaces of the bones, relaxation of the ligaments, and paralysis of the muscles. The exciting causes are mechanical violence or muscular contractions, of such a character as to force the bone from its position. Luxations are produced in various joints with different degrees of facility, the ball and socket joints being more liable to the accident than the ginglymoid. The nature of the joint, also, affects the direction of the luxation. In a ball and socket joint, luxations may occur in four directions, upwards, downwards, forwards, and backwards. In the gingly- moid joints, on the other hand, they occur most frequently laterally, though sometimes backwards or forwards, as in the case of the knee or ankle-joint. Post-mortem Appearances.—A post-mortem examination, in a case of recent luxation, reveals more or less effusion of blood, and laceration of the tissues surrounding the displaced bone, as the capsular ligament and muscles. Lacerations of bloodvessels, and of nerves of considerable size, are also sometimes found. If the luxation has remained unreduced for some time, other changes appear, which are due to the progress of inflammation; thus it will be found that lymph has been effused and organized so as to form various adhesions, which thus bind together the parts surrounding the joint. Large nerves or vessels may then be caused to adhere closely to the displaced bone, as is sometimes the case with those of the axilla in old luxations of the shqulder-joint. If the head of the displaced bone has been in contact with a bony surface for any length of time, in its new position, it will also sometimes be observed that the effusions in this locality have resulted in the formation of callus, thus producing a new articulating cavity, more or less com- LUXATIONS. 491 plete, many specimens of which are to be found in most cabinets. Such new articulations often possess a considerable degree of mobility. Symptoms.—The symptoms of luxations are often well marked. There is pain caused by the stretching and laceration of nerves, or by pressure upon them, in consequence of the new position of the head of the bone. There is change in the appearance of the joint, its natural rotundity and fulness having disappeared, and deformities resulting, as will be fully described in connection with the special luxations. There will be impaired mobility in the joints, and changes in the condition of the surrounding muscles, some being put preternaturally upon the stretch, and some preternatu- rally relaxed. Diagnosis.—The diagnosis requires great care, and a good ana- tomical knowledge of the parts concerned; luxations being liable to be confounded with sprains, fractures, lacerations of the liga- ments of the injured articulation, chronic diseases of the joints, as hip-joint disease or white swelling, and displacement of the arti- cular cartilage. The diagnosis from these diseases and injuries will be given in connection with the special luxation. Treatment—The treatment of luxations may be arranged under two general heads, the constitutional and the mechanical. The con- stitutional treatment consists in the use of such means as will result in the production of complete muscular relaxation, and will be found detailed in connection with the subject of luxation of the hip. The mechanical means are such as are necessary to the applica- tion of force, for the purpose of accomplishing the reduction. Compound Luxations.—When a luxation is compound, the in- jury is not only more dangerous and difficult to treat than a simple luxation, but even more so than a compound fracture, the inflammation resulting from, the entrance of atmospheric air into the cavity of the joint, being generally violent, and terminating in suppuration and hectic fever, so that amputation may be necessary to save life. The prognosis, therefore, should be guarded. 492 PRACTICE OF SURGERY. CHAPTER II. LUXATIONS OF THE BONES OF THE HEAD AND TRUNK. SECTION I. LUXATION OF THE INFERIOR MAXILLARY BONE. Luxation of the lower jaw is produced by causes similar to those which produce fracture of this bone; but, the former, as has been previously stated, is much more common than the latter accident on account of the mobility of the jaw. Anatomical Relations.—The articulation of the lower jaw is formed by the condyloid process of the inferior maxillary bone, which arti- culates with the glenoid cavity of the temporal bone. It is sur- rounded by a capsular ligament, and has within its cavity a structure known as the inter-articular cartilage, which equalizes the two surfaces in the various positions which the bone assumes. The joint presents also an external and internal lateral ligament, and two synovial membranes. Etiology.—Any force applied to the front of the jaw, while the mouth is open, may produce this luxation, by driving it back until the mastoid process of the temporal bone becomes a fulcrum, whence the condyloid process is thrown forward, and brought to bear against the anterior surface of the capsular ligament. This giving way, the head of the bone slips out so as to take a posi- tion in advance of the glenoid cavity. Luxation of the lower jaw may affect either the articulation of one side, or both; and occurs most frequently in persons of middle age, though sometimes seen in early life and in old age. There is also a condition of parts, which permits the production of what is described as a spontaneous luxa- tion of the lower jaw, this being due to a relaxation of the muscles and ligaments of the part permitting the luxation to occur at plea- sure, or from trifling causes. Persons, accordingly, are sometimes found, in whom the simple act of gaping is sufficient to induce the LUXATION OF THE INFERIOR MAXILLARY BONE. 493 luxation. Fortunately, however, the same relaxation which per- mits the ready occurrence of the luxation, renders it also very easy of reduction. Symptoms.—The symptoms of luxation of the lower jaw vary; if it be of one side alone, the Jaw will be twisted towards the opposite side, the chin slightly protruded, and the mouth held per- manently more or less open. If it affects both sides, the mouth will be held forcibly wide open, the chin will be thrust forward, speech and deglutition rendered impossible, the saliva dribble from the mouth, and the appearance of the patient be so characteristic that the accident will be readily recognized. When such a condition occurs, the temporal as well as the mas- seter and pterygoid muscles are put upon the stretch, and often spasmodically contracted, while the muscles on the front of the neck are relaxed. Treatment.—In the treatment, therefore, it becomes necessary to exert such a force as will overcome the contraction of the extended muscles, particularly the temporal and masseter, and draw down the jaw, so as to enable its condyloid process to clear the prominence of the anterior edge of the glenoid cavity, until it can be slipped back into its true position. The patient should therefore be placed upon a low seat, and the thumbs of the operator—unless he be willing to rely upon his dexterity in slipping them out of the way—be wrapped in a handkerchief or towel, and then introduced so as to bear upon the molars of the inferior maxillary bone, these being depressed by the thumbs whilst the chin is elevated with the^ fingers, until the contracted muscles begin to yield, when the bone will suddenly slip backward into its place, and create an audible snap. Generally when the surgeo*n feels the jaw begin to yield to his forces, he should slip his thumbs off the teeth out into the cheek, to avoid having them bruised by the spasmodic closure of the jaw which ensues. When the luxation is reduced, the jaw should be bound up with a handkerchief to keep it at rest; but for some days, after the bandage is dispensed with, the patient should refrain from biting upon hard substances, or opening his mouth widely, lest he reproduce the luxation. 494 PRACTICE OF SURGERY. § 1.—SUBLUXATION OF THE INFERIOR MAXILLARY BONE. Symptoms.—Cases sometimes occur in which the patient com- plains that, whenever he moves the. lower jaw, he heSars a peculiar crackling noise in the articulation, and that it causes him pain. This is generally due to the condition described by writers as sub- luxation of the inferior maxillary bone. Pathology.—The true condition of parts in this affection is gene- rally more or less deficiency in the synovial secretion of the joint, together with such a relaxation of the ligaments as enables the interarticular cartilage to slide forwards and be pinched between the bones. Prognosis.—The case is one rather of annoyance than of danger to the patient. Treatment.—The most effectual plan of treatment is the use of means calculated to give tone to the parts: shower-baths and cold douches proving highly serviceable; but, perhaps, the most suc- cessful treatment is the repeated application of blisters in the neigh- borhood of the articulation. SECTION II.' LUXATIONS OF THE BONES OF THE TRUNK. § 1.—LUXATIONS OF THE VERTEBRA. Luxations may occur in any part of the* spinal column, but the inj ury is not a common one. Generally, it is the result of a force applied to one portion of the spine while the rest is fixed, and requires a considerable amount of mechanical power for its develop- ment, being seldom produced by muscular contraction, except when aided by weights on the head. The part of the spinal column most likely to suffer is the cervical portion (see Fig. 188), especially the articulation between the atlas and dentata. When the latter luxa- tion takes place, sudden death commonly results from pressure upon the spinal cord, which indeed is by no means an uncommon termi- nation in luxations of any of the cervical vertebrae. LUXATIONS OF THE VERTEBRA. 495 In luxations of the cervical (see Figs. 188,189), dorsal or lumbar vertebras, if the luxation is complete, pressure upon the spinal cord Fig. 188. Fig. 189. Fig. 188.—A front view op a Luxation or the Spine between the Fourth and Fifth Cervical Vertebra, the patient having fallen backwards over a high paling and alighted on his head. The spinal cord was torn, and there was complete paralysis, fol- lowed by death in a few days. (After Miller.) Fig. 189.—A side view of the same, the spinal canal being laid open in order to show the compression and laceration of the spinal cord. (After Miller.) at the seat of the injury, and more or less paralysis of the parts supplied by nerves given off" below the seat of compression, will generally ensue, this being followed by death if the pressure is long continued. Symptoms.—The symptoms in those cases which have not at once terminated fatally, have generally been those of compression of the spinal cord, paralysis of the extremities, &c. Besides which, a careful examination of the spinal column will sometimes reveal the displacement of one or more of the spinous processes at the seat of the injury. Diagnosis.—The permanency of the deformity, the immobility and twisted direction of the column, with the sudden paralysis, generally suffice to show this injury, and to distinguish it from a fracture. Prognosis.—The prognosis is always grave, the patient rarely re- covering completely from the effects even of a partial luxation. With regard to the probability of a fatal issue, it may be stated, as a general rule, that the higher the seat of the injury the greater will be the danger to life. 496 PRACTICE OF SURGERY. Treatment—The treatment requires great care. If the case has not immediately terminated in death, it may sometimes be possible by moderate extension and counter-extension to reduce the luxa- tion, and this is especially the case in those instances in which the accident occurs to children from injudicious manoeuvres on the part of parents or friends, such as lifting a child up by its ears to make it "see London;" when, as it struggles violently to free itself, a dislocation is produced, children having been known to drop dead under these circumstances. In such a case, if life is not extinct, it will be justifiable to make a moderate amount of ex- tension by promptly drawing on the head with the hands, whilst counter-extension steadies the pelvis, tbe parts being at the same time coaptated laterally with a view to the reduction of the luxa- tion. But, before the surgeon makes such an attempt, he should inform the friends of the little patient of the possibility of the mani- pulations increasing the lesion and causing instant death. A partial luxation of the vertebrae, or a luxation of an oblique process on one side, occasionally occurs, which can sometimes be reduced in .the same manner. The after-treatment consists in rest in the horizontal position and the employment of means calculated to counteract and subdue the inflammation which will probably arise in the spinal cord or its membranes. Where paralysis occurs after such an accident, it will be requisite to attend carefully to the condition of the bowels and bladder, as in any other case of paralysis of the lower parts of the body. § 2.—LUXATION OF THE RIBS. Luxation of the head of a rib from its articulations with the vertebra, though a rare accident, so rare, indeed, as to be denied by some very respectable surgeons, sometimes occurs, as is shown by the specimens to be found in some cabinets. The difficulties in the way of such an accident are apparent when the strength of the articulation of the ribs with the vertebras is borne in mind, aug- mented as it is by the interarticular ligament, and the articulation with the transverse processes of the vertebras, and supported by the mass of the muscles of the back. When the accident occurs, however, it is generally the result of such violence that the consti- tutional, rather than the local symptoms, become of importance, LUXATION OF THE CLAVICLE. 497 and very little can be done in the way of reduction beyond mere coaptation by the fingers of the surgeon. The eleventh and twelfth ribs are those most likely to suffer from this luxation. Luxation of the sternal extremity of the ribs sometimes occurs, and produces a well-marked deformity, which, if the cartilages on both sides are displaced, sometimes produces a prominence of the sternum resembling the condition ordinarily known as "chicken breast;" a condition sometimes found in children as dependent on the bending or displacement of the cartilages of the sixth, seventh, and eighth ribs. Treatment.—In the treatment of these luxations, after reducing the displacement and overcoming inflammatory action, if the de- formity is reproduced, compresses and a circular bandage may sometimes be required; but usually little can be done to remedy the deformity, the treatment being confined to the relief of the injuries of the internal organs of the chest consequent on the appli- cation of the force which created the luxation. § 3.—LUXATION OF THE CLAVICLE. Luxation of the clavicle may occur at the humeral, or at the sternal extremity. The sternal end may be luxated in three directions, forwards, backwards, and upwards. When a luxation forwards occurs, there is a prominence upon the front of the sternum due to the presence of the head of the clavicle which can be felt distinctly beneath the skin, a shortening of the pectoral space, and an ina- bility on the part of the patient to raise the arm in the natural manner. The cause is generally some force applied to the shoulder in such a manner as to force the outer end of the clavicle towards the sternum. In the luxation backwards, there is also diminution of the pectoral space and inability to raise the arm, but instead of a prominence, there is a hollow where the head of the clavicle should naturally be found. The luxation upwards and towards the opposite clavicle can also be recognized by the position of the head of the bone. Treatment—In all these luxations of the clavicle the treatment is simple, the arm being used as a lever to draw the clavicle out to Its proper length, whilst the shoulder is carried in a direction which 32 498 PRACTICE OF SURGERY. will correspond with the displacement, extension and counter- extension being made, and the shoulder so acted on as to throw the head of the bone back into place. Thus, in the luxation forwards, the shoulder should be carried forwards, in order to force the head of the bone backwards into its natural position. If the luxation is backwards, the shoulder should be carried backwards so as to throw the head of the bone forwards into position; whilst in the luxation upwards the shoulder should be carried upwards and outwards so as to throw the sternal extremity down into its posi- tion. The luxation being reduced, the after-treatment consists in the application of some apparatus suitable for the treatment of fracture of the clavicle, as Fox's, Dessault's, &c, but it is extremely difficult to keep the parts in position, and, in spite of every care, more or less deformity generally results, a fact which the surgeon should bear in mind in his prognosis. There may also be a dislocation of the scapular extremity of the clavicle, and as its articulating surface is of small size, any force which ruptures its ligaments will prove capable of producing the luxation. This may occur in two directions; in the one the ex- tremity of the clavicle,, slips above, and in the other it slips beneath the acromion process of the scapula. Both these luxations are extremely easy to reduce. If the scapular extremity of the clavicle rests on top of the acromion process of the scapula, by elevating the shoulder, at the same time that it is drawn outward, the bone will be brought into its place. So when the scapular extremity of the clavicle has slipped under the acromion process of the scapula, by drawing the shoulder outwards and depressing it slightly, the end of the bone will, start into its place. But the difficulty which will be experienced in the treatment will be found in the fact, that, although comparatively easy to reduce, the bone will again slip out of place so soon as the reducing force is relaxed, and it is often extremely difficult to contrive such a dressing as will retain it in position until union occurs in the lacerated ligaments. Fortunately, however, even should the treatment fail to retain the bone in its original position, the usefulness of the limb will only be impaired to a very limited extent. All the motions of the arm can readily be performed except extreme elevation, and the patient will be able to use the limb in all the ordinary avocations of life. In a female, however, and particularly in a young female, the trifling deformity which results being apparent whenever she wears a low- DISPLACEMENT OF THE LATISSIMUS, ETC. 499 necked dress, it becomes a matter of some importance to correct it; and even in a man, the surgeon will always desire to make as complete a cure as possible. There are but two bandages capable of holding the bone in position; one is the bandage of Yelpeau for Fig. 190. A FRONT VIEW OF THE SPICA BANDAGE OF THE SHOULDER AS APPLIED FOR THE RE- TENTION of a Luxation of the Humeral End of the Clavicle.—In its application, commence by applying the Spiral Bandage of the upper extremity, covering in the whole limb from the fingers to the shoulder so as to protect the skin of the arm from the con- gestion of its veins. On reaching the shoulder, carry another roller obliquely across the chest round under the sound axilla over the luxated end of the clavicle ; thence under the axilla of the injured side, over the point of the shoulder, and then under the sound axilla to follow the same course, each turn covering in two-thirds of the preceding turn, and forming a spica on the shoulder as shown in the cut. (After Nature.) fracture of the clavicle, the arm being bound to the chest by oblique turns, whilst the hand of the patient grasps his sound shoulder; the other, that of the spica of the shoulder (Fig. 190), which is, perhaps, the best of the two for those cases in which its pressure can be borne. § 4.—DISPLACEMENT OF THE LATISSIMUS DORSI MUSCLE FROM THE LOWER END OF THE SCAPULA. There is an injury sometimes alluded to in connection with these luxations, although it does not come within the definition assigned to such injuries, and this is the displacement of the latissimus dorsi 500 PRACTICE OF SURGERY. muscle. As the tendon of the latissimus dorsi plays over a trian- gular surface at the outer side of the inferior angle of the scapula to which it is more or less firmly attached, it sometimes happens, in consequence of a fall or some other violence, that the muscle slides off this surface and slips down beneath the scapula, in consequence of which the patient- loses more or less the power of this muscle in depressing the arm. Symptoms.—This injury may be recognized without any great difficulty by the change in the power of the arm when elevated, and by the unusual prominence of the point of the scapula. Treatment.—To reduce it, draw the arm back so as to relax the muscle as much as possible and coaptate the parts with the fingers, after which the arm should be retained against the side of the body by circular turns of a bandage until adhesion of the displaced muscle occurs. CHAPTER III. LUXATIONS OF THE UPPER EXTREMITY. SECTION I. LUXATION OF THE HUMERUS. Anatomical Relations of the Shoulder-Joint—In the shoulder-joint the spherical head of the humerus plays against the comparatively superficial glenoid cavity of the scapula, which, although deepened by the glenoid ligament, is yet so shallow that the head of the bone may readily be brought to bear against the capsular ligament; and, if sufficient force is applied, lacerate it and escape from its natural articulating position. Such an accident would be of daily or hourly occurrence were it not guarded against by the great mobility of the scapula which gives way before every force-in such a manner that it might seem almost impossible to displace the head of the humerus. Statistics, how- ever, show that this luxation is of comparatively frequent occur- rence; most probably because sudden forces take the muscles by LUXATION OF THE HUMERUS. 501 surprise, and act before they have time to accomplish that adapta- tion of parts which might prevent the displacement. In considering the anatomy of this joint, with a view to the correct understanding of the manner in which these luxations occur, it should not be forgotten that the surrounding muscles exercise a considerable influence upon the joint by adding greatly to its strength; thus the tendon of the long head of the biceps passes through the joint within the capsular ligament in its course from its origin from the upper edge of the glenoid cavity to its insertion into the tubercle of the radius, while the supra-spinatus muscle stretches from its origin above the spine of the scapula to its insertion in the greater tuberosity of the humerus, thus passing over the top of the joint and strengthening it above; the function of this muscle being to assist in the extreme elevation of the arm. More superficially the joint is covered above by the deltoid, while below and laterally are the two teres, the sub- and infra-spinati, and the coraco-brachialis muscles. Etiology.—The luxation of the head of the humerus may be caused by two classes of forces; first, those applied directly to the head of the bone, as falls or blows upon the shoulder-joint; and, secondly, indirect violence, such as that resulting from falls upon the hand or elbow, whilst the arm is carried off from the body, the force being transmitted through the bones of the forearm or arm to the shoulder, and the resistance made by the weight of the body. Varieties.—Luxations of the head of the humerus occur in three directions:— 1. The inferior part of the capsular ligament may be lacerated, and the head of the bone escape down into the axilla, putting all those muscles upon the stretch, which, like the supra-spinatus and deltoid, tend to hold it up in its natural position. This is the luxation downwards. 2. The capsular ligament may be lacerated in front, and a luxa- tion of the head of the humerus forwards ensue. 3. The capsular ligament may be lacerated posteriorly, and the head of the bone slip out to take a position below the spine of the scapula, this being described as a luxation backwards. Besides these entire or complete forms, there may be an incom- plete luxation, in which the head of the bone will rest upon the extreme edge of the glenoid cavity. Symptoms.—The first symptoms which should' be looked for in 502 PRACTICE OF SURGERY. order to establish the presence of these injuries are those which may be classified under the general head of deformity. In order to understand this deformity, and to recognize it when it exists, the natural rotundity and fulness of the shoulder should be borne in mind, as well as the fact that the acromial extremity of the clavicle, and the two tuberosities of the humerus, are naturally on the same level. Bearing these facts in mind, the presence of the various de- formities will be readily recognized. § 1.—LUXATION OF THE HUMERUS DOWNWARDS INTO THE AXILLA. Symptoms.—When luxation of the head of the bone into the axilla occurs, there is a flatness of the shoulder, the natural rotundity of the joint being destroyed, and a depression created; the surgeon being able, in thin patients, to hook his fingers under the acromial process of the scapula. As the deltoid muscle is put upon the stretch by the displaced bone, the arm is usually carried off from the side, whilst, if the surgeon feels in the axilla, he will there find the head of the humerus, forming a smooth round tumor, which, in thin subjects, is even readily perceptible to the sight. Generally there is, in addition, a marked change in the length of the limb, as may be proved by measuring it and the sound limb between two fixed points, as from the acromion process of the scapula to the external condyle of the humerus, measuring first the sound side and afterwards the injured one. In a case of luxation downwards in a full sized adult, the limb will be found lengthened an inch or an inch and a half. Besides the lengthening of the limb, there is also loss of power; the patient not being able to hold the limb by its own muscles, and therefore resting the elbow upon his knee, or support- ing it with the hand of the opposite side. If the surgeon seizes the arm and attempts to elevate it, great pain will be caused in conse- quence of the pressure of the head of the bone upon the axillary plexus of nerves. For the same reason, if the luxation continues unreduced for several hours, the patient will often experience a tingling sensation in the fingers, whilst a certain amount of oedema- tous swelling will ensue in consequence of the pressure made by the head of the bone upon the axillary bloodvessels. Diagnosis.—These symptoms, when taken collectively, are so marked, that a case of luxation downwards into the axilla can gene- LUXATION OF THE HUMERUS FORWARDS. 503 rally be recognized with but little difficulty. Still, cases are occa- sionally presented in which, from the swelling caused by effusion into the surrounding tissues, the diagnosis cannot be certainly made; or difficulty may result from the fact that the luxation is combined with fracture. In the first case, the measurement of the length of the limb becomes peculiarly useful. In the second, the symptoms of fracture of the neck and head of the bone must be borne in mind. § 2.—LUXATION OF THE HUMERUS FORWARDS. Luxation forwards presents a very different condition of parts. The capsular ligament, in this case, is ruptured anteriorly, and the head of the bone escapes forward to take a position on the front of the chest, a little distance below the clavicle, and directly beneath the great pectoral muscle. There is another luxation which some- times occurs, and which is a secondary one, in which the head of the bone leaves this new position, and assumes one higher up and nearer the clavicle. * Symptoms.—When the head of the bone gets into this position, the elbow is carried off from the side more strongly than in the dis- location downwards, and any effort to bring it in towards the chest gives great pain. The arm, also, projects more or less backwards. The deltoid muscle is not put so much upon the stretch as in the last variety, nor is the shoulder so much flattened;. but in a thin person, the fingers of the surgeon may now also be readily hooked under the acromion process, whilst the roundness caused by the head of the bone may be seen near the position of the coracOid process of the scapula, as is shown in Fig. 191. § 3.—LUXATION OF THE HUMERUS BACKWARDS. If the force is applied whilst the arm is carried across the body, the capsular ligament will give way posteriorly, and a dislocation backwards ensue. This deformity is entirely different from the last variety. In luxation backwards, the elbow goes forwards and against the body; whilst in luxation forwards it went backwards and from the body. The head of the bone, also, forms a tumor upon the inferior fossa of the scapula, resting upon the infra-spi- 504 PRACTICE OF SURGERY. natus muscle, where, if the patient is comparatively thin, it may be distinctly felt. Fig. 191. t.-, A front view of the flat appearance of the Shoulder seen in Luxation of the Head of the Humerus forwards. (After Miller.) Mechanism of Luxations of the Head of the Humerus.—In order to understand the manner in which the force is to be applied to reduce these luxations, their mechanism and the muscular attachments concerned should be thoroughly understood. When the head of the bone is luxated downwards into the axilla, the supra-spinatus muscle is put upon the stretch; it is also spasmodically contracted, and its spasmodic contraction in the new position of the bone serves to draw the head of the humerus firmly up against the inferior edge of the glenoid cavity; hence, the spasmodic contraction of this muscle is one of the obstacles which must be overcome in the reduction. Another muscle put upon the stretch and spasmodically contracted, to some extent, is the deltoid, which acts similarly. The other muscles are but slightly changed, the latissimus dorsi and the pectoral being a little relaxed. In the reduction of the luxation downwards, means must, therefore, be used to overcome the spasmodically contracted mus- cles, in order to draw the head of the bone clear of the lower edge LUXATION OF THE HUMERUS BACKWARDS. 505 of the glenoid cavity; after which, the humerus can readily be car- ried off from the body, so as to ride clear of this edge back into its place. In so marked a manner does the contraction of the supra- spinatus aid in retaining the bone in its unnatural position, that in a post-mortem examination of a patient who died whilst laboring under an unreduced dislocation of the humerus downward, Sir Astley Cooper, cutting away the muscles one after another, found himself unable to reduce the bone until he had divided the tendon of the supra-spinatus muscle. In the dislocation forwards, the supra-spinatus is also put upon the stretch, but not so much as the infra-spinatus. The latissimus dorsi is also slightly stretched or entirely unchanged, while the pectoralis major is much relaxed, and would be still more so, were it not for the tumor formed beneath its belly by the head of the bone. The chief obstacles to the reduction are the contrac- tions of the supra and infra-spinatus with the deltoid, and the force must, therefore, be applied in such a manner as to overcome these muscles, in order to accomplish the reduction. In the dislocation backwards, the latissimus dorsi, the supra- spinatus, the sub-scapularis, and the teres major muscles with the pectoralis major, will be stretched, and the deltoid and infra-spinatus relaxed. Diagnosis.—Besides the ordinary points of diagnosis which apply equally to all luxations, such as the diagnosis from diseases of the bones, from fracture, &c, it sometimes happens that in consequence of a sprain or blow, or an injury of the circumflex nerves, or of causes not precisely understood, an atrophy of the deltoid muscle takes place, in consequence of which a flatness of the shoulder is produced, simulating somewhat the appearances presented by a dis- location downwards. The diagnosis, however, is easy, as the limb retains almost its natural length; and although the shoulder is flat- tened, the fingers cannot be hooked under the acromion process as perfectly as they can be in cases of luxation, nor can the head of the bone be felt in the axilla. The disease is to be treated on the prin- ciples required for the development of the muscles, as friction, cold douches, and electricity, the current being made to pass through the deltoid, by applying one pole of the current in the axilla, and the other to the muscle. Treatment.—As muscular contraction is the chief obstacle to the reduction of these luxations, whatever aids in inducing muscular relaxation must facilitate the replacing of the head of the bone in 506 PRACTICE OF SURGERY. Fig. 192. its true position; and there is no better method of inducing this complete muscular relaxation than by means of anaesthesia as produced by ether, or ether combined with chloroform, in the pro- portion of one part of chloroform to three of ether by weight. In the application of any mechanical force for the reduction of this luxation, even when the patient is insensible, the variety of the luxation must be taken into consideration. In the luxation downwards into the axilla, if the patient is completely etherized, it will gene- rally be sufficient, if he is reclining, for the surgeon to make counteT- extension with one hand against the axilla, whilst extension is made at the elbow of the injured side with the other, the arm being gradually extended at right angles to thebody, so as to free the head of the bone from the inferior edge of the glen- oid cavity; or, if the patient is seat- ed or held up, by depressing the arm over the knee placed in the axilla. (Fig. 192.) But should these means fail, or should any circumstance prevent the use of ether, the fol- lowing plan may be adopted. Place the patient in the recumbent posi- tion, and, protecting the axilla by a wad of cotton, carry the arm off, at an obtuse angle, from the body, in order to relax the supra-spina- tus and deltoid. Then the surgeon, drawing off his boot, should sit down by the patient, and place his foot on the pad in the axilla, where it will make counter-extension while he makes extension with his hands by drawing on the wrist, or by drawing on a band made fast by a clove hitch to the arm above the elbow, as shown in Fig. 193. When the muscles begin to yield to this force, bend the arm suddenly over the foot towards the body, and, relaxing the extension, the head of the bone will generally return into its place with an audible snap. But where ether cannot be obtained this plan will often fail, A front view of the Position of the Sur- geon and Patient in a Reduction of a Luxated Humerus, by placing the'knee in the patient's axilla, and bending his arm over it whilst counter-extension is made at the scapula. (After Cooper.) LUXATION OF THE HUMERUS BACKWARDS. 507 especially if the patient be a muscular man. In such a case, it may become necessary to use pulleys, attaching them to the limb by the clove-hitch, in the manner that will be hereafter described in connection with luxations of the femur. Counter-extension may be made by means of a folded sheet or towel placed in the axilla, Fig. 193. A side view of the mode of reducing a Luxation of the Head of the Humerus into the Axilla, by extension at the elbow, whilst counter-extension is made by the foot of the sur- geon pressing against a pad in the patient's axilla. (After Cooper.) or by a nicely padded buckskin band. But even when the pulleys are employed, much of the success of the treatment will depend upon the use of such manipulation as will rotate the head of the humerus free from the edge of the glenoid cavity. The same general rules will be applicable for the reduction of the luxation backwards and the luxation forwards, but with some modification in the direction of the force applied. In both cases, as in that just described, the extending force is to be em- ployed in the line which is naturally taken by the luxated limb; thus in the luxation forwards the line of the extending force should carry the limb off from the body, and in the luxation backwards carry it towards the body. After-Treatment—Having reduced the luxation, the after-treat- ment will consist in any means, such as Fox's apparatus, &c, which will keep the parts at rest until union of the lacerated capsular ligament has occurred; the patient being advised for some length of time to abstain from any motions which would be likely to bring the head of the bone to bear upon the injured portion of the capsular ligament. 508 PRACTICE OF SURGERY. Occasionally the injury to the parts surrounding the joint result- ing from the force which produced the accident, or from that which is employed in the reduction, causes such a degree of inflammatory action as requires the use of active antiphlogistic measures. Thus it may be necessary to cup or to leech around the part, or to apply cold cloths, cloths wrung out of lead-water, &c. Should paralysis of the limb, either partial or complete, result from pressure of the head of the bone upon the axillary plexus of nerves, those measures must be resorted to which are adapted to local paralysis; as stimulating liniments, blisters, or blisters dressed with strychnine. Should these measures fail, much may be done by the judicious employment of electro-galvanism; by cold douches, etc., and in the majority of cases the judicious employment of these measures will ultimately restore the usefulness of the limb. § 4.—COMPOUND LUXATIONS OF THE SHOULDER-JOINT. A compound luxation of the shoulder is a dangerous injury, more so even than compound fractures of the neck of the bone. In its treatment, the parts should first be cleansed thoroughly of all foreign matters, after which the bone should be returned into place, and inflammation actively combated. Should the head of the bone protrude from the wound,*and the muscles around it become spas- modically contracted so as to prevent its reduction, the orifice through which it protrudes should be enlarged with a scalpel, suf- ficiently to enable the bone to be returned into its place as directed in the case of compound fractures, or the head of the humerus may be sawn off, as in a resection of this bone for disease of the shoul- der-joint. SECTION II. LUXATIONS OF THE ELBOW-JOINT. Anatomical Relations.—The elbow-joint is composed of the articu- lating surfaces of the condyles of the humerus, the head of the radius and the sigmoid cavity of the ulna, the part of the articulat- ing surface of the humerus which the olecranon and coronoid pro- LUXATION OF BOTH BONES OF THE FOREARM BACKWARDS. 509 cesses of the ulna play, being called the trochlea, or sometimes the epitrochlea. The articulation of the ulna with the humerus is strengthened by the anterior, posterior, and lateral portions of the capsular ligament of the joint; by the shape of the olecranon and coronoid processes, and by the attachments of muscles, particularly the biceps, which is inserted into the tubercle of the radius, whilst the brachialis anticus is inserted into the coronoid process of the ulna. The radius which articulates with a little head near the external condyle of the humerus, As bound to the ulna by the orbi- cular ligament into which many of the fibres of the external lateral ligament are inserted. This joint presents, therefore, an excellent specimen of the ginglymoid variety of articulations. Varieties.—When a sufficient force is applied to produce a luxa- tion of the elbow-joint, it may occur in three different directions. In the first, both bones of the forearm go backward, and the coronoid process of the ulna rests in the greater sigmoid cavity of the hume- rus. In the second, both bones go outwards, and in the third, both bones go somewhat inwards. It is nearly impossible that a disloca- tion of the bones of the forearm forwards should occur independently of fracture of the olecranon process. In the lateral luxations, al- though both bones are displaced from their natural articulating sur- face, both are not entirely removed from their connection with the humerus. Thus, in the luxation outwards, the radius is entirely removed from the humerus, while the ulna, though displaced from its position in the epitrochlea, is still in contact with the humerus, resting at a point corresponding with the articulating face for the radius. So in the luxation inwards, the ulna may be driven en- tirely off the articulating surface designed for it, while the radius, though luxated from its natural position, will still remain in con- tact with the humerus at a point corresponding with some part of the epitrochlea. § 1.—LUXATION OF BOTH BONES OF THE FOREARM BACKWARDS. The luxation of both bones of the forearm backwards, may be pro- duced by force applied to the hand while the forearm is extended upon the arm, so that the head of the humerus may be brought to bear against the anterior face of the capsular ligament, as when a patient falling forward extends his hands to save himself. 510 PRACTICE OF SURGERY. Symptoms.—The symptoms are marked. There is a deformity which is quite characteristic, and which may be described as having a general resemblance to the shape of the heel of the foot, the triceps being put upon the stretch and its tendon brought into a position comparable to that of the tendo-Achillis, while the ole- cranon projects backwards after the manner of the os calcis. (Fig. 194.) There is pain, which is often very severe from pressure upon Fig. 194. A side view of the appearance of the Elbow-Joint when both bones of the forearm are luxated backwards—showing the lengthening of the elbow and the shortening of the fore- arm. (After Liston.) the ulnar nerve, this being sometimes pinched between the two bones, whilst there is also laceration of the fibres of the muscles and ligaments on the front of the articulation. In addition, there is more or less loss of motion in the joint, the arm being held in a semiflexed position which admits neither of complete flexion or extension. There is also a change in the length of the forearm, as may be proved by taking the measurement of the sound forearm from the internal or external condyle of the humerus to the styloid process of the radius or ulna, and applying the same measurement to the injured limb, when that in the side which is luxated will be found to be shortened to the extent of an inch or an inch and a half. If a circular line be drawn around the joint through the condyles of the humerus, as was directed in fracture of the condyles, it will LUXATION OF BOTH BONES OF THE FOREARM BACKWARDS. 511 also be found that it no longer cuts the point of the olecranon, this being usually found some distance above its normal position. Diagnosis.—The injury most likely to be confounded with this luxation is fracture of the condyles, and particularly such a fracture as allows the bones of the forearm to slip backwards. The latter case sometimes requires nice discrimination; but a diagnosis can generally be made, because the signs of fracture are superadded to those of dislocation. Thus the pain of fracture is present, this being described by the patient as sharp and cutting, while that of luxation is dull and obtuse; and in drawing the circular line around the elbow-joint it will be observed that one of the condyles is out of line as well as the olecranon process. But the most satisfactory diagnostic mark is, that while the luxation when combined with fracture can be reduced with ease, yet upon removing the extend- ing and counter-extending force the deformity is at once repro- duced. A simple luxation also requires more force to reduce it than one consequent on a fracture, whilst it also retains its position after the reduction, which one due to a fracture does not. Treatment.—In the luxation of the bones of the forearm back- wards, as the contraction of the biceps and brachialis anticus pull the coronoid process of the ulna violently against the humerus, thus preventing the reduction, force must be employed to draw the bones off from the humerus, that they may be slipped forward into place. This may be done by etherizing the patient thoroughly, and then seizing the forearm with one hand, draw off the humerus with the other so as to make counter-extension, and flex the forearm, when reduction will generally be accomplished. But if this is not sufficient, or if from any cause ether cannot be employed, two towels may be folded and placed one around the arm and the other around the fore- arm, and be confided to two assistants, the strongest assistant seizing that attached to the forearm. Then, while the surgeon makes exten- sion by the hand of the patient and forcibly flexes the forearm, trac- tion is to be exercised simultaneously by both assistants, when the luxation will hardly fail to be reduced. In many instances, however, even without etherization, all that is necessary to reduce this luxa- tion will be for the surgeon to make extension and counter-extension with his hands at the same time that he flexes the forearm forcibly over his knee, or around a padded bed-post, which answers the same purpose. 512 PRACTICE OF SURGERY. § 2.—LATERAL LUXATION OF THE ELBOW. The lateral luxations of the elbow are of rare occurrence. Etiology.—They are produced generally by a force applied late- rally while the arm is flexed. Symptoms.—There is an increased width of the joint, distinguish- able from that of fracture of the condyles by the fact that the ole- cranon process, or the head of the radius can be felt projecting abnormally on one side of the articulation, and being also unac- companied by the acute pain which always attends a fracture. Prognosis.—The prognosis in lateral luxations of the elbow-joint should be guarded; for, although, if the character of the injury is recognized, it can generally be reduced and deformity avoided, yet anchylosis more or less complete is very liable to occur, from the laceration of the ligaments of this close articulation. To prevent dissatisfaction, the patient should always be informed of this fact at an early period. Treatment.—The lateral luxations are to be reduced by the appli- cation of force in a lateral direction, whilst the forearm is flexed upon the arm. The force may be produced by a towel passed around the forearm and confided to the hands of an assistant, suffi- cient extension and counter-extension being kept up at the same time to prevent the bones binding against each other. § 3.—LUXATION OF THE HEAD OF THE RADIUS. The head of the radius may be luxated without involving the articulation of the ulua with the humerus. This luxation is de- scribed as occurring forwards or backwards. When it occurs back- wards the biceps, which is inserted into its tubercle, is put upon the stretch, whilst in the luxation forwards this muscle is relaxed. Etiology.—The luxation backward is generally caused by falls upon the hand when in extreme pronation, while the luxation for- ward occurs when the hand is in extreme supination, or sometimes the backward luxation has been produced by violent muscular efforts, as in the case of washerwomen wringing clothes. Both accidents are of rare occurrence, so much so that their existence LUXATIONS OF THE WRIST. 513 has been denied by some surgeons. The luxation backward is perhaps the more common. Symptoms.—A careful examination of the elbow-joint will gene- rally reveal the nature of the accident; in the luxation backward the hand will be found strongly pronated, while after luxation for- ward forced supination of the hand will be observed. Treatment—The reduction is accomplished as follows: In the luxation backward flex the forearm upon the arm to relax the biceps, and bring the hand from pronation into forced supination; but in the luxation forward the forearm should be extended,' and the hand carried from supination into forced pronation. It is evi- dent, therefore, that it is a matter of considerable importance to distiriguish between these two accidents, for nothing but failure could be anticipated should the surgeon attempt to reduce the luxation backward with the manipulations appropriate to the dis- placement forwards. § 4.—LUXATION OF THE ULNA. Luxation of the' ulna, by itself, from its articulation with the humerus, is a rare accident; though it sometimes occurs. When it is created, the symptoms so precisely resemble those of the luxa- tion of both bones backward, and the treatment is so much the same, that no further reference than the mere mention of the pos- sibility of the accident is required. SECTION III. LUXATIONS OF THE WRIST. Anatomical Relations.—The wrist-joint is formed by the articula- tion of the radius and ulna with the first row of the carpal bones. Although it is not necessary to go minutely into its anatomy in this place, yet it may be mentioned that the capsular ligament, which is loose and comparatively feeble, is strengthened by the internal and external lateral ligaments, by the sacciform ligament, and by the presence on the palmar surface of the flexor, and on the dorsal surface of the extensor tendons. Special luxations of 33 514 PRACTICE OF SURGERY. the radius or of the ulna alone at the wrist-joint are, moreover, somewhat guarded against by the attachments of the pronator quadratus muscle, which binds the two bones together, and tends to prevent such an accident. Varieties.—Four luxations of the wrist-joint are usually described by writers; thus we are told of luxations forward and backward, as well as of two lateral luxations. These accidents, when met with, are so generally created by extreme violence, that the opinion has already been expressed, in connection with the subject of Bar- ton's'fracture, that they are rare when unaccompanied by fracture, if, indeed, they ever occur, except from the application of great force. The remarks now made refer, therefore, less to such luxa- tions as are the result of simple violence than to a class which are the effect of a peculiar train of circumstances. Thus, if certain pre- disposing causes, as paralysis, or preternatural relaxation of the ligaments of the wrist exist, or if an individual has labored for a considerable length of time under a spasmodic contraction of certain muscles, or if sudden force is applied to the hand, a luxation may undoubtedly ensue and be unaccompanied by fracture, and this may occur in any of the four directions above alluded to. When a luxation forward occurs, that is, when the bones of the forearm go forward, and those of the carpus go backward, the hand is violently extended, the flexor tendons stretched, and there will be a considerable prominence on the back of the wrist. Such a luxation is readily reduced by carrying the hand forward, while a moderate degree of extension and counter-extension is made. In the luxation of the bones of the forearm backward, in which the bones of the carpus are displaced forward, the hand will be flexed, the extensor tendons put upon the stretch, and the tumefaction be upon the front of the hand. In such a case, extension and counter- extension should be made, and the hand carried in the opposite direction to that given for the last injury. After the reduction in either injury the parts should be kept as much at rest as possible, and inflammation be actively combated. Should the luxation have resulted from violence, as is usually the case, the inflammation will often run so high as to induce sloughing of the integuments over the joint, or caries of its bones. THE OS PISIFORME. 515 § 1.—LUXATION OF THE LOWER END OF THE ULNA ONLY. , Luxation of the inferior extremity of the Ulna by itself is an injury which sometimes occurs as a result of violence, or is caused by falls, &c. In order to permit it the sacciform ligament must be considerably lacerated or entirely ruptured. Treatment.—Extension and counter-extension, properly applied, will be sufficient to reduce the injury, and a compress and roller will retain the displaced bone in position. SECTION IV. LUXATION OF THE CARPAL BONES. The bones of the carpus are sometimes luxated. Generally, how- ever, the force which displaces one of these little bones produces also such an injury in the soft parts as induces a degree of inflam- mation which renders attention to the latter the most important part of the treatment; and nothing in the way of reduction, except a moderate degree of coaptation, can be effected. § 1.—LUXATION OF THE OS MAGNUM. The os magnum, however, is sometimes the seat of a simple luxa- tion. The head of the magnum, when luxated from its articulation with the first row of carpal bones, presents a small tumor on the back of the wrist, and is to be reduced by making moderate pressure with the thumb upon the bone, while at the same time the surgeon makes flexion and extension of the hand; after which the parts should be kept at rest, and inflammation combated. § 2.—LUXATION OF THE OS PISIFORME. The os pisiforme is also sometimes luxated, an accident which becomes important, on account of its relaxing the tendon of the 516 PRACTICE OF SURGERY. flexor carpi ulnaris, which is inserted into it. This luxation is to be reduced by simple manipulation, but, like the accident last described, is comparatively rare. SECTION V. LUXATION OF THE METACARPAL BONES. The metacarpal bones may be luxated from their connection with the carpus. The metacarpal bone of the thumb is, however, the only one which would be likely to be displaced, except as the result of such a force as would produce a compound luxation. They may also be luxated at their phalangeal articulations. | 1.—LUXATION OF THE METACARPAL BONE OF THE THUMB. Luxation of the metacarpal bone of the thumb at its superior end upon the carpus is sometimes quite troublesome. It may be caused by a fall, or any similarly applied force; and, when it occurs, hap- pens generally in one of two directions, either forwards or back- wards. This fact, also, is to be noted in luxations between the in- ferior end of the metacarpal of the thumb and its first phalanx, as well as in the phalanges of all the fingers; the great strength of the external and internal lateral ligaments, as compared with the capsular ligament on the posterior and anterior face of the joint, preventing lateral displacement. Fig. 195. When the luxation occurs at the metacarpo-phalangeal articulation of the thumb, the end of the phalanx, corresponding in its general shape with the head of the tibia, rides over the head of the metacar- pal bone, comparable in shape to the rounded head of the condyles LUXATIONS OF THE LOWER EXTREMITIES. 517 of the femur, and the inequalities of the surface prevent reduction, unless the two bones are separated by a proper extending and coun- ter-extending force, and the lower bone is made to describe the arc of such a circle as will free these prominences. (Fig. 195.) Treatment.—In order to reduce this luxation, it is necessary to ob- tain perfect control of the finger or thumb, and this is best done by means of what is known as the clove hitch, a knot which may be made for Fig-196» the metacarpo-phalangeal luxations outof apiece of tape. (Fig. 196.) In making this knot, two loops should be formed in reverse directions, and then brought up the one behind the other, as in the figure. For other luxations, such as the arm or thigh, the clove hitch may be made of a tow- el, sheet, handkerchief, or any pro- per material. Having attached this knot to the luxated member, extension should be made in the case of the thumb by giving its phalanx a circular movement, so as to enable the projecting surfaces to pass each other, when the reduction will be ultimately accomplished, though it may require repeated trials, owing to the difficulty of acting on so short a piece as a pha- lanx. CHAPTEK IV. LUXATIONS OF THE LOWER EXTREMITIES. Luxations of the articulating surfaces of the bones of the lower extremities present a class of injuries which are much more serious than the luxations previously described, the reduction being more difficult, the accompanying symptoms more severe, and the conse- quences, when they are improperly treated, more important. 518 PRACTICE OF SURGERY. SECTION I. LUXATION OF THE HIP-JOINT. Anatomical Relations.—The hip-joint is formed by the articulation of the round head of the femur with the deep cavity of the aceta- bulum ; a cavity which possesses considerable depth in the skeleton, but which is still further deepened in the patient by the cotyloid ligament surrounding its edge. The head of the femur is held securely in this deep socket by a strong capsular ligament, and by the ligamentum teres or round ligament which passes between the head of the bone and the bottom of the acetabulum. In addition to these ligaments, the articulation is materially strengthened by powerful muscles which surround it, such as the glutei and psoas magnus muscles, the pyramidalis, gemini, obturators, quadratus femoris, and the powerful muscles of the front and inside of the thigh, as the rectus, adductors, &c. &c. All these render this articulation so firm that the femur is seldom displaced unless the muscles are taken by surprise, and the force producing the luxation is not only great but sudden; or unless the head of the femur or the articulating cavity of the innominatum are altered by disease so as to permit the action of the muscles to create the displacement. Varieties.—Luxations of the head of the femur may occur in four different directions, and these may be arranged into two classes for the purposes of study. Thus, the four varieties of this luxation may be divided into two—1, those in which the head of the bone goes backwards, and 2, those in which the head of the bone goes forwards of the acetabular line, thus making two of each class. This classification, it must be admitted, is not strictly accurate, yet is it sufficiently so to facilitate the investigation of the symptoms of each variety, and aid the memory in recalling them. It may also be stated—although, like the classification given above, it must be taken with some modification—that all the luxa- tions backward, turn the toes and the foot of the injured side, more or less inwards, whilst all those in which the head of the femur passes forwards, or in which it takes a position anterior to LUXATION OF THE HEAD OF THE FEMUR. 519 the acetabulum, turn the toes more or less outwards; in the one the foot is inverted, in the other everted. The varieties above alluded to may then be enumerated as fol- lows :— Backwards.—1. Luxation upwards and backwards upon the dorsum of the ilium, the head of the femur resting just behind the anterior- inferior spinous process. 2. Luxation downwards and backwards into the ischiatic notch. Forwards.—3. Luxation upwards and forwards upon the pubis. 4. Luxation downwards and forwards into the thyroid foramen. § 1.—LUXATION OF THE HEAD OF THE FEMUR UPWARDS AND BACK- WARDS UPON THE DORSUM OF THE ILIUM. Etiology.—The causes which produce this luxation are such as apply force from below upwards, while the* limb is carried across its fellow. It is accordingly found to result from falls, and parti- cularly from falls upon the knees while carrying heavy weights, &c. Symptoms.—The symptoms of this luxation are as follows: There is shortening, which is sometimes inconsiderable at first, but be; comes very marked in a few hours, varying then from an inch and a half to two inches and a quarter, as ascertained by measurement made in the manner directed under the head of fracture of the thigh; or, if the force producing the luxation also forcibly adducts the limb, the shortening will be marked from the first moment after the accident. The foot is strongly inverted, the toes pointing towards the instep of the opposite foot, or resting upon it. (Fig. 197.) The limb is also very much adducted, and carried towards its fellow so that the knee rests upon the inner and under side of the opposite thigh. There is, moreover, an unnatural promi- nence upon the dorsum ilii, caused by the presence of the head of the bone beneath the muscles; a deficiency in the prominence of the trochanter major, and an unnatural flatness over the cavity of the acetabulum, which in a lean individual may be distinctly felt. The trochanter major can also be felt much closer to the anterior superior spinous process of the ileum than it is in the normal con- dition of the joint. There is a total absence of crepitation, though sometimes a crackling can be heard in the neighborhood of the injured joint, 520 PRACTICE OF SURGERY. Fig. 197. which might mislead a young surgeon; but experience will recog- nize at once that it is the soft crack- ling of synovial or other liquid effu- sions, and totally different from the crepitation of fracture. The patient usually complains of considerable pain, particularly when the parts are put upon the stretch by any motion such as that made by the surgeon in examining the parts. Diagnosis.—With such symptoms there can hardly be any difficulty in making out a diagnosis under ordi- nary circumstances. From fracture of the neck of the femur, which is the only complaint likely to be confound- ed with it, this luxation upwards and backwards can be at once distinguish- ed by the fact that in fracture the shortening is readily reduced, though it is reproduced so soon as the ex- tending and counter-extending forces are removed; whereas in dislocation the deformity is reduced with much greater difficulty, the bone being likely when reduced to remain in place. The diagnosis from the luxation which sometimes occurs in morbus coxarius as a result of change of structure will be given under that head. Mechanism.—With regard to the manner in which the muscles concerned are affected, it will be readily understood, that the glutei muscles arising from the ilium and inserted into the trochanter major are very much relaxed, while the small rotatory muscles are put upon the stretch, or even more or less lacerated. The iliacus internus and psoas-magnus are violently stretched, and the lower adductors are more or less relaxed. Treatment.—Few surgeons of the last two hundred years have probably ever been called on to attempt the reduction of a luxa- tion of the femur without having vividly brought before their minds the powerful muscles, the spasmodic contractions of which it was admitted kept the luxated bone in its unnatural position. A front view of the Appearances in a Luxation of the Femur upwards and backwards on the Dorsum of the Ilium. (After Cooper.) LUXATION OF THE HEAD OF THE FEMUR. 521 Impressed with this idea, the necessity of resisting muscular con- tractility by mechanical force, and augmenting it until the power of the muscles was sufficiently overcome to permit the reduction of the displaced bone, was always strongly insisted on as the promi- nent indication in the treatment, though from time to time sug- gestions were made of the efficiency of certain manipulations in facilitating the extension and counter-extension in the reduction of the bone. It remained, however, for Dr. Wm. W. Eeid, of Eo- chester, in the State of New York, to give such ideas a definite shape, and to prove that a luxated femur even in muscular indi- viduals, and when displaced for several weeks, could be easily reduced in a few minutes by gentle manipulation, with but little pain to the patient, and with great ease to the.surgeon, as compared with the heavy labor of thirty minutes or an hour formerly re- quired of him. In consequence of this valuable suggestion of Dr. Reid, the practice of surgeons prior to the year 1850 will proba- bly be entirely laid aside; pulleys, straps, hooks, sheets, &c, placed upon the shelf, and the former means of reducing luxations of the femur be hereafter looked on with the same feeling that a traveller regards the instruments of torture in the old Spanish inquisitions. In fact the 19th century in surgery will be sufficiently noted for its improvements if nothing else is developed than the inhalation of ether, and the admirable mode of reducing luxations of the femur suggested by Dr. Beid, both of which it should be remem- bered are improvements due to the surgery of the United States; though Europe begins to show a desire to appropriate them to herself. Reid's Plan of Reducing a Luxation of the Femur upwards and backwards on the Dorsum of the Ilium,1 solely by Manipulation.— "Place the patient on his back, on a low firm table, or what is better, upon a quilt folded and laid on the ground. Let the ope- rator stand or kneel on the inj ured side and seize the ankle with one hand and the knee with the other. Then flex the leg on the thigh; next strongly adduct it, carrying it over the sound one, and at the same time upwards over the pelvis by a kind of semicircular sweep as high as the umbilicus. Then abduct the knee gently, turn 1 Transactions of the Medical Society of the State of New York, at its Session, Feb. 1852, p. 25, but previously presented to the Monroe County Medical Society, May 8,1850, and published in Buffalo Medical Journal, Aug. 1851, as well as in the Boston Journal. 522 PRACTICE OF SURGERY. Fig. 198. A view of the Position of the Surgeon and Patient, in the act of reducing a Luxation of the Femur upon the Dorsum of the Ilium.—The thigh being flexed on the pelvis, and the leg bent on the thigh, the surgeon is in the act of drawing the knee towards him with one hand, whilst with the other at the ankle he rotates the head of the femur into the acetabulum by the gentle oscillatory movement described in the text. (After Nature.) the toes outwards, the heel inwards, and the foot across the op- posite and sound limb, making gentle oscillations of the thigh, when the head of the bone will slip into its socket with a slight jerk, or an audible snap, and the whole limb will slide easily down into its natural position beside the other. In a recent case the whole ope- ration can be accomplished in less time than it can be described." The advantages claimed by Dr. Reid for this method are such as my experience of it in several instances strongly confirms. 1. It is simple; 2. The movements are natural; 3. There is little or no pain; 4. There is neither tonic nor involuntary spasms to contend with; 5. It is better adapted to and more certain of success in cases of long standing than extension by the pulleys; 6. It is free from danger under all circumstances, provided Dr. Reid's directions are accurately observed. "A rocking motion of the leg while the thigh is being brought to the straight position and strongly abducted," is objected to by him, as a source of failure in the mani- LUXATION-OF THE HEAD OF THE FEMUR, ETC. 523 pulation, if not of danger.1 " When the thigh is flexed on the trunk, say at an angle of 45°, and is gently abducted, and the head of the bone thus brought close to the lower edge of the acetabulum, if, while gentle oscillations of the thigh are made at the knee, the head of the femur does not immediately enter the socket, the knee should be alternately elevated and depressed, thus varying the angle of the thigh. If by this manoeuvre, alternated with the before-mentioned oscillating or lateral movement, the head does not enter, we should then cease all motion and hold the thigh and leg perfectly quiet for a short period, keeping the former still slightly abducted, so that all the muscles, &c, may become quiescent. The foot and leg must be kept still also, and firmly directed towards the opposite thigh; for if we relax or carry it outward we shall roll the head of the fe- mur away from its resting-place and proximity to the acetabulum, and permit or provoke the muscles to draw it into the foramen ovale, ischiatic notch, or dorsum ilii. After a short time we may repeat our attempts, and in all suitable cases of from four to six weeks' standing, confidently anticipate a speedy and favorable issue."2 The importance of carrying out directions accurately cannot be too much insisted on in all operations, but especially in those which are novel, and I have, therefore, given Dr. Reid's own account in order that errors may be avoided. I have, in four instances, em- ployed his method with success, two of the cases being on the dor- sum of the ilium, one into the sciatic notch, one into the foramen thyroideum, and in May of 1852 reduced, before the Medical Class of the University of Pennsylvania, a luxation of eleven weeks' stand- ing, in a boy of fourteen years of age. The facility with which a luxation on the dorsum of the ilium could be converted into one in the sciatic notch, first struck me in this case, and it is not the least extraordinary part of Dr. Reid's manipulation that the surgeon can readily convert any one form of luxation of the femur into another and then reduce it. In all instances in which I have resorted to Reid's manipulation, I have first etherized the patient, though I am satisfied that it oan be done, as he advises, without inducing anaesthesia. My chief object in the etherization has been to pre- vent any straining and save the patient inconvenience, believing that the manipulation is so perfect that no muscular action is re- 1 New York Journ. Med., July, 1855, p. 66. * Op. citat., p, 66. 524 PRACTICE OF SURGERY. quired to replace the bone, the latter being carried into the aceta- bulum as it would be by similar manipulation on the skeleton. With a view of contrasting the ease and simplicity of Reid's method with the plan which has been employed for years—each geteration having apparently worked in the footsteps of those who preceded them—the position of the patient as he lies stretched be- tween the powerful action of the pulleys and the counter-extending band in his perineum, is shown below. Even with this powerful extension it was often found impossible to stretch the limb, whilst, if the head of the femur hitched on the edge of the acetabulum and was drawn in an incorrect line, fracture of the neck of the femur was liable to be produced. Fig.J.99. A side view of the Position of the Patient, of the Counter-extending Band (a), of the Ex- tending Band (b) as made fast by a,clove hitch above the knee, and of the Attachment and Position of the Pulleys (e) as formerly deemed necessary for the reduction of a luxation of the femur, the patient being at the same time bled ad deliquum animi, nauseated with tartar emetic, Ac. (After Cooper.) After-Treatment.—After the reduction of a luxation of the-femur the two limbs should be tied together and the joint kept at perfect rest for ten days or two or three weeks, in order that the lacerated capsular ligament may be allowed to heal. Should violent inflam- mation show itself around and within the joint, cups or leeches to the part, with the cold-water dressing and purging, may be demanded. § 2.—LUXATION OF THE HEAD OF THE FEMUR ON THE PUBES. In the luxation forwards of the femur upon the pubes the head of the bone takes a position that is easily recognized, though this form of luxation is rare. Etiology.—The causes of this luxation consist in the application LUXATION OF THE HEAD OF THE FEMUR ON THE PUBES. 525 Fig. 200. of a force so that the head of the bone will be forced upwards and forwards, whilst the foot is advanced, a3 in stepping into a hole, especially whilst carrying a weight on the shoulders. Symptoms.—The symptoms are very marked; thus, the limb will be thrown into the characteristic position seen in Fig. 200, being car- ried off from its fellow, the foot everted, the toes especially being turned strongly outwards, so as to bring the heel into such a posi- tion that if the leg was slightly flexed upon the thigh, it would rest upon the instep of the sound limb. The injured limb is slightly shorter than the sound one, the degree of shortening varying according to the circumstances of the case. If the head of the bone rests simply upon the front of the pubis, the shortening will be about one inch, this being most fre- quently the case; but if the femur has slipped up and taken a consecutive posi- tion anteriorly and just below the ante- rior superior spinous process of the ilium, the shortening becomes greater. This consecutive dislocation is generally accom- panied with considerable laceration of the oapsular ligament, as well as of the mus- cles inserted near the neck of the bone. The round ligament is also ruptured in this as in others of the complete displacements of the head of the bone. If the patient is a thin person, the head of the bone may be seen forming a tumor over the pubis, and its movements can be distinctly felt under the skin by the hands of the surgeon. The patient suffers considerable pain, which is often very severe in its character from the pressure of the head of the bone upon the anterior crural nerves. Treatment.—The reduction, according to Reid's plan, would be one of simple manipulation; the patient and surgeon being placed as before directed, the limb being strongly abducted in the right position, and the foot rotated still more strongly outward, so as to make the trochanter act as a fulcrum, and pry the head of the bone A front view of the Position of the Limb after a Luxation of the Femur on the Pubes. (After Cooper.) 526 PRACTICE OF SURGERY. off from the pelvis, when it will- slip into the foramen thyroideum. The thigh should then be strongly flexed on the pelvis, and be carried across its fellow, when, by rotating the leg outwards, so that the sole of the foot will look outwards and upwards, the head will be made to describe a semicircle backwards, till, coming over the acetabulum, it will suddenly slip into its place. Fig. 201. § 3.—LUXATION OF THE FEMUR' INTO THE FORAMEN THYROIDEUM. Sometimes the head of the bone slips out of the acetabulum, and takes a position lower down than that just described, slipping into the foramen thyroideum. This luxation, though also rare, is more common than that just described. Symptoms,—When it occurs, the limb is lengthened about two inches, the amount of this elongation being just equal to the dis- tance of the centre of the foramen thyroideum below a horizontal line drawn through the centre of the acetabulum. The foot is neither inverted nor everted, as a general rule, though it will be found much easier to evert it than to invert it. The head of the bone may be felt in its unnatural posi- tion in thin persons, and the thigh is so much abducted that it cannot be brought near its fellow. When the patient stands upright, the injured limb assumes a posi- tion which is quite characteristic, being shot out in advance of the body (see Fig. 201), and considerably lengthened. The muscles put upon the stretch are, the glutei, and the small rotatory muscles in the back of the thigh, while the adductors and pectineus are relaxed. Treatment. — Like the two luxations above described, that into the thyroid foramen may be reduced by simple mani- pulation, consisting in flexing the thigh on the pelvis, carrying it across its fellow, and a front view of the Position Sivin§ to it a certain amount of circum- of the Limb in a Luxation into duction which slips the head of the bone the Foramen Ovale or Thyroid- m^\* eum. (After Cooper.) into its place. LUXATION OF THE FEMUR INTO THE ISCHIATIC NOTCH. 527 § 4.—LUXATION OF THE FEMUR INTO THE ISCHIATIC NOTCH. Fig. 202. This luxation, which is more frequent than the two preceding displacements, is that in which the head of the bone goes backwards into the ischiatic notch. Etiology.—In order to produce this luxation, the force must be exerted so as to cause -the head of the bone to bear against the posterior part of the capsular ligament. In two cases which recently came under my notice, one was the result of the patient slipping whilst rolling a bale of cotton up an inclined plane, the bale rolling back and striking against the knee, while an- other bale behind the pelvis held him sta- tionary. The other occurred whilst the patient was coupling two railroad cars; the hind car striking the pelvis, whilst the knee was bent and fixed against the bumper of the front one. Sy7npio?ns.—When such a luxation oc- curs the limb is slightly shortened, being usually from half an inch to an inch shorter than its fellow; and the toes are turned inwards, so that the great toe rests on the ball of the great toe of the other foot. (Fig. 202.) The head of the bone may be felt in a thin patient, if seen early after the accident, but otherwise it is difficult to recognize it, owing to the thickness of the glutei muscles. The chief muscles whose actions are to be overcome in this case are the rotatory muscles, as the pyri- formis, gemini, obturators, &c, the gluteus magnus muscle being relaxed. Treatment.—To reduce this luxation by manipulation, the thigh must be flexed on the pelvis, and carried across its fellow, when it should be slowly abducted from the body, in a manner very similar to that directed in a case of luxation upon the dorsum ilii. After-treatment.—In this, as in the other luxations, it will become A front view of the Posi- tion of the Limb in a Luxa- tion Backwards into the Ischiatic Notch. (After Cooper.) 528 PRACTICE OF SURGERY. necessary, after the reduction is effected, to combat inflammatory action, the two limbs being brought together and fastened, if the patient is restless, with a handkerchief or a bandage, and such antiphlogistic measures employed as the degree of the inflamma- tion demands. § 5.—CONGENITAL LUXATION OF THE HIP-JOINT. Etiology.—Under this designation is described a condition some- times seen in children, either immediately after birth, when it may have been caused by violence effected during parturition, or not till some time afterwards, the latter coming under the desig- nation of spontaneous rather than under that of congenital luxa- tion. That such a displacement may occur, considerable relaxation of the muscles and ligaments surrounding the hip-joint must be present; and hence the condition generally arises from some want of innervation, or is the result of injury to the spinal cord, or disease within the acetabulum. Symptoms.—This luxation presents very much the same symp- toms as those already described—the position of the head of the femur being most frequently on the dorsum of the ilium. Prognosis.—A case as thus presented is very difficult to treat, and one for which, indeed, no positive plan of treatment can be suggested. The luxation is generally reducible, but difficult to keep in place. Treatment.—The treatment consists in reducing the bone as before directed, and in the employment of a splint for a few weeks, the use of such measures as are calculated to improve the general health, as cold bathing, tonics, and chalybeates being most bene- ficial. If the disease is dependent upon the tuberculous diathesis, as is sometimes the case, those measures which are required in the treatment of morbus coxarius will be necessary. SECTION II. LUXATION OF THE KNEE-JOINT. Anatomical Relations.—The knee-joint is formed by the articula- tion of the condyles of the femur with the head of the tibia, and LUXATIONS OF THE PATELLA. 529 strengthened by the position of the patella anteriorly. It has no proper capsular ligament, as its place is supplied by a structure formed principally at the expense of the fascia to which the term involucrum is applied. As this does not furnish sufficient support for the joint, a strong external and internal lateral ligament aids in binding the bones together, while the strength of the articulation is increased by the flexor and extensor muscles which pass anteriorly and posteriorly to the articulation. Within the joint are the crucial ligaments, two stout ligamentous cords, which, arising from the condyles of the femur, are inserted in front of and behind the spinous process of the tibia, to which also the semilunar carti- lages are attached. § 1.—LUXATIONS OF THE PATELLA. Besides the regular luxations of the knee-joint, those of the patella alone sometimes occur. Varieties.—There are three varieties of this luxation: in the first, the patella is luxated inwards; in the second, outwards; whilst the third, which is sufficiently rare, consists in a rotation of the bone upon its perpendicular axis, so that its anterior face is turned partly in towards the articulation, whilst its posterior surface is turned partly out towards the front of the limb, one of its edges being prominently presented to the condyles or epitrochlea of the femur. Luxation of the patella upwards or downwards cannot, of course, occur without a laceration of the ligament of the patella, or of the tendon of the quadriceps femoris muscle, unless there is a preter- natural relaxation of these parts. Compound luxations of the patella sometimes occur and require, after the luxation has been reduced, the observance of an active antiphlogistic treatment. It is always a very serious injury, and is exceedingly apt to result in amputation or anchylosis. Etiology.—The causes of lateral luxation of the patella are gene- rally such forces as blows or falls applied laterally, whilst the mus- cles are relaxed in consequence of the leg being fully extended. The rotation of the patella upon its axis, on the contrary, is gene- rally the result of the application of force whilst the leg is flexed. Three or four cases of this injury are upon record, and of these, two were the result of the knees of dragoons striking each other while 34 530 PRACTICE OF SURGERY. charging in sham fights; while a third, also, happened to an indi- vidual on horseback. Symptoms.—AVhen lateral luxation of the patella occurs, there will be increased width of the joint and a change in its natural con- tour- a want of the normal prominence of the patella and an abnormal prominence on one side or the other caused by the exposed position of the condyle. There can, therefore, be little difficulty in recognizing the character of the accident. The pain caused by it is extreme, and great swelling due to serous effusion within the joint rapidly occurs. Treatment.—In order successfully to accomplish the reduction of a lateral luxation of the patella, it is necessary to attempt it while the limb is in the extended position, when little more than judicious lateral pressure will be necessary,. The most convenient manner of effecting it, therefore, is for the surgeon to rest the heel of the injured limb upon his shoulder so as to flex the thigh upon the pelvis and extend the leg upon the thigh, thus relaxing the quadri- ceps femoris muscle as much as possible, and then with the pressure of his fingers push the bone back into its place. When the patella is rotated upon itself a case is presented which is much more difficult to treat. As the muscles are often spasmo- dically contracted, it will be necessary to etherize the patient in order to induce their relaxation; but when this complete relaxa- tion is once obtained, the sudden flexion of the limb will often cause such a strain upon the tendon as will rotate the bone into its place. This luxation being, however, extremely rare, the sur- geon, fortunately, escapes its treatment; for the difficulty of its reduction is so great that it has been recommended to incise the ligament of the patella in order, by its division, to facilitate the operation. It should, however, be remembered, that such a mea- sure, by opening the knee-joint; exposes the patient to the risk of inflammation and anchylosis, and the patient should always be advertised of this fact before it is attempted. § 2.—LUXATIONS OF THE KNEE. Luxations of the knee-joint may happen in four different directions. In the first, the head of the tibia goes backwards, while the condyles of the femur slip forwards; the second is the reverse of this, the LUXATIONS OF THE KNEE. 531 condyles of the femur going backward; besides which two lateral subluxations are usually alluded to by surgical writers, and regard- ed as of more frequent occurrence than the anterior and posterior, owing to the great depth of the head of the tibia presenting an extensive support to the condyles of the femur in all the motions of flexion and extension of the leg on the thigh. These accidents are not uncommon as a result of disease in the bones or of the articulation, but they are rare as a result of the application of force on account of the peculiar formation of this articulation. Etiology.—In order to produce any of them, a force must be ap- plied which will create a strain upon the ligaments upon that side of the articulation towards which the bone slips. Every luxation, therefore, of the knee-joint, will be accompanied with more or less laceration of the ligaments, and of the synovial membrane, and every complete luxation will be accompanied by a laceration also of the crucial ligaments, in consequence of which the patient will be liable for a considerable period after the injury—or until the ligaments have completely united—to a reproduction of the injury. In consequence of the laceration of the synovial membrane, there will also be more or less inflammation in the joint, and this is ex- tremely liable to terminate in anchylosis, partial or complete, if it does not result in suppuration within the cavity of the joint. Treatment.—To reduce a lateral luxation of the knee-joint, a considerable amount of extension and counter-extension is neces- sary, and while this is kept up by assistants the surgeon should accomplish the reduction by judicious lateral pressure. To reduce the luxation forwards or backwards, extension and counter-extension will also be necessary, but here the surgeon must apply his pressure anteriorly or posteriorly, as the case may be, so as to force the bones into the proper position. It is seldom that any great difficulty occurs in carrying out these principles and effecting the reduction if the patient is thoroughly etherized. The difficulty experienced is of another character, consisting principally in the consequences of the resulting inflammation, which is increased by the laceration of the ligaments and the pinching of the synovial membrane in the efforts made in accomplishing the reduction. Great attention to the after-treatment, therefore, becomes necessary;. the inflammation being actively combated by leeches, and the whole antiphlogistic treatment actively carried out, the limb meanwhile 532 PRACTICE OF SURGERY. being kept at perfect rest. But, after two or three weeks, when the tendency to inflammation has subsided, and union of the lacerated ligaments has perhaps occurred, passive motion may be gently made and patiently persevered in, to break up any adhesions which may have already formed. Should inflammatory action have run high, and continued for such a period that false anchylosis has already occurred before the surgeon is able to resort to passive motion, such an instrument as is recommended for the gradual pro- duction of motion at the joint may be resorted to, as will be described in connection with the subject of anchylosis. § 3.—HEY'S LUXATION OF THE KNEE. In connection with luxations of the knee-joint may be mentioned an injury usually described as Hey's Luxation, or as a sub-luxa- tion of the knee-joint, which consists essentially in a luxation of the internal semilunar cartilage. This injury is often very diffi- cult to recognize unless the surgeon's attention has been specially directed to it; the patient complaining of acute pain, and not showing anything like marked deformity, or a tendency to dis- placement. Etiology.—Wrenches of the foot are a common cause of this con- dition of the knee-joint, but the injury seldom occurs except in those who, in consequence of preternatural relaxation of the liga- ments of the knee, especially the internal lateral ligament, are thus predisposed to it. Symptoms.—The symptoms are sufficiently marked; the indivi- dual complaining of intense pain in the knee, and dropping as if shot at the moment of its occurrence. The pain is of a sickening cha- racter, and when the patient attempts to rise, he not only finds it much increased, but perceives a stiffness in the limb which renders it incapable of sustaining the weight of his body. There is, how- ever, little or no'swelling for several hours after the injury; so much so that but for the difficulty of motion, and the inability to sustain the weight of the body upon the limb, it might be supposed that the injury was nothing more than a sprain. On examining the joint carefully, however, the displaced cartilage can generally be felt making a slight prominence under the skin on the inner edge of the knee—provided swelling has not supervened. LUXATION OF THE FIBULA. 533 Treatment.—The treatment is simple, and may be practised in most cases of painful sprains of the knee which are at all obscure in their character, as it can do no harm if a sprain only is present, while if displacement of the semilunar cartilage exists, alone or complicates the sprain, the relief will be great and instantaneous. The success of the manipulation depends upon the fact that the posi- tion of the internal semilunar cartilage is relaxed when the limb is flexed, and consists in the following efforts: Seating the patient upon the edge of a high table, or bed, and stooping before him, manipulate with the limb gently while his attention is engaged in conversation. When at last he is off his guard, flex the limb sud- denly under the edge of the table or bed on which he is seated, and the cartilage will generally slip into its place; the pain being re- moved in a moment, motion restored in the joint, and the patient rendered comparatively comfortable. Afterwards attention should be given to the condition of the joint, the parts being kept at perfect rest, and inflammation combated as after any other injury of this articulation. When the patient begins to walk he should wear an elastic bandage around his knee, in order to impart additional strength to the articulation. When this slipping of the cartilage results, as is sometimes the case, from debility and relaxation of the ligaments, a plan of treat- ment becomes necessary which in principle and practice is precisely that which is required in subluxations of the jaw, consisting in douches, cold baths, blisters, &c, as local measures, accompanied by the use of such means as will improve the general health. § 4.—LUXATION OF THE FIBULA. A luxation of the fibula alone may occur at either extremity of the bone, though it is a very rare event. Symptoms.—The symptoms are readily recognized, and the luxa- tion, as a general rule, can be readily reduced, after which the" parts should be kept at rest until the ruptured ligaments have united. 534 PRACTICE OF SURGERY. SECTION III. LUXATION OF THE ANKLE-JOINT. Anatomical Relations.—The ankle-joint consists of the articulation of the tibia and fibula with the astragalus, and is naturally a strong joint, the prominent malleoliguarding against lateral luxation, and being aided by powerful external and internal lateral, ligaments; and although the capsular ligament anteriorly and posteriorly is extremely imperfect, yet this joint is strengthened by the extensor tendons in front, and by the tendo-Achillis behind. Varieties.—Luxations of the ankle-joint may happen in four dif- ferent directions:— 1. Luxation of the bones of the leg inwardly, which is the luxa- tion previously referred to as occurring when there is fracture of the lower fifth of the fibula; many denying that this luxation can occur without being combined with this fracture. 2. Luxation of the bones of the leg outward. 3. Luxation of the tibia forwards, so that it rests upon the astra- galus anteriorly to its articulating face. 4. Luxation of both bones backwards upon the os calcis, poste- rior to its articulation with the astragalus; besides which there is a partial luxation backwards, in which the bones rest posteriorly to the articulating face of the astragalus, but still upon that bone. § 1.—LUXATION OF BOTH BONES OF THE LEG INWARDS AT THE ANKLE. The luxation in which the two bones of the leg go inwards accompanied with fracture of the lower fifth of the fibula, is the most common of these luxations. The causes are similar to those that will produce fracture of the fibula, which may or may not accompany the accident,.though it usually does do so. Treatment.—The treatment consists in making extension at the foot and counter-extension at the leg, while, at the same time, force is applied laterally to bring the tibia into its place, the limb being afterwards kept at rest and the inflammation of the ankle-joint actively combated. LUXATION OF THE LEG BACKWARDS AT THE ANKLE. 535 § 2.—LUXATION OF BOTH BONES OF THE LEG OUTWARDS. The luxation of both bones of the leg outward is very rare. When it occurs it is usually combined with fracture of the internal malleolus or of the astragalus, but not invariably. It is to be reduced upon the same principles as the luxation inwards, but the force employed to accomplish the reduction must of course be ap- plied in an opposite direction. § 3.—LUXATION OF BOTH BONES OF THE LEG FORWARDS ON THE ANKLE. The luxation forwards of both bones of the leg, it is said always requires that the fibula should be broken, and is therefore rather a luxation of the tibia alone, the front of the capsular ligament being ruptured when the luxation occurs. Symptoms.—There is more or less shortening of the foot, elon- gation of the heel, and prominence on the front of the ankle caused by the presence of the two bones of the leg in their unna- tural position. It is to be reduced by extending the foot. § 4.—LUXATION OF THE LEG BACKWARDS AT THE ANKLE. Symptoms.—The symptoms of luxation of both bones of the leg backwards are precisely the reverse of those just stated; thus, there is more or less apparent elongation of the foot and shorten- ing of the heel, the tendo-Achillis being put upon the stretch and a prominence formed posteriorly by the position of the two bones. Diagnosis.—In either of these luxations the diagnosis is easy. Treatment of Luxations at the Ankle-joint.—The treatment of the luxation forwards consists in the application of strong extension and counter-extension to overcome the contraction of the gastroc- nemius and soleus, as exerted through the tendo-Achillis, and while this is kept up the foot is to be strongly extended, which will cause the bones to slip into their proper position. In the treatment of the luxation of both bones backward, exten- sion and counter-extension must be made, and force applied in a 536 PRACTICE OF SURGERY. direction precisely opposite to that in which it was applied in the last case, after which the limb should be placed in a fracture-box, kept at -perfect rest, dressed with cold water cloths, and every means employed that will tend to combat the inflammation of the ankle-joint that necessarily supervenes. § 5.—LUXATIONS OF THE ASTRAGALUS. Anatomical Relations.—The astragalus articulates below with the os calcis, and anteriorly with the scaphoides, being bound strongly to these bones as well as to the cuboides and os calcis by stout ligaments. Nevertheless, Luxation of the Astragalus alone is an accident which sometimes occurs, and is described as being possible in four different directions—forwards, backwards, and to either side. Symptoms.—This accident is generally easily recognizable before swelling comes on, as the bone can be readily felt, and even seen in its new position; but generally a degree of swelling is rapidly developed, which materially obscures the character of the injury. Treatment.—The treatment consists in attempts to force the astra- galus back into its position, which, if judiciously made, will some- times be successful, after which the strictest antiphlogistic measures, with the use of a fracture-box, must be persevered in for some time. § 6.—COMPOUND LUXATIONS OF THE ANKLE-JOINT. Compound luxations of the ankle-joint sometimes occur, the in- jury being always most serious, and often requiring an amputa- tion. Such success, however, has followed the extirpation of the displaced bone in these cases of compound luxation that it will generally be advisable to attempt this operation before resorting to amputation, for if hectic fever supervenes upon the suppuration which follows the operation, the surgeon can then amputate with quite as good chances of relief, and with as much safety to the patient, as if he had performed the operation in the first place. Cases of simple luxation of the astragalus sometimes resist every attempt at reduction until after the division of the tendons, &c, by OF SPRAINS. 537 subcutaneous section with a tenotome. This fact should be borne in mind in obstinate cases; but, when this measure fails, the parts should be kept at rest and anchylosis permitted to occur, as it is Fig. 203. not considered good surgery to make a compound out of a simple luxation by dividing the parts from without inwards, so as to ex- pose a joint to the action of the atmosphere. \- -'m.;-^-, CHAPTER V. OF THE DISEASES OF THE JOINTS. The principal diseases of the articulations, or of the parts contigu- ous to the bones, are Sprains, Anchylosis, Arthritis, and Morbus Coxarius. SECTION I. OF SPRAINS. A sprain is an injury to the ligaments, tendons, bursa, and other parts surrounding the joints, which results from violence, but in which there is no displacement of the articulating surfaces of the bones. The injury to the parts surrounding the joint is of a very varied character; thus there may be more or less laceration of the 538 PRACTICE OF SURGERY. fibres of the capsular and other ligaments, laceration of. the neigh- boring bursa?, laceration of bloodvessels, of nerves, of muscles or tendons, and, in consequence of the lacerations of the ligaments surrounding the articulation, there is very frequently more or less laceration and inflammation of the synovial membrane. Symptoms.—In accordance with these varied injuries there will be a varied train of symptoms in sprains. Thus, in the simpler form of the complaint, the patient will be found to suffer severe pain, this being increased upon motion, and accompanied by more or less swelling around the articulation. In consequence of the laceration of bloodvessels, there is also more or less ecchymosis of the skin, which becomes a good point by which to judge of the extent of the laceration. More or less variation in the natural shape of the joint1 will also be observed, due not only to effusions around the articu- lation, but to effusions of lymph or of serum into the cavity of the joint itself. Sometimes in the wrist and ankle this tumefaction is due to effusions of serum into the bursa in which the tendons play in the front of these joints. In every case of sprain it should be borne in mind, therefore, that there is more or less laceration of the parts around the joint, and that this laceration will result in such an effu- sion and thickening of tissue as will impair the natural functions of the joint to a greater or less extent. If the sprain is badly treated, this thickening may take place to so marked a degree that lymph may become organized between the two articulating surfaces and true anchylosis result. Diagnosis.—In making an examination of a case of sprain, it should be borne in mind that owing to the change in the shape of the joint, sprains may be confounded with luxations, particularly in the case of the wrist and knee-joint. A sprain may also be mis- taken for a fracture, and vice versa. Thus, a sprain of the wrist with "more or less effusion into the bursa surrounding the flexor tendons producing a marked swelling on the front of the hand, with pain and loss of motion, might be mistaken for Barton's frac- ture. On the other hand, every sprain in the neighborhood of the wrist or ankle should be carefully examined lest fracture co-exist. On account of the manner in which the flexor and extensor tendons of the hand are surrounded by bursas in the neighborhood of the wrist, such a sprain as produces effusions into these bursas, may be followed by inflammation of the bursa itself, and if the complaint is not actively treated, adhesions may result, these sub- OF SPRAINS. 539 sequently interfering materially with' the functions of the tendons. The rapidity with which effusions into these bursas occur, deserves notice, they being sometimes seen within ten minutes after the acci- dent, the swelling having taken place to such an extent as to form a tumor of considerable size before the surgeon sees the case. Usually fifteen to twenty minutes is sufficient to produce a well-marked deformity, which, however, can even then be distinguished by careful examination from fracture or luxation. In this examina- tion, the surgeon should not allow the pain given by his ma- nipulations to deter him from thoroughly learning the condition of the parts; and if the patient is unable to bear the suffering, he should be etherized; for it is of the greatest importance that the precise nature of the case should be understood. The fracture most likely to be confounded with a sprain of the ankle-joint is that of the lower fifth of the fibula, the possibility of which should always be borne in mind when examining the ankle-joint after a sprain, whilst Barton's fracture is frequently conjoined with sprains of the wrist. Prognosis.—The prognosis in the case of a sprain depends very much upon its being early recognized and promptly treated; but the dangers of inflammation, particularly in the wrist and ankle, are such that the prognosis should always be guarded. The pa- tient should, therefore, be told in all cases of bad sprain, that the accident is a serious one, that it will be necessary for him to keep the parts at perfect rest for at least two weeks, and that six weeks, or even three months may elapse before he will recover the perfect use of the joint, if, indeed, he ever recovers it. Let him under- stand that a sprain, if neglected, will also prove a more serious accident than a fracture, and that pains about joints of a rheumatic character may, perhaps, trouble him for years on the occurrence of damp weather. Treatment.—The treatment of a recent sprain should be as fol- lows:— If the patient is. seen five or ten minutes after the accident where there has been little or no time for vascular action, and where there is a simple laceration of ligaments—as shown by the pain—with- out much swelling, the best treatment will consist in the application of means calculated to prevent vascular excitement, such as the cold water dressing constantly applied; lint being spread over the parts, and irrigation of cold water accurately kept up; or the limb may 540 PRACTICE OF SURGERY. be thrust into a vessel of cold water, and kept there fifteen, or even twenty-four hours if necessary. But if six or eight hours have elapsed, and there is marked ecchymosis beneath the skin with swelling, and a tendency towards inflammatory action, a different plan of treatment will be neces- sary, the joint being now leeched freely, six dozen American leeches being applied all round it; after which the warm water dress- ing should be resorted to, this being preferable to the cold in this stage. Much of the discussion which has taken place among sur- geons as to the comparative merits of warm and cold water dress- ings in sprains has doubtless arisen from the fact that they have described different stages of the same complaint. After three or four days, advantage will be derived—-provided all inflammatory action has ceased—from frictions with the hand and some liniment, particularly if it be of a stimulating character. These frictions should be gently but patiently made, and continued for half an hour at a time. A very good liniment for this purpose is the fol- lowing:— R.—Tr. rad. aconit. f^j; Tin. sap. camph. fjiij. M. et ft. linimentum. The parts should also be kept at perfect rest, by the use of carved or felt splints, until motion ceases to be very painful. In every case of a sprain of the ankle, for example, serious enough to require treatment, I would insist upon the patient keeping the limb at rest for at least two weeks. After having kept the parts at rest during this period, pas- sive motion may be made in order to guard against anchylosis. The inflammatory stage being now passed, and that in which motion is proper having begun, the weakened vessels and tissues debili- tated by the injury and inflammation, will derive tone from cold douches, cold bathing and gentle use. If a sprain is neglected or improperly treated, a condition some- times results which is described by authors as chronic sprain. There are here more or less thickening of tissue and other derangement due to inflammatory action. The treatment should be that which is adapted to any chronic inflammation, more benefit being derived from counter-irritants, as blisters, &c, patiently applied than from any other plan. Eest, by means of a carved. splint is, however, ARTHRITIS, OR WHITE SWELLING. 541 absolutely essential, as, if the inflammatory action is not checked, it may result in caries of the bones of the articulation, especially in cases of sprain of the ankle-joint. SECTION II. ARTHRITIS, OR WHITE SWELLING. The term white swelling is an old name which was employed to designate any disease of the ankle, knee, or hip-joint characterized by tumefaction, provided it was without redness and the other usual signs of inflammation. As the disease is not a simple inflammation of the synovial membrane, and the term Synovitis is therefore in- applicable, the best which could be employed to express the real condition of parts is Arthritis. Arthritis is a special disease of the knee or ankle-joint, the some- what similar condition of the hip-joint being embraced in the com- plaint known as Morbus coxarius. It is characterized by tumefac- tion, without any of the ordinary signs of inflammatory action so far as external observation goes. This tumefaction is also different from that of cedema, the skin not pitting upon pressure, nor is there that sense of fluctuation which would be present if the swelling were due to a serous effusion into the cavity of the joint as the result of synovitis. Arthritis occurs generally in scrofulous patients, and is most common in countries in which the climate is moist. Hence, as might be expected, it abounds in the hospitals of London, while it is comparatively rare in those of the United States. It occurs generally in patients between 20 and 30 years of age, avoiding alike the extremes of youth and old age. Symptoms.—The symptoms are as follows: The patient first notices a certain degree of tenderness about the articulation, which, gradually developing with the disorder, often causes marked suffer- ing; after which th^ joint becomes stiffened, and there is more or less loss of its proper motions. When the swollen joint is handled, no sense of fluctuation is communicated to the touch, but a peculiar sen- sation is perceived, which indicates the presence of a thick gelatinous substance beneath the skin. This substance presents a soft pulta- ceous mass which yields somewhat to pressure, but does not permit the skin to pit as in oedema. The tumefied joint is whitish or 542 PRACTICE OF SURGERY. bluish in its color, there is no enlargement of the superficial ves- sels, and no pinkish hue, as in the tumefaction of joints due to rheumatism or gout. The disease progressing, the parts become hot, the skin dis- tended and shining, and then a slight vascular congestion may be noticed, which gives a pinkish or purplish tinge to the tumor. By and by ulcerations communicating with the joint are developed in the skin, and discharge a thin bloody ichor; symptoms of hectic are developed; the patient becomes prostrated with colliquative sweats and diarrhoea, presenting not unfrequently evidences of tho- racic disease, and finally dies. Or a more favorable change takes plade, the patient surviving the exhaustion of the suppuration, and getting well with anchylosis. Throughout the course of the complaint it should be remembered that there is no distinct sense of fluctuation around the joint, as there is in synovitis; the disease consisting rather in a chronic inflammation and effusion into the cellular tissue and beneath the ligaments surrounding the joint, than in the serous tissue, though occasionally the symptoms of synovitis will be added to it. Pathological Condition.—In dissections made after death or ampu- tation, the following pathological changes have been observed. The cellular tissue exterior to the joint is thickened in a marked man- ner and infiltrated with a thick jelly-like substance, which the French have designated as "fongosite'," a term by which they do not mean to designate anything malignant, but simply to indicate the character of its structure. In the latter stages of the disease not only is the capsular ligament thickened, but its tissue is softened, and between that part of the ligament which is lined by the synovial membrane and this membrane a pale yellow semi-transpa- rent matter is deposited, which is several lines in thickness, without bloodvessels, and evidently due to effusions of plasma of a caco- plastic character. By similar effusions partially organized, if the disease is of. long standing, the ligaments, tendons, and muscles surrounding the articulation are glued together producing a con- siderable amount of false anchylosis. If the action continues, the disease extends itself to the cartilages, or to the bones themselves, producing ulceration of the cartilages and caries or necrosis of the articulating extremities of the bones. Diagnosis.—-To arrive at an accurate diagnosis in this complaint it is only necessary to bear in mind the symptoms, a synopsis of ARTHRITIS, OR WHITE SWELLING. 543 which may be thus briefly presented. First, the tuberculous ap- pearance of the patient; next the fact that the disease is usually developed without any marked injury, the patient being often un- able to account for its production, or assigning it to trifling causes; then that in its earlier stages at least, it is combined with no marked signs of inflammation; and lastly, that there is no marked fluctua- tion as in simple synovitis, while the sense of touch gives evidence of the presence of a certain peculiar soft matter deposited beneath the skin. Prognosis.—The prognosis should be guarded, the result depend- ing in a great measure on the constitution of the patient. This disorder may terminate either in death by hectic, by anchylosis, or by amputation of the limb, the patient often recovering rapidly after the operation, but exhibiting in a few months the evidences of pulmonary consumption. / Treatment.—The first and most important indication in all these cases is to improve the general health, the treatment demanded in every disease resulting from the tuberculous diathesis or compli- cated, being equally applicable to this one. Tonics are of value in the early stages, particularly chalybeates, with a view of im- proving the condition of the blood. With regard to the local treat- ment, much is to be expected from the judicious leeching when the joint is very hot and acutely inflamed, or when the disorder is of a more chronic character, from the use of counter-irritants, as blis- ters, repeatedly applied in the neighborhood of the joint; or stimulating and mercurial frictions; or plasters, particularly those which combine the two characters, an excellent one being a mix- ture of the emplast. galbanum comp. with mercurial ointment, which may be spread and kept constantly on the joint. The local use of mercurials is especially demanded with a view of diminishing the plasticity of the lymph effused around the joint. Benefit has also resulted, in some cases, from painting the part well with the tincture of iodine; a plan of treatment which, besides its specific effect, stimulates the vessels of the skin to increased action. During this treatment, the parts should be kept at perfect rest by means of a carved splint of wood, a felt splint, or one of gutta percha, these being made upon the same principle as those which will be described in connection with hip-joint- disease. By such means the joint may be kept at rest without any necessity of con- fining the patient to bed, a practice which is much to be depre- 544 PRACTICE OF SURGERY. cated, as the confinement is badly borne by this class of patients, who need fresh air and exercise quite as much as medical treat- ment. In permitting a patient to exercise, much will depend upon the means that are selected, such only being resorted to as will per- mit the general movements of the body, whilst the affected joint is kept at perfect rest, such as riding in a vehicle with the limb care- fully supported. In warm weather it will also prove useful, espe- cially in hospitals, to have the patient's bed placed in the fresh air of a yard for a few hours each day. Should, however, the disease progress in spite of treatment, and hectic supervene, much may be done for the relief of the patient, the necessity of amputation, which would soon become urgent, be- ing in many cases avoided, by a resort to the operation of resection of the joint, a class of operations which are daily growing in favor, and by means of which many limbs have been saved, that, under the old rSgime, would inevitably have been sacrificed by the knife of the surgeon. SECTION III. ANCHYLOSIS. When a joint becomes stiffened, as the result of diseased action either within or around it, and is left entirely to the course of nature, it is most apt to be flexed oribent (ayxaxoj, crooked); hence this condition of stiffness and loss of motion in an articulation is usually designated as anchylosis. Varieties.—Two conditions of parts are met with in stiffness of the articulations. 1st. False anchylosis, or immobility, due to inflam- matory action in the parts exterior to the articulation, as in the bursa, fascia, tendons and muscles, with some thickening of the ligaments. 2d. True anchylosis, due to the destruction of the interior of the joint and the bony fusion of the two articulating surfaces of the bones which compose it. Anchylosis, it will be seen, therefore, is the result of changes due to inflammatory action, within or in the neighborhood of an articulation. It is also sometimes spoken of as complete and incomplete, perfect or imperfect, these terms indicating the amount of motion left in the articulation by either true or false anchylosis. ANCHYLOSIS. 545 Pathological Conditions.—The state of the parts in false anchylosis presents generally a deviation from the normal condition of the ligaments, tendons, and fascia exterior to the joint; the ligaments being thickened, stiffened, and contracted, especially on the side of the joint which corresponds to flexion, whilst the tendons and fascia are similarly retracted, so that they cannot be readily elongated, even when considerable force is used. Sometimes false anchylosis results from the formation of bands of lymph within the synovial capsule of the joint, where they act the part of adventitious ligaments, and limit the motion of the articulating surfaces. Sometimes a true false membrane is formed within the serous tissue of the joint, similar to that seen on the pleura, in consequence of which adhesions are developed. Sometimes, in true anchylosis, the articulating cartilages and synovial membranes having been removed by suppuration or in- terstitial absorption, the two bony surfaces are brought in contact and fused one upon the other; whilst in other cases various bony spines and processes, which often correspond with the position of the lateral ligaments, join the bones together, or limit their movements. Etiology.—Various causes may create anchylosis; sometimes true anchylosis is the result of ossification of cartilages and interverte- bral substances, as in the ribs and spinal columns of old persons; sometimes it is consequent on suppurations and caries of an articu- lation, as is seen in white swelling and.hip disease. False anchy- losis is generally the result of inflammatory exudation, which, owing to rest, contracts adhesions and creates thickening; hence it results from sprains, synovitis, fractures in the neighborhood of joints, badly treated luxations, &c. Symptoms.—Anchylosis is rendered evident by loss of motion in the articulation, this loss of motion varying in accordance with the natural motion of the joint, and showing itself in a restricted de- gree of flexion, extension, or rotation. In false anchylosis there is usually a change in the shape of the joint, and any marked attempt at motion causes more or less marked pain. In true an- chylosis there is often marks of inflammatory action around the part, with irregular enlargement of points about the articulation. If inflammatory action still exists in a joint which is partially fused by true anchylosis, the attempts at motion may also prove painful, but usually in true anchylosis, especially if chronic, attempts at motion do not develop the patient's sensibility. 35 546 PRACTICE OF SURGERY. Prognosis.—The prognosis of anchylosis is always dependent on its extent and the position in which the limb has been placed. If the anchylosis is of the false variety, it may be overcome and the joint rendered again useful; but if it has ended in true bony union of the articulating surfaces of the bones, motion in the part cannot be restored except by the formation of a false joint by an operation. The prognosis is also influenced by the position of the limb; thus, anchylosis of the elbow-joint would give a com- paratively useful limb if the forearm is flexed on the arm, whilst the knee-joint would be most serviceable if anchylosed in the straight position, patients being able to walk with considerable facility on a limb with a straight, though stiff knee. Treatment.—The treatment of anchylosis may be classified under four periods: 1, that which is proper during its formation; 2, that required for its prevention; 3, that demanded for its removal; 4, that which is necessary in order to change the position of the joint without the destruction of its immobility, as in a resection. 1. There are many instances in which the surgeon may be glad to obtain anchylosis of a joint, this being preferable to amputation of the limb, as in caries of the carpus and tarsus—wounds involv- ing the knee and shoulder-joints, and in compound luxations of the ankle, &c. In all such cases the treatment should consist in per- fect rest of the part in that position which will give the most utility to the limb, and in preventing the exhaustion of the patient's strength, the development of hectic being carefully watched. 2. The prevention of anchylosis is to be accomplished by com- bating every inflammation which involves an articulation, and hastening, by appropriate means, its termination in resolution, whilst at the same time such motion should be kept up as will prevent adhesions of the adjacent tissues, and stretch those which have a marked tendency to retract. The means of doing this will be alluded to hereafter. 3. After anchylosis, whether true or false, is well established, its removal may be attempted by the use of such means as will overcome the adhesions; such as stimulating and alterative fric- tions, especially those containing mercurial ointment; or by the use of cold water, so as to stimulate the absorbents; both of these means being specially applicable to cases of false anchylosis, whilst the true bony union of a joint may be overcome either by me- chanical extension or by an operation. ANCHYLOSIS OF THE ELBOW-JOINT. 547 4. The change of position in a truly anchylosed joint which has been allowed to stiffen in an inconvenient position, may be accom- plished by means of a Eesection,1 or by the application of such forces as will fracture the union, the case being subsequently treated as a fracture. As the means required in the treatment of the anchylosis of different joints require to be varied, they may be better understood in connection with special cases, especially those of the elbow and knee-joints. § 1.—ANCHYLOSIS OF THE ELBOW-JOINT. Without recapitulating what has been mentioned in connection with anchylosis generally, attention may now be given to the treat- ment of false anchylosis of the elbow joint. Condition of the Parts.—The elbow-joint being a ginglymoid articulation, is very liable to be affected by false anchylosis, the chief adhesions being found between the coronoid process and the front of the condyles of the humerus, and as the most natural position of the upper extremity is the extended one, this joint is most frequently found to be stiffened in the straight or partially flexed position, thus rendering it useless to the patient for many purposes; because with a straight and stiff elbow a patient cannot bring the hand to the mouth, or perform many of the daily acts of life. As the tendon of the biceps passes in front of the joint and the fascia brachialis receives an expansion from the tendon, these tissues are apt to become involved in the disorder, and to become thickened and tense, whilst the triceps tendon is not unfrequently similarly involved behind. In false anchylosis there is, therefore, considerable adhesion of all these tissues, but often only such as may be overcome by judicious treatment. Treatment.—The best plan of accomplishing this, is to obtain the relaxation of and increased circulation in these parts by soaking the joint, for a half hour daily, in water as hot as the patient can bear it, and then rubbing the part well with mercurial ointment or some stimulating liniment. Should inflammation exist, the applica- tion of leeches and poultices, or the warm-water dressing may also prove desirable. After having thus prepared the part, such me- chanical means may be resorted to as will gradually elongate the contracted tissues. One of the best of these is the splint shown in Fig. 204. 1 See Operative Surgery, vol. ii. p. 380, 2d edit. 548 PRACTICE OF SURGERY. Fig. 204. A view of Kolbe's Modification of Stromeyee's Splint, as applied fob the belief of False Anchylosis of the Elbow.—This apparatus, as made by Kolbe, of Philadelphia, consists of two light pieces of wood, which are strapped around the arm and forea,rm, the joint being made to move by means of the screw seen on the front. Prior to its application the arm should be bandaged, especially if much force is to be used. (After Nature.) § 2.—ANCHYLOSIS OF THE KNEE-JOINT. When false anchylosis affects the knee-joint, the natural position of the limb being that of flexion, the articulation is most frequent- ly stiffened in the flexed condi- tion, the ham-string tendons, to wit, the biceps, semimembran- osus and semitendinosus, being permanently contracted, and ren- dered prominent behind the knee. There is also usually more or less thickening of the fascia in the popliteal space, with or without a certain amount of mobility in the patella. Treatment.—After employing on this articulation the same ge- neral means as were stated in connection with the preliminary treatment of false anchylosis of the elbow-joint, mechanical ex- tension of the leg may be gradu- ally accomplished by the means suggested by Stromeyer, or some of the modifications of his appa- ratus, such as that shown in Fig. 205.1 1 These instruments can be obtained of Kolbe, surgeon's instrument maker, No. 45 South Eighth St. below Chestnut, Philadelphia. A side view or Kolbe's Modification of Stromeyer's Splint for the treat- ment of Anchylosis of the Knee.—By means of an ingenious joint in the bend of the knee, which is acted on by the key seen in the figure, Mr. Kolbe has succeeded in obtaining great power, and yet very accu- rately regulating its application. (After Nature.) MORBUS COXAR1US. 549 SECTION IV. MORBUS COXARIUS. Hip-joint disease, morbus coxarius, and coxalgia, are terms applied to a condition of the hip-joint, which is sooner or later combined with ulceration, caries, or some other disease of the bones forming the articulation, and resulting in a more or less complete destruction of the functions of the joint. The term coxalgia should, however, be restricted to a form of disease which is purely nervous or hysterical in its character, and which, although simulating somewhat in symptoms the true morbus coxarius, is accompanied by no organic changes. Such a condition is sometimes found in children, in connection with dentition; in young females, previous to menstruation; in hysterical women, and in hysterical men, for there is a class of men, delicate, sickly, and nervous, who are as truly hysterical as females; men or boys of weak and broken-down constitutions, and who very frequently are masturbators. These patients will sometimes complain of pains about the hip-joint, which, though simulating hip disease, are purely neuralgic in their character. By the term Morbus Coxarius is designated a disease which results in more or less destruction of the head of the femur, of the cavity Of the acetabulum, and sometimes of the adjacent parts of the ilium. It generally destroys the usefulness of the joint, and if it does not terminate in hectic fever and death from exhaustion, results at best in anchylosis of the articulation, and in a greater or less deformity with loss of power in the joint. Etiology.—The causes of the complaint may be described as con- stitutional and local. The most common constitutional cause is the tuberculous dia- thesis, in consequence of which tuberculous matter is deposited in the head and neck of the femur, or in the acetabulum, though the last is very rare. When tubercles form in the head and neck of the femur they act as a foreign body and excite inflammation, pre- cisely as when deposited in the lungs, the bodies of the vertebrae, or elsewhere. The other causes of this complaint are, exposure to cold or dampness, or anything likely to produce congestion or in- flammation of an unhealthy character in the articulations. 550 PRACTICE OF SURGERY. Among the local causes may be enumerated blows, falls, sprains, over-exertion of any kind, or any cause likely to produce syno* vitis in this joint. A very common cause among boys is some injury received while playing foot-ball or shindy. With regard to the influence of age, the complaint is certainly more common in the young than in those over twenty-one years of age, and the most usual period of its development may be fixed at from four to eighteen years. Symptoms.—In the acute form of the complaint the symptoms are as follows: After a fall, a blow, or an excess of exercise, the patient is conscious of a dull pain in the hip, of which he complains, or if a child not yet intelligent enough to give an account of its sufferings, gives evidence of the presence of pain by indisposition to exertion, and by cries whenever motion of the joint is neces- sarily made, especially when the limb is flexed or abducted. If, however, the child is old enough to describe its symptoms, the pain will be alluded to as being seated in the hip, or as extending down the limb from the hip, or as being at the inside of the knee. So frequent and prominent is the latter symptom that parents are often misled by it, and suppose the knee-joint to be the seat of the disease when it is really situated in the hip. An explanation of this fact is to be found in the supposition that the inflammation of the joint has involved branches of the anterior crural and obtu- rator nerves, and that the pain thus produced is referred to their extremities, instead of the true locality of the irritation. In this stage, the patient generally complains of stiffness in the articulation, and exhibits great unwillingness to move the limb; but as he exercises it during the course of the day this stiffness wears off, and the joint becomes more flexible. After this state of things has continued for some little time, the pain increases and tumefaction of the joint takes place; the part becoming full and tense, whilst more or less fever is developed. This stage of the disease is more readily recognized, but is not so often seen as that which is more chronic. Most frequently the affection passes with- out treatment through this its first stage, or is tampered with by domestic remedies, and is first presented to the surgeon only after its full development, or in the second stage, when a marked, dispo- sition to flex the limb will be noticed, as well as a disposition to carry it across its fellow. As the progress of the disorder has now attacked the muscles around the joint, it will be noticed that when the MORBUS COXARIUS. 551 patient stands, he is generally inclined to stand with the limb flexed and carried in towards the opposite leg (Fig. 207), because the in- flammation within the articulation has extended from it to surround- ing parts, involving the rectus, the psoas magnus, and iliacus internus muscles, the latter of which, passing over the front of the articula- tion, are inserted into the trochanter minor, and, becoming inflamed, are less painful when they are relaxed by flexion of the limb. Atro- phy of all the muscles around the joint is a condition also often observed in connection with the progress of the disease in the articulation. Thus, there may be wasting of the glutei muscles, the buttock becoming thin and flabby (Fig. 206), while from the diseased condition of the head of the femur the foot inclines in- wards or outwards, as the case may be. The eversion or inversion of the foot becomes a matter of some importance, because it points out the condition of the articulation. If the foot inclines inwards, as is most frequently the case, it is generally due to such a de- struction of the acetabulum as permits a luxation of the femur to occur upwards and backwards upon the dorsum ilii (Fig. 207), but when the foot inclines outward, it will be due to such a dis- eased condition of the head and neck of the bone as permits the action of the rotatory muscles to draw the trochanter outwards, though the head of the bone may still retain its normal position. At this period, more or less decided shortening begins to be noticed (Fig. 206); though this shortening is sometimes due to the flexed condition of the limb or to inclination of the pelvis, rather than to a luxation of the femur on the pelvis. Sometimes, instead of shortening, there is apparent lengthening.of the limb, this, how- ever, being generally due to an inclination of the pelvis. If firm pressure is now made upon the trochanter major the patient will complain of pain, because the head of the bone is thus driven more or less into the acetabulum, and therefore produces pressure upon the diseased surfaces. In the same manner a blow upon the sole of the foot will be productive of pain in these patients, and for the same reason—a fact which would at once dis- tinguish the case from one of rheumatism; while in synovitis the amount of fluid effused into the joint would so far diminish the succussion as to interfere materially with the creation,of pain by such a concussion. There is also very often a fulness over the front of the joint below the groin, and tenderness upon pressure in that spot, as well as an increase of pain at this point, when the N 552 PRACTICE OF SURGERY. thigh is abducted. The buttock also becomes flattened, and marked change may be noticed in the line of its fold, which is i Fig. 206. Fis- 207« Fig. 206.—A full view of the Back and Buttock in Hip Disease of the Left Side, showing the wasting of the glutei muscles, and the change in the line of the fold of the nates. (After Liston.) Fig. 207.—A front view of Hip Disease of the Right Side, showing the shorten- ing, inclination of the pelvis, and flexing of the limb. (After Liston.) longer a transverse line, but forms an angle sometimes of 45 de- grees with the spine. (Fig. 206.) In the third stage, the peculiar symptoms of the disease are most apparent. The limb becomes very much shortened, inflammation is developed in the soft parts and skin covering the articulation, ulceration is established, pus escapes, and a probe carefully intro- duced along the sinuses which form, touches upon a bare surface of bone. Through these orifices small portions of bone are often thrown off. The portions of the body subjected to pressure as the patient lies in bed, as the point of the trochanter of the sound side, and the prominent points of bone along the back, now, by their pressure V MORBUS COXARIUS. 553 upon the soft parts over them in the exhausted state of the system, also give rise to those ulcerations and sloughs known as bed-sores. It does not follow, however, that this stage of the disease will in- variably terminate in death, as sometimes the strength of the patient is sufficient to enable him to sustain the drain of the suppuration and the exhaustion of hectic irritation, and he will finally get well by anchylosis. Diagnosis.—With regard to the diagnosis of morbus coxarius in its first stage, care should be taken not to confound it with rheu- matism or a neuralgic condition of the joint; though the history of the complaint, and the general train of accompanying symp- toms will generally suffice to effect this diagnosis. When the acute form of the disease is at its height it might possibly be confounded with Psoas abscess, as in this complaint, as well as in morbus coxarius, there is more or less irritation shown in the muscles of the back, more or less fulness in the groin, and the patient is in- clined to flex the limb and turn the toes in. But if the buttock of a patient laboring under psoas abscess be examined, it will be found that the line of the cheek of the buttock is normal and not sloping, as in hip disease; while, if pressure is made upon the sole of the foot or upon the trochanter, the patient will not com- plain of pain. In the latter stages of the disease, if the history of the case were not known, it might possibly be confounded with those spontaneous luxations of the femur which have been already alluded to. Prognosis.—The prognosis in hip disease is always unfavorable, both on account of the great length of time necessary to accomplish a cure, and also from the character of the cure being always uncer- tain. The time required to accomplish this cure, even in favorable cases, is always considerable; and the patient and his friends should be informed of it; being told, in every instance, that it is hardly probable that the case will terminate in less than eighteen months, and that, though some do occasionally recover without deformity, and preserve the usefulness of the joint, yet such cases are very rare ; while the number which terminate fatally is perhaps as great as those which recover with anchylosis. Pathology.—The evils resulting from morbus coxarius are so great that the true pathology of the complaint has long been re- garded as a question of marked interest to the surgeon. As, how- ever, few patients die with this affection, except after the disease 554 PRACTICE OF SURGERY. has existed some time, the changes noted have been rather such as were due to the last than to the first stage, and indicated rather the result than the progress of the disorder. Although the evi- dences of diseased action found after death have been varied, there is no reason to doubt that the starting-point is inflammatory action, though the causes which excited it have differed. As the result of the modification created by inflammation in the part first involved, we find synovitis, softening and disintegration of the articular carti- lages, with their removal, and the destruction of the substance of the bone, this destruction most frequently affecting the head of the femur, though the acetabulum often participates in it to a varied extent. Sometimes the destruction of the bone is noticed as more decided in the neck of the femur than elsewhere, the head tending then to repose against the base of the neck, so that the trochanter major approaches close to the pelvis. Sometimes after great destruction of the cartilages the head of the bone and the acetabulum are found covered more or less per- fectly with a porcelaneous deposit, new bony matter having been formed, compact, smooth, and hard, so as to facilitate the motion of the joint. The ligamentum teres is usually destroyed in bad cases, the capsular ligament softened, or much thickened, and the whole appearance of the parts greatly altered. Frequently the disease progresses to such a point that the altera- tion in shape of the acetabulum and head of the bone permits a luxation of the femur upwards and backwards upon the dorsum ilii, where it either forms for itself a new articulating cavity, or may become anchylosed to the side of the ilium in an unnatural position. The question of the frequency of this luxation of the head, of the femur as a consequence of hip-joint disease has recently at- tracted much attention among surgeons, in consequence of the paper published by Dr. March, of Albany, in the Transactions of the American Medical Association, vol. vi. p. 479, 1853. This distinguished surgeon, after taking considerable trouble in investigating the subject, and even visiting Europe, arrived at a conclusion which is directly opposed to the views of most surgeons, and the correctness of which can, it is thought, be best disproved by an examination of the specimens, from some of which the accom- panying cuts are taken. (Figs. 208, 209, 210, and 211.) MORBUS COXARIUS. 555 i In this paper, Dr. March advanced1 the opinion that " sponta- neous dislocation of the hip (as purely the result of morbid action unaided by superadded violence) seldom or never takes place," an opinion which, if established, would certainly influence very mate- rially the treatment of this disorder, as well as expose surgeons every day to the complaints of patients at the lameness and de- formity which they so constantly suffer from in this complaint even under the most careful treatment. Various preparations, exhibiting the frequency of this luxation of the femur as a result of hip disease, are in my cabinet as well as elsewhere, and show that there are many facts to militate against Fig. 208. Fig. 209. Fig. 208.—A front view of the Changes in the Articulation as made by Hip Disease.—The head of the femur in this specimen is luxated just above the superior and posterior edge of the acetabulum, whilst the old acetabulum is partially filled up, elon- gated, and forms the inferior edge of the new acetabulum, bone having been deposited on its margin. The head of the femur is flattened, its neck is shortened, and the compact layer of the head extends over the neck. Both the head and the new acetabulum are also eburnated at the points of chief contact. 1. Head of the luxated femur in its new acetabulum. 2. The old acetabulum, partially filled up, and changed in its shape. This drawing is taken from a preparation of the right ilium, which has been macerated and dried, and is No. 40 B of my cabinet. (After Nature.) Fig. 209.—The Left Innominatum after Maceration and Drying, showing the Changes consequent on Hip Disease.—The old acetabulum is elongated and partially filled up, the head of the femur being entirely removed, and nothing of it left but a stump of the neck of the bone. . This, by constant pressure on the middle of the dorsum of the ilium, has hollowed out a deep and large cup, which is convex on the venter of the ilium. 1. Remains of the neck of the femur as luxated. 2. The large new acetabulum made by the femur. This drawing is taken from a preparation of the left ilium, and is marked in my cabinet as No. 42 B. (After Nature.) Dr. M-arch's opinion. From four of these, selected as evidence of the presence of luxation, but not as exhibiting the most marked destruc- tion of the joint, the Figs. 208, 209, 210, and 211 have been made. Treatment.—In considering the proper mode of treatment for this 1 Transact. Amer. Med. Assoc, vol. vi.'p. 479, 1853. 556 PRACTICE OF SURGERY. tedious disorder, it must be borne in mind that in its first stage, owing to certain causes, there is an inflammation created in the arti- Fig. 210. Fig. 211. Fig. 210.—A Three-quarter view of the Pelvis of a Female who has had Hip Disease on the left side, showing a luxation of the head of the femur upwards, and the formation of a new acetabulum on the edge of the dorsum ilii between the anterior- superior and the anterior-inferior spinous processes. The old acetabulum is partially filled up, the new one as well as the head of the bone exhibiting evidences of caries. The ver- tebral column is also curved towards the left side, and all the bones are quite thin. This drawing is taken from a preparation marked No. 45 B of my cabinet. (After Nature.) Fig. 211.—A FRONT VIEW OF the Changes CAUSED by Hip Disease, the head of the bone being much flattened and partially luxated backwards, whilst the old acetabulum is so filled by new bony deposit as to change its appearance, and render the hip shorter and more prominent. This drawing is from a preparation marked No. 47 B of my cabinet. (After Nature.) culation, this inflammation being present whether the disorder is due to constitutional taint resulting in the production of tubercles in the femur, or to a limited irritation, which creating originally a mere synovitis, subsequently ends in caries. In either case, it must be admitted that an inflammation is created, which has a tendency to produce changes in the articulating surface of the joint, to develop abscesses, to destroy the ligaments, and produce such alterations in the articulation as will allow the contraction of the muscles to draw the head of the femur out of the aceta- bulum. As this very brief review of the symptoms of the disease as given above, shows a variation of condition, so must the treat- ment, in order to be successful, be adapted to the stage of the dis- order in which the patient is presented to the surgeon. Thus, if the disease is seen in its first stage with the symptoms* of acute inflammation of the joint, the treatment should be strictly MORBUS COXARIUS. 557 antiphlogistic in its character, leeches being applied around the articulation, not over the trochanter, where they are at some dis- tance from the joint, but below the line of the groin, where they come closely upon it. At the same time it is necessary to keep the parts at perfect rest, which can only be done in a manner adapted to the exigency of the case by means of a splint, this being equally ne- cessary in all stages of the complaint. But in the early period of the disease there is no such disposition to flex the limb as is after- wards observed, and any straight splint will, therefore, fulfil the purposes required; Liston's splint, as before described in connection with fracture of the thigh, answering very well. An objection to it, on the part of some surgeons, is the pressure which it causes upon the acetabulum by bearing on the trochanter, but this is by no means proved to be its action; whilst the facility with which it may be obtained in the earlier stages of the complaint, is a recommenda- tion to its use. Subsequently, however, in the second and third stage, where the tendency to flex the limb is marked, it will be necessary to employ a splint of a different character, and the best is that originally suggested by Dr. Physick, about the year 1812. This is made of wood carved to fit the angle of the limb, and extends from the waist to the ankle, being covered on the out- side with sheepskin, and lined with flannel or lint. This splint may be made by any good mechanic by laying a piece of poplar of sufficient thickness against the side of the body and limb whilst the patient is in bed, and marking the outline of the limb with pencil upon the wood; after which, with a gouge hollow out the splint until it is deep enough to receive one-half the circumference of the limb, and then shave it down on the outside with a spoke- shave to prevent it from being unreasonably heavy. After this it may be coated with glue, sheepskin being applied externally, and lint or flannel placed internally. (Fig. 213.) If there is any difficulty in procuring this splint—which can be neatly carved in most of our great cities—a very good substitute for it can be made of gutta- percha, cut to correspond with the general outline of the limb, soaked in warm water, and moulded upon the limb so as to fit it accurately. Or the same thing may be done, and a very good splint ob- tained by taking ordinary binders' board, soaking it in warm water, and moulding it to the part. By such means as these, rest may be insured, the splint, well padded with cotton, being secured to the limb and body by the ordinary 558 PRACTICE OF SURGERY. Fig. 212. Fig 213. t Fig. 212.—A side view of the Splint applied to the patient, as employed in the treatment of Hip Disease, showing the turns of the bandage which bind it to the limb, and especially the figure of 8 turns around the groin, those over the hip being shown by dotted lines. (After Nature.) Fig. 213.—A side view of Physick's Carved Splint. (After Nature.) MORBUS COXARIUS. 559 turns of a roller, making figure of 8 turns around the groin, so as to secure this part particularly, and thus prevent the flexion of the thigh. (Fig. 212.) When it is first applied the patient often becomes restless, and if a child, is apt to cry, so that the splint will hardly be borne more than half an hour the first day. The next day, however, it will perhaps be borne for an hour, and in the course of a few days perhaps for twenty-four hours; indeed, such comfort is given that in the case of children, the child will often be quiet only when the splint is in place, and will cry incessantly when it is removed. It has been urged as an objection to this splint that it makes pressure against the trochanter, and some even of its advocates have recommended, in consideration of this idea, that an orifice should be cut in it at a point corresponding with the position of the joint, with the view of preventing this pressure. But no such change is necessary, the shape of the splint, and the manner in which it is continued on the side of the chest, preventing any such force from being unduly exercised against the articulation. The parts being thus kept at rest, much benefit will be derived from the use of purgatives twice or three times a week. A drachm of the compound powder of jalap may be given to an adult, and a proportionate dose to a child every Monday, Wednesday, and Fri- day night. This purging acts not only on the principle of revul- sion, but also by relieving the congestion of the portal circle. The function of nutrition is, therefore, more actively carried on, and instead of being exhausted by frequent purgation, the patient sometimes actually grows fat under the treatment. The dose of the cathartic employed, whatever it may be, should not be sufficient to purge violently, but merely enough to give two or three soft evacuations. After the employment of these means, and by the local antiphlogistics above alluded to, the inflammation will often be so far diminished that the patient will suffer comparatively little pain. Occasionally, however, this becomes unusually severe, being neuralgic, or due to irritation of the nerves from the extension of the inflammatory action, and then some anodyne will be required, the Dover's powder presenting about the best that can be re- sorted to. In the second stage, besides the above measures, counter-irritants, as blisters, &c, will often be found useful; but local bloodletting 560 PRACTICE OF SURGERY. will not now be well borne, nor will it afford such relief as it did in the acute stage. In the third stage, when suppuration has come on and a discharge of pus begins to take place through ulcerated orifices near the tro- chanter, and in the groin, it may become necessary to cut a hole in the splint over the joint, in order to permit the escape of pus, and the application of poultices; but it is very seldom useful to expedite the escape of the pus by puncturing the integuments. Treatment will also be required to support the patient under the exhaustion of the suppuration. A full diet, as nutritious as can be borne without pro- ducing fever, should, therefore, be directed, while quinine and iron, and other tonics, may prove serviceable, especially if hectic fever supervenes. A very important part of the treatment in this stage is to give the patient fresh air, to do which he should be placed in a little wagon and thus drawn about. By these means the tend- ency towards luxation of the head of the femur will in many in- stances be prevented, and a cure accomplished with a more or less anchylosed limb; but this anchylosed limb will yet serve as a sup- port for the body, and the patient, although lame, will be enabled to walk with a certain degree of facility. Should the disease terminate in recovery after luxation of the head of the femur has occurred, and should the limb become an- chylosed in its false position, it will sometimes be found advanta- geous, should the health of the patient justify it, to resort to Dr. Barton's operation," and make a resection near the hip-joint, so as to establish a false joint, and thus allow the patient to recover with a limb at least somewhat more serviceable than it would otherwise have been. 1 See Operative Surg., vol. ii. p 392, 2d ed. PART VII. AFFECTIONS OF THE EYEBALL AND ITS APPENDAGES. On account of the delicacy and importance of the eye to the use- fulness and comfort of the human race, its disorders have always been carefully studied, and their treatment made to a considerable extent the duty of a special class of practitioners. Excellent trea- tises, creating volumes of considerable size, have, therefore, been devoted to their consideration. It is of course impossible, in a general work like the present, to do more than give a brief outline of this extended class of disorders; and what is now offered is pre- sented in order to meet the wants of those students who may not be desirous of taking up, during their pupilage, the examination of this subject in all its details. The disorders of the eye may be divided into two general classes: 1st, those which affect its appendages; and 2d, those attacking the ball itself. By the diseases of the appendages of the eye surgeons understand all such as affect portions exterior to its globe, as the lids, lachrymal gland, ducts, sac, muscles, &c.; whilst the affections of the ball embrace those which involve its different coats or humors, as the conjunctiva, or the lens, &c. CHAPTEE I. AFFECTIONS OF THE APPENDAGES OF THE EYE. SECTION I. BLOWS UPON THE EYE. Blows upon the region of the orbit of the eye produce generally more or less ecchymosis and discoloration all round it; this being 36 562 PRACTICE OF SURGERY. due to the rupture of small vessels beneath the skin; the violence of the blow being pretty well indicated by the extent of the dis- coloration. Treatment.—These cases are to be treated: 1. By such means as are calculated to check the effusion of blood into the subcutaneous cellular tissue; and 2. By such as will lead to the absorption of that already effused. In order to attain the first object, nothing is better than cold and pressure, articles of a stimulating character being resorted to after a few days, in order to promote the absorption, such as the tincture of arnica, or any other stimulating tincture, spirits of hartshorne, &c. The practice of painting the injured part flesh color, under these circumstances, which is sometimes resorted to, retards absorption; and, while it improves the appearance of the patient for a time, postpones the period of his cure. SECTION II. FOREIGN BODIES IN THE EYE. Foreign bodies may lodge between the lids and the ball, or be driven into the eye itself, and in either case should be removed as soon as possible, in order to keep down inflammatory action. Treatment.—The treatment depends upon the character of the foreign body, and the position which it has assumed. Thus, if caustic substances, such as lime, have been introduced between the eyeball and the lids, bland injections should be immediately em- ployed to counteract their corrosive effect, as those of olive oil, mucilage, &c. When the foreign body has passed back into the folds of the con- junctiva, and cannot be readily seen by opening the lids, it may be found by everting them, as may be readily accomplished by pressing a probe or the end of a pencil upon the lid, while, with the other hand, traction is made upon the tarsal cartilage. The eversion being accomplished, the eye can be fully examined for the foreign body, the latter being generally readily discoverable, when it may be wiped out with the end of a handkerchief or with a camel's hair pencil. It sometimes happens, however, that, owing to the force of its propulsion, the foreign body is driven into the structure of the eye, as into the conjunctiva, or through the conjunctiva into the WOUNDS OF THE EYELIDS. 563 sclerotic coat; or it may be imbedded in the structure of the cornea itself. Turners who work in metals are exceedingly liable to these accidents, small pieces of steel or other metal being thrown off by the revolutions of the lathe, and, striking upon the eye, penetrating it more or less deeply. In such a case, if the fragment has been driven quite through the coats into the ball of the eye, it is gene- rally useless to attempt to remove it, as an abscess will form, and it will be thrown off when that opens—a process which involves the destruction of the eye and the consequent loss of sight. If the fragment, however, is simply imbedded in the sclerotic coat, or in the laminae of the cornea, it may generally be removed by being- raised up with the point of a curved cataract needle. Any little particle which is not removed in this manner being thrown off by the ordinary processes of suppuration and ulceration. If the foreign body is driven into the substance of the cornea, the same plan is to be carried out, but greater care will be requisite in effecting the removal, particular attention being also paid to the treatment of the consequent uleer, lest it result in the production of corneal opacity. The inflammation arising from these injuries should be combated on general principles. SECTION III. WOUNDS OF THE EYELIDS. Injuries of various kinds, as well as surgical operations, some- times lead to the production of wounds of the eyelids; the treat- ment of which requires the use of sutures and the observance of the general principles described in connection with wounds. The sutures in these wounds should, however, be removed in from twenty-four to thirty-six hours after their introduction. On account of the loose nature of the cellular tissue of the part, these wounds are liable to cause ecchymosis from the infiltration of the blood beneath the skin —a result which should be explained to the patient at the commencement of the treatment. 564 PRACTICE OF SURGERY. SECTION IV. HORDEOLUM. Hordeolum, or stye, is a little inflammatory swelling, which is often quite painful, and generally due to inflammation either in the cellular tissue of the lids, or in one or more of the Meibo- mian glands, the inflammation causing the obstruction of the duct and an accumulation of its secretion, from the distension of which an abscess follows; or there may be simply the crea- tion of a phlegmon of the lid, as seen elsewhere. By the patient this affection is frequently confounded with a condition which is, in fact, a true abscess, and the result of inflammation of the cel- lular tissue between the fibres of the orbicularis palpebrarum and the skin. This more simple affection runs the course of abscess elsewhere, and is far from being as painful as the true Hordeolum. Treatment.—In either case the treatment is precisely that which is adapted to any ordinary abscess, warmth and moisture being applied either by means of poultices, or the warm-water dressing, or something more stimulating, as the alum curd. As soon as the formation of pus is observed, it should be evacuated by means of a cataract-needle, or some similar instrument. The popular plan of treating styes, by extracting one or two of the cilia, is only successful when the bulbs of these hairs are so situated that their withdrawal ruptures the abscess and eva- cuates its contents. Other popular remedies are still practised and believed in by the vulgar, as rubbing the stye with a wedding-ring moistened with saliva, or having it touched by the tongue of one's lady love, either of which are said to be exceedingly efficacious, though, if useful, can only be so through the stimulus of the saliva. The chronic induration and thickening of the edges of the lids which are left after a stye or after a succession of styes, are to be treated by means calculated to produce absorption of the effused lymph to which the induration is due; such means are to be found in frictions with mild mercurial ointment, or with red precipitate, or iodine ointment, &c. OPHTHALMIA TARSI. 565 SECTION V. OPHTHALMIA TARSI. Ophthalmia Tarsi, or Psorophthalmia, is a complaint of an inflamma- tory character also, involving the Meibomian glands, the secretions of which are in consequence disordered, so that the eyelids are glued together during sleep. This affection is common among the strumous children of asylums and hospitals, with whom it assumes a chronic character, and is exceedingly obstinate, resulting in de- struction of the bulbs of the eyelashes, loss of the cilia, and a thickening of the conjunctiva of the lid, the latter being often more or less everted, so as to present the peculiar raw appearance of the edges of the lid which has been denominated " blear eye." Treatment.—In its acute form this affection is to be treated by the antiphlogistic measures adapted to inflammation elsewhere; but when it becomes chronic, more advantage will be obtained from im- proving the patient's general health by the use of tonics, chaly- beates, &c, as,well as by stimulating local applications, rather than from depletory measures. In the case of scrofulous children much benefit will also be derived from the continued administration of cod-liver oil, and from such general means as are adapted to the treatment of the tuberculous cachexia. The local treatment is to be conducted upon those general prin- ciples which regulate the treatment of ulceration elsewhere, with the exception that, in this case, ointments are preferable to washes. The use of astringent ointments will often prove highly advan- tageous, such as that of the precipitated carbonate of zinc, which may be smeared upon the edges of the lids. Ointments of an alterative character, calculated to act upon the diseased Meibomian glands, are also exceedingly useful, and of these the best is proba- bly the citrine ointment (Unguentum Hydrargyri Mtratis of the Pharmacopoeia), which may be applied to the edges of the lids either pure, or diluted with varied proportions of simple cerate, according to the acuteness of the disorder. It should be applied by means of a camel's-hair pencil the last thing before retiring at night; the pa- tient immediately closing his eyes and not opening them again, if possible, till he falls asleep. Upon rising in the morning, the eyes 566 PRACTICE OF SURGERY. should be washed in warm water, not in cold, as the latter, by the reaction which follows its use, gives rise to increased vascular action. Sometimes this disease results in the production of such changes of structure as require local applications to modify more completely the action of the part, lest destruction of the mucous membrane, eversion of the lid and other unpleasant consequences result: in this case, nothing better can be recommended than light cauteriza- tion of the edges of the lids with the nitrate of silver. SECTION VI. TRICHIASIS. Trichiasis (*piz°f, a hair) is the name given to a complaint which consists in the in-growing of the eyelashes. As normally placed, the eyelashes of the upper lid are convex downward, and those of the lower lid convex upward, so that when they meet, dust is effect- ually excluded from the eyes, and yet there is no danger of the hairs coming in contact with the delicate conjunctival surface. Sometimes, however, as a result of disease, whether'such as elon- gates the lid, or only affects the bulbs of the cilise, the eyelashes are brought against the ball, producing much irritation, and result- ing, finally, if unrelieved, in inflammation of a troublesome cha- racter. Treatment.—The treatment may be palliative or radical. The palliative treatment consists in the extraction of the cilia by means of fine forceps, and, if the extraction is performed carefully, the relief will be complete for the time. Generally, however, a new growth of ciliae reproduces the disease, and it may then become ne- cessary to resort to some radical mode of cure. If the disease is produced by inversion of the lids or entropion, it will be relieved by the operation appropriate to that condition, but if due to a dis- order of the bulbs of the ciliae, the only method upon which the slightest reliance can be placed, is cauterization of a sufficiently active character to destroy their bulbs completely. DISTICHIASIS.—ENTROPION. 567 SECTION VII. DISTICHIASIS. Distichiasis (Stj, double, 'and sr^os, a row) is a modification of the above complaint, in which there are two rows of eyelashes, the inner one of which turns in so as to irritate the ball. Treatment.—The treatment recommended in trichiasis is equally applicable in distichiasis. SECTION VIII. ENTROPION. Entropion (sv, in; and tptrtfya, I turn) is a complaint in which the eyelids are inverted, the edges of the lids and the eyelashes being turned in upon the ball. (Fig. 214.) The causes are various. Any irritation producing contraction of the mucous membrane lining the lid may result in this deformity. It may, moreover, be produced by diseases of the tarsal cartilage and various other causes, the evils of this complaint ^LSIi being chiefly those of the trichiasis which results from it. Treatment.—The treatment may be divid- ed into two varieties, the palliative and the radical. The palliative consists in applying strips of adhesive plaster to the lids in such a view op Entropion as 1 . AFFECTING BOTH EYELIDS, a manner as to keep their edges off from showing how the eyelashes are the ball, a plan which may be aided by ex- eye!16 (AfternMiiier.) tracting the cilias; but the relief obtained from this treatment is merely temporary, and, in the great majority of cases, an operation for the radical cure will have to be attempted.1 1 See Operative Surgery, vol. i. p. 276, 2d edit. 5(33 PRACTICE OF SURGERY. SECTION IX. ECTROPION. Ectropion (sxtptita, I turn off), or eversion of the eyelids, is a con- dition precisely opposite to that which has just been described, and gives rise to various inconveniences which are chiefly due to the exposure of the lid as well as the ball, and the deformity which this creates. It may be caused by chronic thickening of the conjunctiva, as the result of inflammation, or by the cicatrix of burns, &c, and may be met with either in the upper or lower lids, the latter causing marked deformity (Figs\ 215 and 216). Fig. 215. Fig. 216. Fig. 215.—Ectropion of the Upper Eyelid, showing the deformity which it creates, and the amount of the conjunctiva thus exposed to the dust of the atmosphere. (After Miller.) Fig. 216.—Ectropion of the Lower Lid, the result of a cicatrix on the cheek. (After MiUer.) Treatment.—The treatment must consist in the removal of the cause; thus, if the ectropion be due to chronic conjunctivitis or chronic psorophthalmia, these complaints should be treated, and their cure will generally produce a removal of the complaint; but should these measures fail, an operation may be resorted to.1 SECTION X. LAGOPHTHALMUS. Lagophihalmus (a.ayoj, a hare; and o-j^atyo?, an eye), or hare-eye, is the name given to a complaint due to a loss of power in the orbi- 1 See Operative Surgery, vol. i. p. 272, 2d ed. PTOSIS.—ANCHYLOBLEPHARON. 569 cularis palpebrals muscle which results in an inability to close the eye, of so marked a character that the ball remains uncovered dur- ing sleep, it being said that the hare never closes her eyes in sleep. It may ensue upon various causes, as exposure to cold, or any cause capable of producing local paralysis. Treatment.—When dependent upon such causes it is to be treated as a local paralysis would be elsewhere, a small blister being put upon the temple or over the eyebrow, the raw surface thus created being afterwards dressed with strychnine ointment until slight twitchings of the muscles are perceived. SECTION XI. PTOSIS. Ptosis (rftfojts, a falling), or falling of the eyelid, is the opposite condition of the lid, in consequence of which it droops so as to cover the eye partially and interfere with distinctness of vision. It may be produced by any cause that results in palsy of the third pair of nerves. Belaxation of the levator palpebrae being thus caused, the contractions of the orbicularis palpebrarum muscle draws down the lid. Treatment—The treatment must be conducted upon the same general principles as are applicable to lagophthalmus. SECTION XII. ANCHYLOBLEPHARON. Ankyloblepharon (ayxvM?, contraction; and Pu$apov, the eyelid) sig- nifies union of the edges of the lids to each other, and may result from various causes, as burns, cicatrizing ulcers, psorophthalmia of a chronic character, &c. Treatment.—The adhesions may be divided; but if extensive, the complaint will return in spite of every effort, and reproduce the deformity. • 570 PRACTICE OF SURGERY. SECTION XIII. SYMBLEPHARON. Symblepharon ( mPIA<.GRAM 0F THE Catoptkic Test of the State op the Lens.—A. The cornea. B. lhe front of the lens. C The anterior surface of the posterior side of the lens. D. Xhe candle.—1. The anterior erect image formed on the cornea. 2. The deep-seated erect image formed on the front of the lens. 3. The middle and inverted image formed by the posterior face of the lens. (Original.) DISPLACEMENT OF THE LENS. 591 in the focus of the mirror or at some distance anterior to its surface. This inverted image is therefore noticed between the two upright images just described; it is fainter than either of them, moves down whenever the candle is moved up, and up whenever the latter is moved down, its motions being precisely the reverse of the mo- tions made by the candle. In order to derive full advantage from the application of this test, the pupil should be dilated by placing around the eye some of the extract of belladonna, or by dropping into it the solution of atropia. The room should also be darkened, whilst the operator, seating himself upon a chair rather higher than that upon which the patient is placed, holds a bright candle before the eye; and looks first for the most anterior image, which is invariably to be seen if the cornea is clear. That found, he should proceed—disregarding the first image entirely—to look for the second, or the small in- verted image, which will be present in the healthy eye, but not in one where there is cataract, the opacity of the lens preventing the rays of light from falling upon the concave mirror, where this inverted image is formed. In the same manner, if the capsule of the lens is affected so that the anterior surface of the lens loses its mirror-like qualities, the deep upright as well as the inverted image will have disappeared. The diagnosis of cataract, therefore, is positive, although of course the catoptric test will not enable the surgeon to decide whether or not the complaint is complicated with glaucoma, with amaurosis, or any other disorder, 'either of which would render the performance of the operation useless. Treatment.—The treatment of cataract being purely operative, its details will be found in the volume on Operative Surgery.1 The after-treatment is the same as that of other operations on delicate tissues. § 1.—DISPLACEMENT OF THE LENS. It sometimes happens, as a result of blows or other violence, that the lens is displaced, either backward into the vitreous humor, or forwards into the anterior chamber, though most frequently for- wards. If it is thrown backward into the vitreous humor, nothing 1 See Operative Surgery, vol. i. p. 303, 2d edit. 592 PRACTICE OF SURGERY. can be done but to treat any inflammation that may arise upon general principles, and when the patient has recovered completely, supply him with a cataract glass. But if the lens is dislocated for- wards into the anterior chamber, it sometimes acts as a foreign body, and creates such an amount of irritation and inflammation as justi- fies the surgeon in making a section of the cornea and removing it, as in the ordinary operation for the extraction of cataract. SECTION VII. AMAUROSIS. Amaurosis, which is often confounded with cataract by the inex- perienced, is a condition in which the sight is impaired or lost, owing to changes in the vitreous humor, the retiua, optic nerve, or the cerebral centres which preside over vision. It is sometimes also due to choroiditis. It has various synonymes, different terms being applied to special forms, which are after all only varieties of amau- rosis as above defined; thus, some writers draw a distinction be- tween glaucoma and amaurosis, describing as glaucoma that peculiar variety of amaurosis which is due to choroiditis or retinitis, and which results in a peculiar green appearance of the pupil, and limiting the term amaurosis to a diminution of the sight, or blind- ness resulting from derangement of the optic nerve, or of the cere- bral centres connected with vision, as the thalami nervorum opti- corum. Among the various terms applied to the complaint, are gutta serena; black cataract, or suffusio niger, on account of its color ■ and green cataract when the color of the pupil justifies such an appellation. Symptoms.—The symptoms are as follows: There is a gradual loss of vision, accompanied or preceded by symptoms of cerebral disturbance. Sometimes it happens that, while the patient sees well during the day, he cannot see at all when the stimulus of light is diminished, as during the night; this is what is called nyctalopia, or night-blindness. Or, the reverse condition may occur, the patient seeing best during the night. The patient is sometimes near, and sometimes far-sighted (myopia and presbyopia). Generally, there is cloudiness of sight, a condition designated as visus nebulosus. Or the patient may see objects in a different position, or of a differ- AMAUROSIS. 593 ent shape from reality, or the objects may appear lengthened, the flame of a candle appearing three or four feet long; this condition being designated as visus defiguratus, a condition which, according to Beer, always indicates serious disease of the brain. Sometimes the patient sees only one-half of an object (hemiopia), or he sees motes and other indistinct forms floating before the eye (muscse volitantes). Sometimes he sees fiery spots in every direction, or objects appear to be flame-colored—a condition which is generally accompanied by tinnitus aurium, and other symptoms indicating congestion of the brain. The catoptric test in amaurosis will show the three images perfect, and it can thus be, with readiness, diagnosed from cataract. Etiology.—The causes of amaurosis may be either local or gene- ral. The local causes are changes in the structure of the optic nerve, or the vitreous humors, or the retina, or choroiditis, etc. Excessive use of the organ will also sometimes produce this com- plaint, and hence it is often found in opticians and microscopists— a class of men in whom, when true amaurosis is not developed, certain changes of the power and even shape of the eye sometimes occur which are quite as peculiar as the appearances of the eyes of those who are near-sighted. Amaurosis may also follow an injury of the supra-orbitar nerve. Among the general causes may be mentioned fever, mental anxiety, &c. Varieties.—There are several varieties of the complaint; thus it has been divided into incipient and developed, partial and complete, functional and organic, idiopathic, sympathetic and symptomatic, terms which explain themselves. Prognosis.—The prognosis depends upon the causes and upon the condition of the patient. Generally speaking, it is favorable if the disease is due to congestion of the organ, and unfavorable if created by a change of structure. Treatment.—The treatment oT this complaint, as of many other diseases of the eye, is both constitutional and local, the constitu- tional treatment being the most important. If the affection is due to local or general plethora, or to congestion of the vessels of the part, active antiphlogistic measures must be resorted to. If it can be traced to a checked discharge, such a condition, for example, as at times follows the operation for hemorrhoids, the indication is clear, depletion must be resorted to, and this in the case just alluded 38 594 PRACTICE OF SURGERY. to, is best effected by leeches applied around the anus. Leeches in this location indeed are singularly applicable to the congested con- dition just described, and in France are frequently made use of no matter what the cause may be by which the congestive amaurosis has been produced. Various other modes of treatment have resulted successfully in cases proceeding from certain causes. Thus, mercury given so as to induce gentle ptyalism, has proved successful in cases ensuing on effusions of lymph, and saline purges have proved efficacious in cases due to a congested condition of the vessels. Where the disease depends upon paralysis of the optic nerve, the same treatment should be adopted as is applicable in local paralysis elsewhere—blisters dressed with strychnia ointment, counter-irri- tants, &c, being resorted to; and it is in these cases that benefit has been derived from passing a current of electricity through the tem- ples. Fumigations with the .vapor of hydrocyanic acid have also been much lauded, and may be applied by means of a glass cup, with a neck so shaped as to apply itself to the ball; but this has often failed to produce the benefit that was at one time expected from it. PART VIII. DISEASES OF THE EAR. The diseases of the ear, like those of the eye, are so numerous and involve an organ the anatomical study of which is so often neglected by the student, that their treatment has generally been declined by the mass of the profession, and become the business of a special class of surgeons. Still there are certain general princi- ples which may be readily carried out by every practitioner, and it seems, therefore, desirable to express some general views of these diseases in this place, if only to induce the student to notice the simplicity of the pathology of these affections, as well as the fact that they are often due to inflammatory action, and amenable to the general laws of inflammation, so that hereafter they may use their influence to take this class of patients out of the hands of the quacks, to whom they so often abandon themselves. Anatomical Relations.—The external ear is composed of the car- tilages covered by the skin, the latter being liable to simple or erysipelatous inflammation, like the skin of other parts of the body. This skin is reflected from the ear into the meatus externus, and its cuticle is continuous with the membrane lining that passage, in which are the ceruminous glands. At the bottom of the meatus externus is the membrane of the tympanum or drum of the ear, which forms a septum across the meatus, and is covered externally by the cuticle, or by the lining of the meatus, whilst internally its covering is continuous with the lining membrane of the internal ear. The proper membrane of the tympauum is of a clear pink color when healthy. On its inner side is the tympanum, or the cavity which contains the four small bones of the ear, and within or beyond these we have the cochlea and semicircular canals, con- cerning which, all that need be said in this place, is that they are 596 PRACTICE OF SURGERY. lined by a membrane which sufficiently corresponds with the mu- cous membranes elsewhere, to be named a mucous membrane, and which is liable to the same inflammations and diseases as mucous membranes generally. The tympanum is connected with the mouth by a passage designated as the Eustachian tube, which opens into the throat about two lines below the floor of the nostril, and just behind the posterior half arch of the palate. A probe bent to a Jth of a circle, and passed into the nostril till it reaches the soft palate—as may be known by the effort of the patient to swallow— and then made to rotate a quarter of a circle, will readily enter this orifice. The Eustachian tube is lined with a mucous membrane which is continuous with the mucous membrane of the pharynx and oeso- phagus, and of that of the internal ear. Inflammation of the mu- cous membrane of the throat may, therefore, travel along through the Eustachian tube and involve the ear, thus presenting all the symptoms, and being followed by very much the same results as inflammation of the urethra or ductus ad nasum. CHAPTEE I. AFFECTIONS OF THE EXTERNAL EAR. SECTION I. OTITIS. By the general term otitis is designated an inflammation of the ear; one of the specific forms of which is designated as external otitis, and is an inflammation in the meatus externus that results in abscess, this abscess involving either the skin or the mucous membrane of the meatus, whilst the other is known as internal otitis, and involves the structure of the tympanum. § 1.—OF EXTERNAL OTITIS. Symptoms.—The symptoms of external otitis are those of abscess elsewhere; thus, there is violent pain in the part, which is described EXTERNAL OTITIS. 597 by the patient as that of earache, and which is due to the effusions causing swelling in a dense unyielding structure. This pain may be told from simple neuralgia of the ear by seizing the external ear with the thumb and finger and drawing it gently upwards, as in external otitis, the pain will be augmented by the stretching of the external meatus, whilst in the pain from internal otitis or from neuralgia, this motion will not affect it. Sometimes, after pus is formed, it tends downward and escapes through the fissure at the bottom of the meatus, so that the abscess will point below the ear, whilst sometimes it points behind, or in the meatus itself. Treatment.—The treatment of external otitis should be conducted upon the general principles of abscesses: warm moist applications, antiphlogistics, injections of warm water into the ear, leeches be- hind or below the ear being resorted to. When pus has evidently formed beneath the cartilaginous tube, it should be evacuated as soon as possible. The laudanum and oil so recklessly dropped into the ear under these circumstances by the old women and quacks does positive harm when the otitis is superficial, because of the stimulating quality of the laudanum, as the lining membrane of the external meatus is very delicate, and that part covering the membrane of the tympanum quite as delicate as the ocular conjunctiva. Great comfort will, in some cases, be derived from the use of a hop-poultice, which presents heat and moisture conjoined with ano- dyne effects. This poultice should be made of hops mixed with flour, and moistened with hot vinegar or water, tbe introduction of the flour being for the purpose of obviating the disagreeable rust- ling and crackling under the ear which would result from the use of the hops alone, even when moistened. Anything which presents heat and moisture to the parts is always of service, and this is the true solution of the success of the popular remedy of the roasted onion, from which benefit is sometimes obtained. Frictions of aco- nitia, rubbed up with lard in the proportion of 1 gr. to the drachm, or the tincture of aconite combined with soap liniment, &c, are exceedingly useful in allaying pain, but they are rather more serviceable in otalgia than in otitis, as will be hereafter shown. 598 PRACTICE OF SURGERY. § 2.—INTERNAL OTITIS. Sometimes inflammation attacks the more internal structures of the ear, and there may be internal otitis, or inflammation of the tympanum proper, which, by inducing a suppuration within the cavity of the tympanum, will involve the bones of the ear or the Eustachian tube. Symptoms.—The symptoms of internal otitis are similar to those of the external form, but more marked; the pain being deeper- seated, and more pulsatile, whilst there is also more heat, pain in the head, and fever. Diagnosis.—The diagnosis of internal from the external form of otitis is readily made, because in the internal variety there is not the same sensibility when the ear is drawn upwards, as in the external, except when the two forms of the disease are combined. There will also be a greater degree of constitutional disturbance, as indicated by fever, &c. Like the external variety, internal otitis may terminate in an effusion of pus, which, being prevented from escaping into the external meatus by the membrane of the tym- panum, may distend it until it bursts, when the bones of the ear may be rendered carious and be thrown off by the external meatus, or the pus may escape by the Eustachian tube into the throat. Prognosis.—The prognosis is favorable, except when it is due to the effects of scarlet fever. It is, however, under all circumstances, less favorable than in external otitis. Treatment.—As the inflammation is deep seated, and involves delicate and most important parts, the treatment should be active; thus, it may be necessary to bleed as freely as the patient will bear, or to leech around the ear, and employ all such antiphlogistic measures as are applicable to inflammations of a similar grade elsewhere, the use of antimonials being advisable, whilst calomel, particularly when combined with Dover's powder, in order that it may excite the secretory action of the skin, is especially service- able. The moment of the formation of pus behind the membrana tym- pani is generally marked by a chill; and after this the examination of the ear by means of a speculum will often show the presence of pus if the accumulation has taken place to such an extent as to INTERNAL OTITIS. 599 involve the membrana tympani, the latter being then prominent externally instead of depressed. Treatment—The indications for the treatment of internal otitis are the same as are presented in any other abscess; thus the pus must be evacuated, and there should be no hesitation in puncturing the membrana tympani in order to accomplish this, the dangers from the accumulation of pus in the internal ear, and the production of caries or necrosis of the small bones, with the distension and dis- organization of the tympanum, being much greater than those aris- ing from simple puncture of the drum of the ear. The puncture may be made by a needle, a short straight pointed bistoury, or still better by means of Deleau's instrument, prepared especially for the purpose, taking good care, however, whatever be the instrument employed, to avoid striking the handle of the malleus.1 Having thus got rid of the pus, warm water should be injected into the meatus with the view of thoroughly washing it out, when the symptoms will generally be much alleviated. The after-treatment is the same as that of any other abscess, the little wound in the tympanum healing rapidly like any other incised wound, and with the greater rapidity because the previously distended membrane having now collapsed, the edges of the punctured wound are brought into accurate juxtaposition. Indeed, so readily is union effected in per- foration of the membrane of the tympanum, that in those cases where it is desirable from any cause to keep a wound in it open, a free crucial incision or the use of caustic is necessary to obtain that result. Should the fears or ignorance of the patient lead to a neglect of these measures and the pus be not evacuated, the membrane will not be saved, as its distension by the pus will terminate in ulceration, the ulcer that is left being difficult to heal and often destroying the whole membrane, whilst the luxuriant granulations from its edges will give rise to a fungus that will fill the meatus. Or if ulceration does not take place, or if the membrane of the tympanum does not rupture, Still the violent irritation will impair its usefulness by leading to a deposit of lymph, the membrane becoming so thickened that it will cease to vibrate. If pus collects and the membrane is rup- tured, the little bones of the tympanum may also be loosened from 1 For an account of this operation, with, drawings of the instruments, &c, see Operative Surgery, vol. i. p. 413, and Plate XXVIII., 2d edit. 600 PRACTICE OF SURGERY. their connections and be discharged with the pus that escapes, the patient being thus rendered permanently deaf, a condition which is not unfrequently seen in children as one of the sequelae of scarlet fever. The inflammation of the pharynx which is so characteristic of this fever, also often extends itself along the Eustachian tube to the internal ear, where it develops inflamma- tion, and sometimes notwithstanding the best treatment, but more frequently on account of bad treatment, or for want of any treat- ment, rapidly destroys the small bones of the ear by ulceration and caries. When the membrana tympani is ruptured, a patient can generally be made to show it by directing him to close his nose and mouth and expel the air from his lungs, when, if the Eustachian tube is still patulous and the membrane is perforated, the air will escape from the external ear. Absence or perforation of the mem- brane from any cause will also account for the power sometimes observed in certain individuals of expelling tobacco smoke from their ears; a most dangerous practice, as the irritation of the smoke is liable to lead to inflammation of the internal ear, and thus result in permanent disorganization of the organ. The treatment of the cases of inflammation of the internal ear which arise during scarlatina, or as a sequel to it, is plain. As the irri- tation and inflammation started originally in the pharynx, the first remedies should be addressed to the throat, and indeed careful treatment of the pharyngitis during this fever will often prevent the condition of the ear under consideration. But should inflam- mation occur notwithstanding these precautions, it is to be treated upon the same general principles which have been laid down for the treatment of acute internal otitis arising from any other source. § 3.—CHRONIC OTITIS. Chronic otitis is, as its name imports, merely a chronic condition of the affection just described. It is precisely similar to chronic inflammations in other mucous membranes, such as chronic con- junctivitis, chronic gleet, &c, and is to be treated on the same prin- ciples, the greatest service being obtained from counter-irritants, in the use of which the patient must steadily persevere for months in order to obtain benefit. Cases of chronic deafness, in which the patient hears imperfectly OTALGIA, OR EARACHE. 601 under ordinary circumstances, though he can hear distinctly the ticking of a watch when placed between his teeth or against his mastoid cells, so as to receive the reverberation of sound that passes through the bones of the cranium to the ear, are usually cases of chronic otitis. They are by far the most frequent forms of deafness, and are sometimes spoken of as cases of nervous deaf- ness and pronounced incurable, though really due to chronic inflam- mation and thickening of the mucous membrane of the internal ear, and often amenable to a treatment based on the principles which would be appropriate to any chronic inflammation elsewhere. Treatment.—The treatment of chronic otitis should consist in the use of the warm foot-bath every other night, this being ad- vantageously combined with counter-irritants, the employment of which should be kept up from nine to eighteen months; such as tartar emetic ointment, croton oil, or small blisters constantly kept behind the ear. As to the popular employment of Scarpa's oil, British oil, Acoustic oil, or the thousand and one nostrums generally dropped into the ear, it is only necessary to say that usually they are positively injurious, or if beneficial are so chiefly by their stimulating properties. SECTION II. OTALGIA, OR EARACHE. Otalgia is the name applied to neuralgic pain in the ear; which in children and others may be produced by sudden exposure to cold, by sitting in a draught, by.getting the feet damp, &c.; or it may be due to carious teeth, like the usual forms of facial neuralgia. Diagnosis.—Otalgia may be diagnosed from otitis—except when the two are combined—by the fact that the most careful examina- tion by means of a speculum discovers little or no appearance of inflammation in the ear. Treatment—The treatment will be that of neuralgia generally. Thus an ointment of aconitia, gr. i to 3ij of lard, applied around the ear will often produce prompt relief, and the otalgia of child- ren will frequently be promptly relieved by painting the ear and immediately around it with the tincture of aconite. The affection 602 PRACTICE OF SURGERY. is much more common in children than in adults, and in them seems often to be due to dentition and indigestion, which when present should receive attention. SECTION III. OTORRHCEA. Otorrhcea is the name applied to any irritation which results in a puriform discharge from the external ear. It is often one of the sequelae of otitis, and is most frequently seen in children. If there is caries or necrosis of the small bones of the ear, or of the mastoid cells, this discharge will be exceedingly offensive, presenting the ordinary characteristics of discharges from dead or diseased bones, the sulphuretted hydrogen contained in the discharge under these circumstances not unfrequently blackening the parts around the ear, and producing appearances which are quite characteristic, espe- cially when lead-water has been used as a wash. Otorrhoea is also frequently a result of scarlet or of other fevers. The discharge, however, is often referable to a much simpler source, and may be due to an inflammation in the external mucous membrane covering the tympanum, or to the lining of the external meatus which has resulted in the secretion and discharge of pus. Treatment—Whether this or the former and more serious condition exists can generally be told by washing out the ear, and examining the canal by means of a speculum. The washing out of the ear should be practised by means of a syringe, which should be of sufficient size, say large enough to hold four fluid- ounces of liquid. Having filled this with tepid water or tepid soap and water, draw the patient's ear upward and forward with one hand, and grasping the syringe with the thumb and middle finger, slip the forefinger through the ring in the piston,' intro- duce the nozzle into the external meatus and inject the fluid simply by bringing the forefinger towards the thumb and middle finger. Before, however, this is done, the patient should be directed to hold a cup close beneath the ear for the purpose of receiving the fluid as it escapes from the ear. Neglect of this simple precaution will lead to the soiling of the patient's clothes with the fluid used, which should be carefully avoided, especially where it is necessary OTORRHEA. 603 to repeat the operation a number of times, as it is desirable not to disgust a patient with the operation in the beginning. After thus thoroughly washing out the meatus, the membrane of the tympanum should be examined by means of the speculum auris, an instrument the use of which, it should be fully understood, is merely to dilate the external orifice of the meatus, and to reflect the light into the bottom of the canal. This examination will at once show whether the tympanic membrane is thickened or diseased, and whether it has been destroyed by ulceration, or is distended by pus. But care must be taken by the young practitioner not to mistake the natural appearance of the part for the evidences of disease. This caution is by no means a groundless one, as the depression and opacity caused in the normal membrane by its attachments to the handle of the malleus have been mistaken by beginners for ulcera- tion. The alterative local treatment of otorrhoea should be conducted upon general principles, whether the disease involves merely the external meatus or the whole internal structure of the ear. When otorrhoea has existed for a length of time, there is the same indi- cation for the application of astringent and alterative salts that exists for their employment in chronic inflammations of mucous membranes elsewhere. Injections, therefore, may be thrown into the ear, consisting of solutions of any of these astringents, as sulphate of zinc or nitrate of silver, of the strength of one grain to the ounce of water, or the liq. plumb, subacetat. may be advantage- ously substituted in the proportion of gtt. vj to two or three ounces of water, being augmented in accordance with the chronic character of the discharge. The constitutional treatment is also important, as the disease is very common, perhaps most common among tuberculous children. Here, of course, the constitutional treatment of the tuberculous diathesis must also be adopted, as the use of the iodide of potas- sium, cod-liver oil, tonics, &c. The inflammation of the mucous membrane, which produces the otorrhoea, sometimes also results in ulceration of the membrane of the tympanum, in consequence of which fungous granulations sprout from the ulcerated surface, so that upon looking into the ear, these fungous granulations can be readily seen, their appear- ance being such that they might be mistaken for polypus of the ear. The former, however, possess a mulberry-like surface, which 604 PRACTICE OF SURGERY. is quite characteristic, while polypus presents a fleshy tumor, with a surface that is generally smooth and even. In the adult, otorrhoea is sometimes caused by the presence of foreign bodies in the meatus, and not unfrequently from accumula- tions of the secretion of the ceruminous glands, mingled with dirt, dust, epithelial scales, and other matters. Many individuals, who are very cleanly in other respects, are not unfrequently careless in' regard to the condition of the external ear, never washing it out, and merely removing the wax from time to time with a tooth- pick. When a person of such habits goes on a journey, the dust and cinders of the road collect in the ears, and becoming adherent to the wax, the patient soon finds himself quite deaf, a condition which he generally ascribes to the effect of the noise of the cars instead of its true cause. This accumulation of dirt and wax in the external ear, if allowed to remain, will soon act as an irritant, precisely as any other foreign body would, and nine cases out of ten of otorr- hoea, in healthy adults who have not suffered previously from an attack of otitis, will be correctly attributable to this cause, and re- lieved by simple syringing the meatus, with the subsequent use of mild astringents. SECTION IV. FOREIGN BODIES IN THE EAR. The mention of the accumulation of wax, or a foreign body, in the meatus, leads naturally to the consideration of the fact that foreign bodies may get into the ear. These may consist of bits of cotton, used for stopping the ear, or of the hair which grows within the orifice, both becoming agglutinated with the ear wax. In the case of children, small foreign bodies, such as beads, beans, grains of coffee, bits of ribbon, peas, cherry-stones, &c. &c, are often mischievously thrust into the external meatus, and require to be removed. In these cases, the attempt to remove them with the probe or forceps should not be made, because it is most frequently unsuccessful, and only exaggerates the irritation already created. A much safer, less painful, and more certain method, is that recommended by Dr. Marion Sims, formerly of Alabama, now of New York, and con- sists in washing them out by means of a syringe with a small POLYPUS OF THE EAR. 605 nozzle. The syringe used for this purpose should be of good size, and from twelve to twenty syringes full, if necessary, be thrown in, before the attempt is given up, the meatus being rendered as straight as possible, by drawing the ear upwards and backwards. If insects get into the ear, they may be removed by pouring in a little oil of almonds or olive oil, which, checking the respiration of the insect, compels it to come to the surface, when it may readily be removed. SECTION V. POLYPUS OF THE EAR. Like other mucous membranes, that lining the external meatus, and covering the membrana tympani, may be the seat of those various morbid growths which pass under the common name of polypi, and which may here be produced under the same conditions and in the same manner as polypus elsewhere, whether in the nostril, in the uterus, rectum, or urethra. Polypus of the ear generally arises from the walls of the meatus, or from the external surface of the tympanic membrane, though it may spring from its internal surface, where by filling the tympanum, it causes the membrane to ulcerate, and then forces its way through, so as to appear in the external meatus, where it sometimes attains such size as to extrude at the external orifice. Symptoms.—When a polypus forms in the ear and attains some size, the patient begins to complain of frequent earache, for which he is unable to assign any cause, not being subject to neuralgia, and not having been exposed to cold, &c. Soon after this a running from the ear of a sero-purulent character will be noticed, this discharge being the same as that which accompanies polypi, wherever situated. Next, he may suffer more or less from deafness, because the growth from the polypus obstructing the passage, and the altered character of the membrane itself, interfere with the transmission of sonorous undulations; or, if the polypus has arisen from the side of the meatus, it may act as a foreign body, and plug up the canal. The slightest ocular examination of the meatus will at once reveal the true character of the disease, as in looking into it a fleshy-looking, smooth tumor can be seen, varying from the size 606 PRACTICE OF SURGERY. of a pea to that of a tumor, which fills the whole meatus, and pro- trudes beyond the external orifice. Treatment—The treatment, as already stated, is that of polypus elsewhere. The indications are evidently to produce the removal of the tumor itself, and to cause such a change in the surface from which it has grown, as will prevent its reproduction. Both these indications may be accomplished in various ways. The removal of the tumor, for example, may be efiected by means of the polypus forceps, with which it can be twisted off if great care is taken. But to this method there are serious objections. Thus, if the polypus grows from the membrane of the tympanum, the mucous membrane covering that structure, or the whole structure itself may be torn away, and the little bones of the ear be displaced, so as to create serious injury to the hearing of the patient. Instead of the forceps, the removal of a polypus of the ear may be accomplished by means of the ligature, which is much the best method; or it may be effected, in many instances, by the constant and patient application of the nitrate of silver, after each applica- tion of which, the surgeon should be careful to put a little oil into the ear, to prevent the excess of caustic from inflaming the ad- jacent structures. The application of the ligature may be very readily accomplished by forming a loop with an ordinary silk ligature, and, having passed it over the polypus, carry it down as far as possible by means of a probe, as directed in the Operative Surgery.1 After this operation, but more particularly after removing the tumor by means of the polypus forceps, there will be more or less hemorrhage; but this can generally be checked by means of the ordinary styptics. SECTION VI. DEAFNESS. Deafness is a complaint from the treatment of which many mem- bers of the profession often shrink, thus leaving it in the hands of quacks, who deceive the patient with false promises, and not only rob him of money, but also do him irreparable injury. Much of 1 See vol. i. p. 417, 2d edit. DEAFNESS FROM EXCESS OF WAX. 607 the unwillingness shown in regard to the treatment of deafness, has doubtless, been due to the tedious, and often unsatisfactory charac- ter of the treatment, as well as the apparent necessity for a pecu- liar apparatus for its treatment. Though this may be true in some cases, there are yet many in which every practitioner of medicine can furnish relief, or at least gain such a knowledge of the patient's condition as would justify him either in advising a consultation, or in urging upon the patient the advantages of doing nothing. § 1.—DEAFNESS FROM EXCESS OF WAX. Deafness may be produced by several conditions of the ear: the most common, and the first to which attention should be given, is the accumulation of the secretion of the ceruminous glands, which, when allowed to remain as already mentioned, becomes mingled with particles of dust and dirt and other foreign matter, and not only produces at times the otorrhoea already referred to, but also creates more or less deafness. Besides this there may be a true increase of activity in the ceruminous glands, leading to a considerable augmentation in the quantity of wax produced. When from either of these causes the wax accumulates in the meatus, blocks it up, and becomes hard and inspissated, it acts like a foreign body and produces very marked symptoms, of which the imperfect hearing is usually that which most attracts the patient's attention. Symptoms.—In the deafness from this cause the patient complains not only of loss of hearing, but of roaring and ringing in the ears. When the meatus is examined with a speculum under these circum- stances, it will generally be found to be diminished in depth, and to have at its bottom a dark brown or blackish body which blocks up the passage completely. If this wax has become very dry from time, or any other cause, it will be movable, and will sometimes rattle in the ear; but if it is yet soft and adheres to the sides of the meatus, it will often be found adhering firmly to the mucous membrane of the canal, and sometimes to the external covering of the membrane of the tympanum. In the attempts of nature to get rid of this mass, inflammation is not unfrequently developed, and pus secreted, as already shown in connection with otorrhoea. Treatment.—As this wax is in fact a foreign body, and as such re- - 608 PRACTICE OF SURGERY. quires removal by such means as will at once free the passage and thus enable sound to reach the membrane of the tympanum, the prognosis of the complaint is very favorable, and the plan of treat- ment a simple one. This is as follows: Drop into the ear at bed- time some glycerine or warm oil of sweet almonds, for the purpose of softening the wax as much as possible, and then next morning wash out the passage with plenty of warm water and a syringe, throwing in about twenty syringes full, as advised in the removal of foreign bodies. It is a good plan, however, not to wash the ear too much at the first time, but to desist when some impres- sion appears to have been made upon the hardened wax, and to resume the washing next day, repeating the operation as often as necessary until the whole is removed. After the wax has been completely gotten rid of, the condition of the meatus should be ex- amined, and if it is found to be red and inflamed near the bottom, as it will often be, owing to the removal of the cuticle, or epithelium, it should be treated as ordinary inflammation elsewhere. Sometimes the condition of the passage is such as to require the use of a weak solution of sulphate of zinc, of acetate of lead, or the nitrate of silver, the surgeon being careful to coat the external ear and side of the neck with sweet oil before throwing in the last injection, in order to prevent the ugly black stains which will otherwise be made by the solution wherever it comes in contact with the skin, as this both disfigures and annoys the patient. Having once re- moved the wax, the ears should be kept scrupulously clean, or if the condition appears to depend upon increased activity of the ceru- minous follicles, some mild astringent wash may be dropped into the ear each night and morning for a week or ten days. § 2.—DEAFNESS FROM DRYNESS OF THE EAR. Sometimes deafness, instead of proceeding from the accumulated secretion, or increased activity on the part of the ceruminous glands, is-the result of excessive dryness of the external meatus and of the membrane of the tympanum, caused by a diminution of the secretion. The general symptoms of this condition are in many respects similar to the symptoms produced by an accumu- lation of wax in the ear; thus there is the same dulness of hearing, and the same sensation of ringing and roaring in the ear. But a DEAFNESS FROM DRYNESS OF THE EAR. 609 diagnosis may be made by means of a very simple test. In most instances of deafness from dryness of the tympanum, the patient hears better when there is a good deal of noise. Thus a conversa- tion which, under ordinary circumstances, would not be heard, he will often hear quite distinctly, as, when riding in an omnibus, the noise of which would perhaps make the voice quite inaudible to a person with a perfectly healthy ear. This same peculiarity, it may be here mentioned, is also found in what is called nervous deaf- ness, a disease which the best authorities believe to be much rarer than is generally supposed by the majority of the profession. A diagnosis from nervous deafness may be very readily made, from the fact that in deafness from dryness of the tympanum, the patient can often hear the ticking of a watch perfectly well if it is placed in his mouth, or against his mastoid cells; while in deafness from disease of the nerve this will not be the case. Dryness of the tym- panum can also be recognized by means of the speculum, the membrane of the tympanum, which, in health, is pink and translu- cent, being then observed to be whitish, opaque, and presenting more or less the appearance of damp parchment, although not quite so thick. Treatment.—The treatment of this form of deafness, is that of chronic deficiency of secretion elsewhere, the mucous surface being stimulated into activity by means of various irritants. During the interim the natural moisture of the parts may, however, be tempo- rarily restored by means of glycerine dropped into the ear, this being the best substance known for preserving moisture on a dry surface, but if glycerine be not at hand, melted chicken-fat may be substi- tuted. With a view of stimulating the part to an increased secretion, the nitrate of silver may be very properly employed, the solution being dropped or injected into the ear; or, still better, applied with a camel's-hair pencil, the external ear being first oiled as before directed. It may be used in the proportion of from one to four grains to the ounce of water. External irritants may also be applied in the neighborhood of the ear, and they are very useful, when applied either directly in front of the meatus, or still better behind it, and over the mastoid cells, as by blisters, or by means of adhesive plaster mixed with tartar emetic, or by tartar emetic ointment, or croton oil, or collodion containing cantha- ridin, &c. The popular plan of treatment, by warming salt upon a shovel 39 610 PRACTICE OF SURGERY. and rubbing it while warm behind the ear, is not a bad one, as the hot salt acts like any other stimulant, and some patients find the sensations produced by it extremely agreeable. Or the external membrane of the tympanum may be painted with citrine ointment applied with a camel's-hair pencil, pure, if the patient can bear it, or diluted with lard. At the same time, the general health should be attended to, the patient taking a foot-bath every two or three nights as a revulsive. When the membrane of the tympanum is thickened, as well as dried, it may be recognized by the fact that when the patient closes his mouth and nose and expels the air from his lungs, the usual sensations produced by the impression of the air driven through the Eustachian tube against the inner side of the membrane is not produced. The treatment in these cases is precisely that which has been stated under the head of simple dry- ness, except that the stimulating washes which are introduced into the ear may here be made a little stronger. But when the mem- brane of the tympanum has been thickened in this manner for a considerable length of time, when it resists treatment, and we are satisfied that the obstruction of this dried and thickened membrane is the true cause of the patient's deafness, a very simple operation may be attempted, which can do no harm, if properly performed, and that is, the puncture of the membrane. For this purpose, va- rious instruments have been contrived, and perhaps the best is that of Deleau, as shown in the Operative Surgery.1 If no benefit is derived from this operation, the wound may then be allowed to heal, which it generally does very readily; but if the hearing is improved, a free crucial incision should be made, and the wound kept open by the occasional application of the nitrate of silver, until a permanent opening is thus established, which will permit the waves of sound to act directly on the internal ear. § 3.—CATARRHAL DEAFNESS. Deafness may also be due to a catarrhal inflammation of the mucous membrane lining the internal ear; this having arisen either in the ear itself, or had its origin in the throat and been transmitted to the ear through the Eustachian tube. 1 See vol. i. p. 418, 2d edit. CATARRHAL DEAFNESS. 611 Symptoms.—The symptoms, as might be expected from the nature of the complaint, are those simply of chronic otitis, as already described, the disease being liable to result in internal abscess and destruction of the small bones of the ear. As the inflammation of the mucous lining of the Eustachian tube produces a thickening which diminishes its calibre, or causes such a secretion as partially obstructs it, it will generally be found at a very early period, that though the patient is unable to blow air through this tube into the ear, yet a watch, introduced into the mouth, will be heard with perfect distinctness, owing to its contact with the cranium. Treatment.—The treatment of this form of deafness is that of catar- rhal inflammation, as already described. If the inflammation has originated in the pharynx, and that structure is yet in a state of inflammation, the remedies should be addressed to the throat, by swabbing it out with a probang, or sponge wet with a strong solu- tion of the nitrate of silver or some similar substance. After which, the disease of the ear may be treated as was directed under the head of chronic otitis. Obstruction of the Eustachian tube as a cause of deafness is, however, much less frequent than was formerly supposed, the Eu- stachian tube being by no means so small or so easily obstructed as was at one time thought, whilst the angle at which it is placed, as well as the size of its orifice, favors the escape into the throat of any secretions that may accumulate within it. It is, however, sometimes closed by a thickened condition of its lining membrane as the result of chronic inflammation, though this is by no means common. Such an obstruction, when it occurs, is generally the result of a chronic inflammation of its lining membrane, and com- mences primarily in the pharynx, though it may exist either in the course of the tube, or at its orifice, in the pharynx, in which loca- tion it is generally the result of the adhesions produced by such deposits of lymph as result from syphilis or scarlet fever. Obstruc- tions in the Eustachian tube may be tested by the introduction of an ear catheter or bougie, as well as by closing the nose and mouth and making a full expiration, as already mentioned.1 1 For the operation of catheterism of this tube, as well as the after-treatment, see Operative Surgery, vol. i. p. 420, 2d edit. 612 PRACTICE OF SURGERY. SECTION VII. NERVOUS DEAFNESS. Nervous deafness, or that due to a paralysis of the auditory nerve, which is a disorder often alluded to, is really a rare affection. It, however, sometimes occurs, and may arise from organic changes in the portio mollis, from tumors pressing upon the nerve, and from organic changes in the cerebral centres which may or may not result in paralysis. But it should be remembered that it is very seldom seen, and when it does exist, is generally coexistent with some other disease in the ear. When these diseases exist, they should be treated as directed elsewhere. When, however, true nervous deafness exists, very little can be done for the patient. Cases which appear to be due to mere paralysis of the portio mollis, in which there is no pain in the head, no cerebral disturbance in which the existing condition appears to be a mere loss of power, may sometimes be benefited by transmitting a cur- rent of electricity through the ear, applying one pole behind the ear, and the other in front, or to the mouth and throat. Counter-irritants behind the ear or to the nucha, may also be employed, and will sometimes prove useful, whilst blisters dressed with strychnine have been of service. But before a case is pro- nounced to be one of nervous deafness, and before such measures as those suggested are adopted, a most careful examination should be made of both the external and the internal ear, to ascertain whether disease exists in them. If the patient can hear a watch tick when placed against his head, it may be safely asserted that some power yet exists in the nerves of the organ of hearing. PART IX. AFFECTIONS OF THE NOSE AND ITS CAVITIES. CHAPTER I. AFFECTIONS OF THE NOSE. Anatomical Relations.—The external nose is covered with skin, which is maintained in shape by means of the ossa nasi and the nasal cartilages, and abounds in follicles; whilst it is lined through- out with a mucous membrane called the Schneiderian or nasal mucous membrane. The nasal passages communicate with the pharynx by means of an opening on each side, which is designated as the posterior nares; with the eye by means of a bony tube lined by mucous membrane, and known as the ductus ad nasum; with the antrum Highmorianum, which is situated in the superior max- illary bone, by a lateral orifice through which the mucous mem- brane of the nose is reflected and lines the antrum. SECTION I. LIPOMA. When the external sebaceous follicles of the nose become ob- structed and hypertrophied, they become the seat of a genuine fatty degeneration, which sometimes attains considerable size, and is designated as Lipoma, though this term is also applied to any fatty tumor no matter where it is located. When connected with the nose, the lipomatous tumor attains various sizes, those which are small and most frequently seen being oftener met with in the case 614 PRACTICE OF SURGERY. of drunkards. Usually, this lipoma is about the size of a pea or a bullet; but it may attain much greater size, and has been seen, though rarely, of the size of the fist or even larger. The only treatment applicable to them is excision. SECTION II. LUPUS. Lupus is a disease of the skin which frequently attacks the alae of the nose, and is characterized by a rapidly spreading ulcer. Symptoms.—It commences as a small, smooth, and shining tuber- cle, a little larger than a pea, the skin of which, becoming dis- tended, cracks, and rapidly develops ulceration. The ulcer thus formed is very much disposed to assume the phagedenic character, and that not only in its extent but also in its depth, the varieties of the disorder being named according to the rapidity with which it spreads; thus, when it extends itself notwithstanding all efforts to check it, and speedily invades and destroys the surrounding tissues, it is called lupus exedens, or the noli-me-tangere of the old writers, a term which was applied to the complaint because all remedies seemed only to aggravate it and increase its disposition to spread. Another form of the disease, which is milder, and without so marked a disposition to ulcerate and travel, is generally found in scrofulous persons, and is known as lupus non exedens. Etiology.—Lupus may be caused by various circumstances. Sometimes it is hereditary, and takes on all the characters of ma- lignant disease, being only distinguishable from cancer by the mode of its origin, lupus beginning in a tubercle, while cancer, parti- cularly epithelial cancer, begins as an epithelial ulceration or fis- sure. Frequently, lupus is associated with the syphilitic taint, and, under these circumstances, while the progress of the lupus carries away the soft parts of the nose, the syphilitic disease produces caries of the bones, thus producing horrible deformity. Lupus itself, uncombined with syphilis, seldom involves the bones of the face. Prognosis.—The disease is exceedingly intractable. Treatment—To consider the treatment of lupus in full would lead us deeply into the pathology and treatment of the tubercular OZ.ENA. 615 class of skin diseases, and it must, therefore, at present suffice to state, that the general principles required in the treatment of un- healthy inflammation will generally suffice for its relief, whilst the loss of substance caused by the ulcer can sometimes be relieved by one of the rhinoplastic operations described in the volumes on Operative Surgery,1 though, as the disorder is very apt to return, but little permanent benefit is derived from any operation. SECTION III. OZ.ENA. Ozaana (o^u, I smell of something) may be defined as an unhealthy inflammation of the Schneiderian mucous membrane which is generally connected with disease of the periosteum, or with caries or necrosis of the bones of the nose, and is very frequently a result of syphilis. Symptoms.—The symptoms of ozaana are, first, those of coryza; but the discharge presently becomes profuse, then muco-purulent, and then rapidly assumes the peculiar stinking odor which is cha- racteristic of the disease, and from which it is named. Sometimes the ulceration of the mucous membrane is deep, and involves the bones, spreading rapidly and casting off scales of bone, when, if the disease is syphilitic in its character, the nasal bones fall in and produce all those deformities which will be alluded to in connection with secondary syphilis. Diagnosis.—The diagnosis of ozaena may be made by noticing that it is characterized by a fetid discharge from the nostril, though such a discharge will also sometimes take place in children, particu- larly those who are scrofulous, but in whom it is unaccompanied by any disease of the bone, a point which renders the diagnosis comparatively easy. Prognosis.—The prognosis of ozaena will depend very much upon the causes and the complications of the complaint; if due to syphilis, of course the prognosis will be unfavorable, and, in all cases, should be guarded, lest the caries of the bones create the entire destruction of such as are involved. 1 See Operative Surgery, vol. i. p. 325, 2d edit. 616 PRACTICE OF SURGERY. Treatment—The treatment of ozaena should be both constitu- tional and local. If the disease arises from a tuberculous taint, or is due to syphilis, the constitutional treatment adapted to these conditions will, of course, be necessary; whilst, if the patient is weak and exhausted, tonics and chalybeates will be imperatively demanded. The local treatment should be conducted upon gene- ral principles; thus, as there is ulceration of a mucous membrane, which is more or less connected with disease of the bones, alter- ative and astringent washes may be expected to prove serviceable, especially the solutions of lead, which, being thrown into the nos- tril, diminish the fetor by combining with any free sulphuretted hydrogen which may be present. The strength of a solution of acetate of lead for this purpose should be from five to ten grains to the ounce of water. The mild chlorides are also serviceable in the same manner, such as the chloride of soda in the form of Labarraque's solution. The late Dr. Horner, of Philadelphia, ob- tained much benefit in several cases from the use of chloride of lime in the proportion of two drachms to the ounce of water. Advantage will also be found from the alterative effects of solutions of nitrate of silver. But when the caries, or necrosis of the turbi- nated and other bones has gone on to any extent, the disease will often prove exceedingly intractable. SECTION IV. RHINOLITHES. Rhinolithes is the name given to nasal calculi, or little concre- tions, which consist generally of inspissated mucus and some of the phosphates. They may be of various sizes, from that of a pea to that of a bullet, or a little larger, and should be removed from the nose in the same manner as any other foreign bodies; they are, however, very rarely met with. ABSCESS OF THE SEPTUM NARIUM. 617 i SECTION V. FOREIGN BODIES IN THE NOSTRIL. Foreign Bodies in the nostril may be of various sorts and sizes, as beads, pieces of ribbon, peas, grains of coffee, or any other articles likely to be thrust up the nostril by mischievous children. Grains of coffee, which are sometimes introduced, are particularly troublesome, because, imbibing moisture from the part, they swell and may thus not only become firmly imbedded, but also produce displacement or fracture of the turbinated bones, or even fracture of the vomer. Treatment—To get rid of these foreign bodies, a pair of forceps may be used if properly curved to suit the nostril, the instrument being introduced into it close to the septum in order to avoid the turbinated bone, when a little manipulation will enable the surgeon to seize the foreign body and withdraw it. Foreign bodies may also sometimes be extracted by means of a probe bent into the shape of a hook; or their removal may frequently be accomplished by the use of the syringe, which is a better plan. SECTION VI. ABSCESS OF THE SEPTUM NARIUM. The presence of foreign bodies and other causes, most of which are not understood, sometimes produces abscesses in the septum narium, the seat of which is in the cellular substance found be- tween the two layers of cartilage by which the septum is formed. The result of such an abscess is, of course, a separation of the two layers of cartilage, in consequence of which the patient soon notices such a bulging of the septum towards one or the other nostril as creates a deformity. Treatment.—The treatment is simple; the abscess being punctured and treated as abscesses elsewhere, the chief danger being from the continued distension of the cartilages creating a condition of the septum narium which will induce permanent deformity. The ulcer left after the evacuation of the abscess should be treated by nitrate of silver and other alterative applications, and when, as a conse- 618 PRACTICE OF SURGERY. quence of the complaint, dryness of the nostril occurs, glycerine may be used as in the case of dryness of the tympanum, or if this be not at hand, a substitute may be found in melted chicken-fat. SECTION VII. POLYPI NARIUM. Polypi of the nostril, like polypi elsewhere, may be the result of several different conditions of the nasal mucous membrane. Varieties.—In consequence of this diversity of origin, there is some variety in the polypi themselves, and they have hence been variously classified. The simplest division is, however, that which arranges them according to their density, dividing them into soft and hard; a division which sufficiently corresponds with the divi- sion into simple and fibrous, or into benignant and malignant; although the correspondence is not scrupulously exact. 1.—SOFT POLYPI. Fig. 223". The characters of the soft polypi are as follows: They present, when cut into, an apparently homogeneous soft tissue, which con- tains one or more cells, and are filled with the mucous fluid of the part; this fluid escaping when the sac containing it is punctured or lacerated. Polypoid tumors of this character are generally due to some obstruction in the muciparous follicles, the secretion of which distends and elongates them be- neath the mucous membrane until a tumor is formed which presents the cha- racters just described. This tumor is generally covered by the distended mu- cous membrane which, owing to its te- rat-tvertir1 •sectlln of the Nasal nuity, readily permits endosmose and Cavity, snowing the appearance J ' J r and position of the soft mucous exosmose to go on; the secretion escap- polypi. One is seen hanging into „ .... . the anterior, and another project- lUg from Wlthm through the Covering, e P°s(Arf°errnj0r^ Bell^ and moisture being absorbed in the same manner from without; a fact which ac- SOFT POLYPI. 619 counts for several of the symptoms of soft polypi, as their giving rise to muco-purulent discharges, and being larger in damp than in dry weather. In color, this polypus is pinkish, and has in it very few vessels, these being chiefly seen on the mucous membrane covering its external surface. In shape the soft polypus is usually pedunculated, as shown in Fig. 223. Symptoms.—The symptoms of polypus in the nose are well marked. The patient complains of feeling something in his nostril, and has, therefore, a constant desire to blow his nose, from which he finds a thin mucous discharge. He also notices that he breathes through the nostril more freely in dry weather than in moist. As the polypus grows, the symptoms become more marked, its bulk encroaching upon surrounding parts, until it may at last block up the entire nostril and so press on the orifice of the ductus ad nasum as to prevent the passage of the tears into the nose. In consequence of this the tears will often overflow the eye, and, the patient being ignorant of the true cause, refers all his symptoms to a troublesome coryza, which he is not able to get rid of. As the tumor grows still larger, it will protrude from the nostril ante- riorly, and show itself externally, or it may project backwards through the posterior nares into the top of the pharynx (Fig. 223); or it may work its way, if its growth still continues, through fis- sures in the bones of the face, and appear in parts apparently wholly unconnected with the nostril; thus tumors have been produced in the temple as a result of an excessive growth of one of these polypi in the nose. This encroachment on the face is, however, much more common with the fibrous than with the soft polypi. Another symp- tom which, so soon as the polypi have attained any size, develops itself in a very marked manner, is an alteration in the voice, which assumes a peculiar nasal twang on account of the obstruction of the nostrils, interrupting the reverberation of sound, the patient speak- ing as he would do if he held his nostrils between his thumb and finger. Upon looking into the nose this polypus can generally be seen as a smooth, pinkish swelling, owing to its being covered by the Schneiderian membrane; but caution must be used lest the anterior extremity of the inferior turbinated bone be mistaken for the poly- pus, when it projects towards the anterior nares. Prognosis.—The prognosis of soft polypi in the nostril is favorable, as the tumors can generally be removed, and although they will 620 PRACTICE OF SURGERY. frequently return, yet they can be removed again and again, until the tendency to their reproduction is finally overcome, unless they be malignant or have induced serious organic changes in the adja- cent parts. Treatment.—The treatment of polypi may be either palliative or radical; the palliative consisting in puncturing the tumor with a sharp-pointed bistoury, evacuating its contents, and allowing it to collapse. Although this treatment is in the majority of cases only palliative, yet it is not unfrequently followed by destruction of the sac and a disappearance of the disease. Should, however, this not happen, as is more frequently the case, the sac will begin shortly to refill, and resort must be had to the operation of extirpation as a means of effecting the radical cure.1 Sometimes a polypus can be removed simply by causing the pa- tient to sneeze violently, when, in the efforts consequent upon this action, the tumor will be expelled by being torn off from its base by the air as it is forcibly driven through the nostril. To produce this effect, ordinary snuff may be employed, or one of a more stimulating character, as powdered sanguinaria, cloves, rhubarb, or powdered sage, though any active sternutatory will answer the purpose. Having by any of these means gotten rid of the tumor, any wash which is astringent and alterative in its cha- racter may be used as an injection into the nostril, with a view of preventing the reproduction of the complaint—the best of these being the nitrate of silver. When the latter salt is used, the pre- caution should be taken of anointing the upper lip and the orifice of the nostril with sweet oil, in order to prevent the wash from discoloring the skin. § 2.—OF FIBROUS OR HARD POLYPI. The fleshy, fibrous, or hard polypi, present characters which, in many respects, correspond with the variety that has just been described; thus, they have a tendency to grow rapidly, and invade the surrounding parts, producing by their pressure caries and ne- crosis of the bones with which they come in contact. Those of the bones thin enough—as the walls of the antrum under certain con- 1 For these operations see the Operative Surgery, vol. j. p. 343, 2d edit. OF FIBROUS OR HARD POLYPI. 621 ditions—are also apt to become distended, and the patient is hor- ribly deformed, creating a distortion of the features which has been designated as " frog-face." (Fig. 224.) Fig. 224. Frog-face, or the deformity caused by Polypi of the Nose encroaching on the bones of the face. (After Liston.) Prognosis.—These polypi, when once formed, are very apt to be- come the seat of some of the malignant deposits already described, and, under these circumstances, it is generally useless to attempt anything like thorough extirpation, as the tumors will be rapidly reproduced, and, perhaps, the best advice that can be given is to let them alone, for the more they are irritated the more rapidly will they run their course and end in the destruction of the patient by encroaching upon the brain, or adjacent parts of the throat, &c. Seat.—The seat of polypi of this class is generally the back part of the nostril, where they distend the posterior nares, and some- times project into the mouth. 622 PRACTICE OF SURGERY. Ireatment.—The treatment of the fibrous polypus, when not be- lieved to be malignant, is very similar to that of the soft variety; but the prognosis of the removal of this class of polypi is less favorable than that just described, whilst in the malignant variety it is decidedly unfavorable. SECTION VIII. ULCERATION OF THE POSTERIOR NARES. Another disease affecting the nostril is an ulcer which is some- times found upon the nasal surface of the soft palate, or on the sides of the posterior nares, and is produced by various causes, but espe- cially by the irritation created by excessive smoking, the passage of more or less of the smoke over the nostril creating an irritation which results in inflammation and the production of a superficial ulcer, which is shortly covered by a small dry scab. Symptoms.—At certain times, particularly when the patient first rises in the morning, he experiences considerable irritation in the part, which he refers to the back of the mouth, and, after violent efforts at hawking, expels the little scab which has just been alluded to, as well as a certain amount of thick tenacious mucus or pus. Treatment.—In the treatment of this condition, it will often be sufficient simply to direct the patient to rinse out his nostril every morning by snuffing up into it a little cold water, but if this is not sufficient, he may mix with the water which he employs for this purpose, a little soap, and, if that fails, resort to injections of sul- phate of zinc, of nitrate of silver or similar articles, which will generally effect a cure. Sometimes cauterization of the pharynx with a small curved probang will prove exceedingly efficacious, though it is not possible to reach the seat of this ulcer by an in- strument passed up behind the soft palate, from the throat. EFFUSIONS INTO THE ANTRUM. 623 CHAPTEE II. AFFECTIONS OF THE ANTRUM HIGHMORIANUM. Anatomical Relations.—The Antrum Highmorianum is a large cavity situated in the superior maxillary bone, which communi- cates with the nostril, and is lined with a mucous membrane that is a continuation of the mucous membrane of the nose. This lining membrane is, of course, subject to the same diseases as those which attack the nasal mucous membrane; thus, it may be the seat of inflammation, of polypi, &c. It is also important to recollect, that the superior dental branch of the fifth pair of nerves passes along the inferior wall of the antrum on its way to the teeth, being there simply covered by the lining membrane of the antrum. SECTION I. EFFUSIONS INTO THE ANTRUM. Etiology.—Effusions into the cavity of the antrum may be the result of a simple increase in the mucous secretion of the part, or they may ensue on a serous discharge from the lining membrane, such as sometimes takes place from the Schneiderian mucous membrane as the result of catarrh. These accumulations, owin<* to their being circumscribed, will often give rise to very dis- tressing symptoms, one of the most painful of which is the neu- ralgic pain created by the pressure of the effused fluid upon the dental nerve, of which mention has just been made. Sometimes this fluid will continue to accumulate until, rising to the level of the orifice, it is evacuated through the nostril, and relief is obtained. Treatment.—The treatment consists in the employment of such means as are applicable to irritated conditions of the mucous mem- branes generally—as warm applications—but if the accumulation 624 PRACTICE OF SURGERY. of the fluid obstinately remains, it may be gotten rid of by punc- turing the antrum, precisely as one would get rid of the pus in an abscess. SECTION II. ABSCESS OF THE ANTRUM. Etiology.—Abscess of the antrum is a complaint connected with inflammation of the lining membrane, and due to the same causes as would produce inflammation in the nose. Any irritation of the antrum, such as that created by exposure to cold; or the ex- traction of teeth under certain circumstances, as where the violence done at the moment of extraction produces fracture of the alveolar process; or where the prongs of the tooth, being unusually long, encroach upon the cavity of the antrum, may also develop an ab- scess of this cavity. Symptoms.—From these circumstances, and from many other unexplained causes, inflammation of the lining membrane of the antrum is developed, from which an accumulation of pus results, which having no exit, gradually increases in quantity and creates an abscess, thus producing severe suffering, until it has sufficiently filled the antrum, and begins to escape into the nostril, when prompt relief follows as in the evacuation of abscesses elsewhere. These symptoms will also be frequently aggravated by the violent neu- ralgia which is produced, as in the serous effusions into the antrum by pressure upon the dental nerve, as it passes along the inferior wall of the antrum. Treatment.—The treatment is first to evacuate the pus as soon as possible; but, as it is here necessary to act upon a bony structure, peculiar means become necessary in order to accomplish this. If the abscess has been caused by the extraction of a tooth, the pus may perhaps be evacuated by puncturing the floor of the antrum through the cavity in the alveolar process, by some suitable instru- ment, such as a small trocar and canula, the trocar being withdrawn whilst the canula is left to keep the orifice in the mucous mem- brane open and permit the escape of the pus through it. After the entire evacuation of the matter, it will often be useful to inject the cavity of the antrum through the canula with tepid water, in order to POLYPUS OF THE ANTRUM. 625 wash it out thoroughly, as may be readily done by fitting the beak of a syringe to the mouth of the canula. But sometimes an abscess of the antrum occurs which is not a result of the extraction of teeth, and, under these circumstances, it becomes necessary to make an opening through the sides or walls of the antrum, as may generally be done by turning the lip forcibly upward, and puncturing the anterior and external walls of the superior maxillary bone by means of a strong trocar and canula, or by a sharp bistoury; this being a very simple operation, as the bones of the part are naturally thin, and, under the circumstances described, are not unfrequently rendered yet thinner by disease. SECTION III. POLYPUS OF THE ANTRUM. Polypus of the antrum may at times occur, though it is compara- tively a rare disorder, unless found in connection with polypi of the nostril. Treatment.—If the polypus is benignant, the treatment is to re- move, by ligature or otherwise, the polypi in the nostril if there be any, and to do likewise with so much of the polypus of the antrum as protrudes into the nostril, or can be reached from it; after which it will be necessary to act upon the diseased mass remaining in the antrum by means of astringent and alterative injections, which are to be thrown into the nostril. But most generally polypi of the antrum are either primitively malignant in their character, or become the seat of malignant deposits, and then create a tumor of the antrum, which has a disposition to invade surrounding parts, the neighboring bones being encroached upon until they become diseased, and a peculiar condition results which requires extirpation of the superior maxillary bone entire.1 1 See Operative Surgery, vol. i. p. 379, 2d edit. 40 626 PRACTICE OF SURGERY. SECTION IV. AFFECTIONS OF THE CHEEK. Under this head may be placed the various tumors of the cheek, which are, most generally, small encysted tumors, sebaceous tumors, &c, and the treatment of which is removal by excision. Under the same head would also be placed Salivary Fistula, or the fistu- lous ulcer, resulting from wounds of the duct of Steno, as is fully described in the Operative Surgery.1 SECTION V. AFFECTIONS OF THE LIPS. Affections of the lips consist in cancer and harelip, the first having been already alluded to under the head of Cancer, and the cure of the latter by operation being described in the volumes on Operative Surgery.2 1 See Operative Surgery, vol. i. p. 363, 2d edit. 2 See vol. i. p. 349, 2d edit. PART X. AFFECTIONS OF THE THROAT AND NECK. CHAPTER I. AFFECTIONS OF THE THROAT. SECTION I. FOREIGN BODIES IN THE PHARYNX. Anatomical Relations.—The term Pharynx is applied to all the upper portion of the oesophagus, or the orifice of the throat, and is formed by a series of muscles which are designated as the superior, middle, and inferior constrictors; the object of these being to seize upon the bolus of food, and, by their successive contraction, carry it down into the oesophagus, the muscular coat of which, by like contractions, carries it down into the stomach. The pharynx is attached posteriorly to the bodies of the vertebrae by a certain amount of loose cellular substance, which, like all cellular sub- stance, may become the seat of inflammation and abscess. The entrance from the mouth into the pharynx is guarded on each side by the two half arches of the soft palate which have between them the tonsil gland. Just below this point, and anterior to the pharynx, or at the root of the tongue, is the epiglottis cartilage, which closes the orifice through which the air passes into the larynx and trachea when the patient swallows. As the thyroid cartilages, which compose the upper part of the larynx, are open posteriorly or rather united only by muscular tissue, they do not afford that protection to the surface of the larynx which is next to the pharynx 628 PRACTICE OF SURGERY. that they do on its front, whilst the rings of the trachea being also imperfect on the posterior side, any force that distends the pharynx and oesophagus acts with great readiness upon the air-passages, so as to produce compression and all the consequent symptoms of difficulty of respiration, and strangulation. It should also be no- ticed that the situation of the great vessels of the neck with regard to the oesophagus and pharynx is such, that any forcible distension of the oesophagus or pharynx is liable to interfere with the freedom of the circulation by inducing spasm of the muscles of the neck, and thus compressing the veins which bring the blood from the brain. Etiology.—The foreign bodies which are most likely to get into the pharynx are such as are ordinarily taken into the mouth for the purposes of nutrition, although bodies of various characters may, through a variety of accidents, obtain the same position. Of these foreign bodies, the most common are such as fish-bones, especially the smaller bones of such varieties as the herring or shad, the smallness of which causes them to pass unnoticed to the fauces, when, getting transversely, their length is sufficiently great to cause them to lodge across the pharynx; or, the offending sub- stance may be a piece of tough meat or gristle taken into the mouth during a meal. In the same manner, foreign bodies taken into the mouth for any purpose may accidentally be swallowed, such as pins, which are often held in the mouth by housemaids and others, bits of glass, beads, coins, &c. Seat.—When any of these substances are swallowed, the first place at which their progress is likely to be arrested, is at the half arches, where the body, if sharp, such as a pin, needle, or fish-bone, will often be found sticking directly into the structure of the tonsil, the imbedding being sometimes effected by means of the spasmodic contractions of the isthmus of the fauces, the muscular contrac- tions of which have sometimes such power, that cases are on record in which pins and similar pointed articles have been driven com- pletely through the fauces, so as to wound the great vessels of the neck. Diagnosis.—In these cases, the surgeon will generally be able to recognize the foreign body by the sight, simply by directing the patient to open his mouth widely; but if from the minuteness of the body, or its position, he fails to do so, and the symptoms clearly indicate its presence, he should have no hesitation iu introducing FOREIGN BODIES IN THE PHARYNX. 629 his finger into the throat, by means of which the substance, if present, can always be recognized. Very frequently, however, it passes the isthmus of the fauces, and becomes fast in the pharynx, where it may generally be looked for about the bottom of the middle constrictor muscle, though some- times it is held in the embrace of the superior constrictor. Here, also, its presence can be recognized by means of the finger, which, under these circumstances, should be passed down a little below the orifice of the larynx. Symptoms.—When a foreign body is thus arrested in the pharynx, it is very apt to produce such pressure upon the larynx or trachea, as will be followed by violent spasm in the muscles of respiration, with evidences of strangulation. As a general rule, foreign bodies which pass fairly into the pharynx, yet are of such a size or shape as prevents their passage into the stomach, hitch upon a point that corresponds with the posterior face of the larynx, and by irritating the thyroid muscles induce spasms which are very violent in their character, owing to the irritation of the nerves of respiration. The patient therefore soon gasps and struggles for breath; whilst, by the contraction of the respiratory muscles thus thrown into a state of spasm, the larynx is pressed forcibly back upon the foreign body, and the danger is increased. Treatment—The treatment in these cases must always be prompt, particularly if the foreign body is large, as the spasm will soon re- sult in closure of the glottis, when the patient will be suffocated in a few minutes. A person when seen making these violent spasmodic efforts, under circumstances which would lead to the suspicion of a foreign body being the cause, should therefore at once be compelled to lean for- ward and drop his head upon the chest in such a manner as to relax the muscles of his throat, and thus prevent as much as possible the occurrence of contraction in such muscles as will, by forcing the larynx against the pharynx only increase the evil. Then, having fastened the jaws apart by means of a fork handle or a cork, thrust a finger into the throat and hook out the foreign body, if possible, when the relief will be prompt. If, however, this manipulation should fail, the patient's head should be retained by assistants in the same position while the surgeon resorts to more efficient means. Thus, if the foreign body is a piece of tough meat, or any similar substance which will not 630 PRACTICE OF SURGERY. be injurious if swallowed, all that is required in the way of instru- ments will be simply the probang of the shops or a flexible stick, the extremity of which is guarded by several folds of muslin firmly tied on. By means of either of these instruments, the foreign body may then be pushed down into the stomach, which will of course be followed by complete relief of the difficulties due to the irrita- tion of the laryngeal muscles. If, however, the body is of such a nature that it would be mani- festly improper to carry it down into the stomach, it may be re- moved by forceps adapted to this purpose,1 the best of which is that contrived by Dr. Henry Bond, of Philadelphia, and an account of which, in connection with an excellent paper on foreign bodies in the pharynx, was published in the North American Medical and Surgical Journal, vol. vi. p. 322, in 1826. SECTION II. AFFECTIONS OF THE MUSCLES OF THE NECK. • Torticollis, or wryneck, is an affection connected with the muscular structure of the neck, which is generally due to a spasmodic con- traction, often a permanent one, of the sterno-cleido-mastoid muscles. Treatment.—In its milder form this disorder is only a rheumatic affection of the muscle, and may be readily relieved by means of warm stimulating frictions, a very good article for the purpose being found in the tinctura saponis camphorata, combined with a due proportion of the tincture of the root of aconite, or it may be necessary to abstract blood by cups. The popular plan of covering the neck with a damp cloth, and ironing it with a warm flat-iron so long as the patient can bear it, is also not a bad plan of treatment. A more permanent contraction of the muscle requires, ^however, a more decided course of action; and it should be borne in mind that here, as in strabismus, while there is a preternatural contrac- tion of the muscles of one side, there is a preternatural relaxation in its antagonistic muscle, so that if the condition has existed for some weeks or months, and promises to remain permanent, it will be necessary to resort to an operation, this being conducted upon 1 See Operative Surgery, vol. i. p. 479, 2d edit. HYDROCELE OF THE NECK. 631 precisely similar principles to that alluded to in connection with strabismus;1 but here the operation must be followed by the proper application of mechanical means to overcome the contraction. The operation of myotomy, as generally practised for the relief of these deformities, is a very simple one, and only dangerous in the hands of a surgeon grossly ignorant of the anatomy of the part. In its performance, it should ever be borne in mind that the muscle, in which the section is generally made, is placed just above the carotid artery and the great veins of the neck.2 The new tissue formed by the or- ganization of the lymph which is thrown out between the edges of the divided muscle, being very extensi- ble, should subsequently be brought to such a length as will insure a re- moval of the deformity by means of various mechanical contrivances, such as are to be found either in the handkerchief of Mayor, specially de- signed for this purpose, or in an in- strument which regulates the position of the head by means of a pad and screw, or in a sort of helmet, with shoulder-bands so contrived as to hold the head in the proper position. (Fig. 225.) Bronchocele, or Goitre, with other tumors of the neck, will be found described in detail in the Operative Surgery, vol i. p. 506, 2d edit. SECTION III. HYDROCELE OF THE NECK. Hydrocele of the neck is the name given to a disease which con- sists essentially in the accumulation of fluid in the proper structure 1 For the details of myotomy, see Operative Surgery, vol. i. p. 503, 2d edit. 2 See Operative Surgery, vol. i. p. 501, 2d edit. Fig. 225. Helmet, &c, fob the treatment of Torticollis after the operation of Myotomy.—1, 2. Straps to pass un- der the chin and around the head. 3. A movable rod to adjust the helmet to necks of different lengths. 4, 4. Straps to surround the shoulders. 5, 5. Straps to fasten the shoulder-brace around the chest, and thus furnish a point of sup- port for the apparatus. (After Nature.) 632 PRACTICE OF SURGERY. or in the capsule of the thyroid gland. This fluid is generally serous in its character, the conditions favoring its development, and the pathological changes which are its proximate cause, being very imperfectly understood. Its treatment is that of hydrocele of the tunica vaginalis testis. Thus, its contents should be evacuated by means of a trocar and canula, and the tendency to its reproduc- tion overcome by means of injections of some stimulating substance, that most frequently used being solutions of the tincture of iodine in water, gradually increased in strength until sufficient adhesive inflammation is established to obliterate the cavity of the sac. SECTION IV. POISONS IN THE STOMACH. As the stomach is chiefly to be entered by the surgeon through the neck, we may now study the effects of poisons found in this viscus, whether introduced accidentally or with murderous or suicidal design. Varieties.—These poisons may be divided into three great classes: 1, those from the mineral; 2, those from the vegetable; and 3, those derived from the animal kingdoms. 1. The mineral poisons most frequently taken are arsenic, cor- rosive sublimate, salts of copper and lead, and the mineral acids, such as the sulphuric, nitric or muriatic acids, and the like. 2. The vegetable poisons are generally narcotic articles, such as opium, cicuta, stramonium, belladonna, laurel, &c, as well as mush- rooms, truffles, and other similar articles of diet in particular con- stitutions and under certain circumstances; there are also some vegetable poisons which cannot correctly be called narcotics, such as strychnia. 3. The poisons derived from the animal kingdom are very vari- ous, those perfectly innoxious in some seasons being sometimes poisonous under diverse conditions; thus fresh pork, so generally used as an article of diet, will act upon certain constitutions, in hot weather, as a positive poison; and this, perhaps, not merely from its nature, but also from the manner in which it is often eaten, being bolted in masses that are unmasticated. In some cases of poisoning thus induced, a brisk emetic has occasionally brought POISONS IN THE STOMACH. 633 away large lumps of undigested pork several days after they were swallowed, the debility, delirium and cutaneous eruption disap- pearing soon after the pork was vomited. Poisoning from this cause has been sometimes noticed among the laboring classes in the summer season. So also certain shell-fish, though often used as articles of diet, will occasionally produce in some individuals symptoms of poisoning, one being well known to me, upon whom stewed oysters will act as a positive poison, creating violent retch- ing—evidences of gastritis—prostration, and a marked form of erythema nodosum. Besides these ordinary articles there are certain animal substances which invariably act as poisons if given even in a comparatively moderate quantity: such as cantharides, &c. Symptoms.—The symptoms produced by these different classes of poisons will vary greatly, and must be separately alluded to. 1. Mineral Poisons.—The symptoms produced by the ingestion of a mineral poison are usually the symptoms of violent irritation and inflammation of the mucous membrane of the alimentary canal. The tongue, therefore, presents more or less evidences of deficient secretion, and is dry, whilst the throat is sore, and the pharynx inflamed, there being at the same time all the ordinary evidences of violent gastritis. There is also vomiting with frequent and violent retching, besides which, if the inflammation of the stomach progresses, it may result in perforation and all the usual symptoms of peritonitis. As these symptoms gradually increase, cold sweats come on, and in a variable period the patient dies. 2. Vegetable Poisons.—The symptoms of vegetable poisoning are generally excessive narcotism, and all the symptoms of congestion of the brain, as loss of sensation, vertigo, dizziness, loss of vision and hearing, headache, snoring or stertorous respiration, loss of consciousness, coma, and all the symptoms of compression of the brain. 3. Animal Poisons.—The symptoms of the various animal poisons will depend very much, both in their violence and character, upon the nature of the articles taken. As a general rule, however, it may be stated that there is in these cases a disposition to vomit, accompanied by all the other symptoms of gastric and intestinal irritation or inflammation, whilst it is not unusual for these animal poisons, when not sufficiently active to destroy life, to be followed in certain constitutions by the development of skin disease, &c. &o. 634 PRACTICE OF SURGERY. Treatment of Poisons in the Stomach.—The indications for the treat- ment of poisons in the stomach, are, 1. To evacuate the organ; 2. Where this cannot be accomplished, or after it has been accom- plished, if there is any reason to suspect that a portion of the poison- ous matter has remained behind in the stomach or bowels, to employ proper antidotes; 3. To get rid of any portion which may thus have passed into the bowel, even after the administration of the antidote, by means of brisk and active purgation; 4. To combat any effects of the poison which may occur notwithstanding these measures, these effects being generally found either in inflammatory action in the mucous coat of the stomach, as in the case of the mineral and animal poisons, or in narcotism of the brain, as in the case of certain vege- table poisons. The means to be employed in carrying out these various indica- tions differ materially in accordance with circumstances. Thus, the simplest manner in which the first indication may be accom- plished, and the contents of the stomach evacuated, is by means of emetics, and as these are sometimes demanded with great prompt- ness, it is as well to remember those that are most likely to be found under ordinary circumstances, the simplest and most readily and speedily obtainable of which is, that of mustard, salt, and warm water, a teaspoonful of the ordinary table mustard and a tablespoonful of salt being put into a tumblerful of lukewarm water, and drank off by the patient at a draught, after which the throat may be tickled with the finger or a feather with the view of exciting more prompt emesis. This substance generally acts with great promptness and efficiency. Another article which is appli- cable under these circumstances, particularly in the case of mineral poisons, where it acts not only as an emetic but as an antidote, is one which is also readily obtainable, though not now found so generally in houses as formerly, namely, common lamp oil; few persons being able to drink a tumblerful of it without having prompt emesis induced, whilst if it should not vomit it will yet sheathe the coats of the stomach from the action of acrid substances. Powdered ipecacuanha, if it can be obtained, is an excellent emetic, and may be administered in the dose of a teaspoonful every ten minutes, warm, drinks being freely given in the interval until the desired effect is produced. Sulphate of zinc may also be resorted to in doses of half a scruple; or tartar emetic in doses of from two to five grains; sanguinaria, or bloodroot, in doses of a scruple; or ANTIDOTES FOR POISONS IN THE STOMACH. 635 lobelia or tobacco, though these articles should be cautiously given and carefully watched, lest the injury resulting from their depress- ing and prostrating effect be no less than that resulting from the poison itself. The effects of the tobacco can be obtained either by giving it internally, or simply (and this is preferable) by macerating the leaf and binding it upon the skin at the pit of the stomach. But a more certain mode of thoroughly evacuating the stomach is by the use of the stomach-pump and oesophageal tube,1 which should be passed into the stomach so as to pump out its contents. Having thus gotten rid of as much of the poisonous matters as possible, the next duty of the surgeon is to resort to proper anti- dotes; these, of course, varying according to the nature of the poison, as each one has its appropriate and more or less efficient antidote. After thus neutralizing the effects of irritating poisons, the gastritis, &c, should be treated on general principles. § 1.—ANTIDOTES FOR POISONS IN THE STOMACH. 1. Arsenic.—The antidote for arsenic is albumen or gluten, which may be conveniently administered in the form of the white of eggs or of flour and water, or lightly calcined magnesia, which should be given very freely, the albumen forming with the arsenic a com- paratively insoluble and innoxious compound which may be subse- quently removed from the alimentary canal by emetics and purga- tion. The albumen, however—though it should always be resorted to if other means are not at hand—is not nearly so efficient an antidote for arsenic as it is for corrosive sublimate, and the surgeon should therefore, if it be in his power, resort at once, in the case of arsenic, to the hydrated sesquioxide of iron, which is usually kept by the apothecaries ready prepared, and which is the most efficient antidote for arsenic known. 2. Corrosive Sublimate.—The best antidote for corrosive sublimate, as already stated, is albumen, though gluten, milk, or Peruvian bark, may also be resorted to if albumen cannot be obtained. Any of these articles, to be thoroughly useful, should be given freely, and followed by the use of emetics and purgatives. 3. Nitrate of Silver.—For nitrate of silver the antidote is common table salt. 1 See Operative Surgery, vol. i. p. 486, 2d edit. 636 PRACTICE OF SURGERY. 4. Salts of Lead.—For the salts of lead the proper antidote is diluted sulphuric acid, which forms with them, by a chemical reac- tion, the sulphate of lead, this being an insoluble compound. If, however, the salt of lead taken is the carbonate, the sulphuric acid should be cautiously given, and some means employed to prevent distension of the stomach from the carbonic acid gas, which will be rapidly evolved. 5. Salts of Copper.—In cases of poisoning from the salts of cop- per the antidotes recommended are albumen, oil, &c.; but as the compounds thus formed are by no means perfectly insoluble, resort should afterwards be had to purgation and emetics. Vegetable Poisons.—Among the substances derived from the vegetable kingdom, the most common source of poisoning is the narcotics. In case of suspected poisoning from any of these sub- stances, the first thing to be done is to empty the stomach, and this will be performed most efficiently by means of the stomach-pump; but if that is not at hand, or while waiting for it, prompt emetics may be given. The stomach having thus been properly evacuated, the next indication is to purge with a view of removing any of the substance which has passed into the bowels. In order to obtain full benefit from this treatment, the purge given should be an active one, as elaterium, gamboge, large doses of calomel, or similar prompt and efficient drastic cathartics. After having removed from the stomach all of the drug that can be obtained, and whilst waiting for the operation of the purgative, the effect of any portion of it which may have previously been absorbed should be counteracted by keeping up the activity of the brain until the sedative influence of the poison shall have passed off. This object may be effected by stimulating measures of various kinds, all of which should be steadily persevered in, as it is an established fact, that if the activity of the brain can be kept up for six or eight hours, in a case of narcotic poisoning from an article like opium, the patient will generally recover. A very good mode of carrying out this indi- cation is by stimulating the nerves of the skin, and the simplest manner in which this can be effected is by switching the patient well by stripping him and striking him round the legs with a switch. The same end may be effected by the application of cold; either by leading him up and down a cold room, or giving him every fifteen or twenty minutes a shower-bath, or throwing a bucket of cold water over him; but this treatment should be ANTIDOTES FOR POISONS IN THE STOMACH. 637 cautiously practised, for if the cold is carried so far as to produce its sedative effects, it will only add to the power of the drug. If, however, all these means seem to fail the surgeon should not de- spair, as he has yet a resource which, in skilful hands, has saved life, and that is, to attempt to keep up the action of the brain by the galvanic battery, the most convenient form of which is to be found in the electro-magnetic machine, already alluded to. Mineral Acids.—In the case of poisoning by the mineral acids, the antidote is to be found in the free use of the alkalies, avoiding, however, the carbonated alkalies on account of the distension which would result from the consequent evolution of carbonic acid gas. In the case of oxalic acid, a vegetable acid which is sometimes a source of poisoning, the most serviceable antidote is lime, which may be obtained from a piece of chalk, or by scraping the ceiling of a room, and which forms with the oxalic acid an exceedingly insoluble compound. In all cases of poisoning in which the substance used is acrid or corrosive in its nature, the indication to follow the use of the antidote by free mucilaginous drinks is a clear one, as they sheathe the mucous coat of the alimentary canal, and facilitate the action of the cathartic which is to be subsequently employed. PART XL AFFECTIONS OF THE ABDOMEN. CHAPTER I. HERNIA. Hernia, or rupture, is the name of a disorder which consists in " a protrusion of any of the abdominal viscera covered by the peritoneum through a natural or preternatural opening in any part of the abdominal parietes." As it is a very common com- plaint—about one person in every eight suffering from it—and as it is one which exposes the patient to great inconvenience, and may at any moment result in his death, it is an affection to which surgeons have always paid great attention. This attention has, however, resulted in such an anxiety to describe all the parts minutely, that the vast multiplication of terms which resulted from their detailed anatomical statements has produced, as its legitimate result, a confusion of ideas. The present account will, therefore, be a comparatively brief outline, though it is hoped it will prove sufficiently explicit for all practical purposes. Seat.—Hernia may occur in any portion of the abdominal parietes except one, and that is posteriorly in the line of the spinal column. Its most common seats are, however, at those parts of the abdomi- nal parietes which give exit to bloodvessels, to the spermatic cord of the male, or to the round ligament of the female. Varieties.—For the purposes of methodical study, hernia is clas- sified, 1, according to the location at which the protrusion occurs; or 2, according to the contents of the tumor, i. e., according to the character of the portions of the viscera that have protruded. When under the first division a tumor occurs in the groin, it is therefore called an inguinal hernia; if its contents have passed 640 PRACTICE OF SURGERY. down into the scrotum, it is spoken of as scrotal hernia; if it comes down in the sheath of the femoral vessels, it is called femoral hernia; when found at or near the umbilicus, it is designated as umbilical hernia; and when it passes through the abdominal walls at any other point, it constitutes ventral hernia. A combination of ventral and inguinal hernia is called ventro-inguinal. If the hernia passes out through the ischiatic notch, it is called ischiatic hernia ; through the thyroideal foramen, thyroideal hernia; through the diaphragm into the cavity of the thorax, phrenic hernia; while an inguinal hernia in the female, which passes down into the labium, receives the designation of pudendal hernia. In the older works on hernia, certain names will also be found applied to these various forms of hernia which it is perhaps as well to understand, and which are intended to point out the locality and contents of the tumor. Thus, an inguinal hernia was formerly designated as a Bubonocele, or groin tumor, a very incorrect term, and one which evidently would be quite as correctly applied to a bubo as to a hernia; whilst scrotal hernia received the name of oscheocele, femoral hernia was entitled merocele, and an umbilical hernia was called an exomphalos. 2. The hernial tumor, in the second place, has been variously named according to its contents; thus, if it contain intestine, it is termed enterocele; if omentum, epiplocele, and if both, entero-epip- locele. Certain terms, moreover, are applied to the varieties of hernia in accordance with the condition in which their contents are found. Thus, if they can be restored to the abdomen at pleasure, the hernia is said to be reducible; if this is not possible, it is said to be irre- ducible; and when, from any cause, an irreducible hernia is so con- stricted as to impede or prevent the passage of the feces and the circulation of the blood in the tumor, it is spoken of as strangu- lated; whilst if present at birth, it is designated as congenital hernia. Hernial Sac.—As the bowels and omentum are both behind the bag of the peritoneum, they must, as they escape from the abdomen, push this membrane before them, and every hernia thus obtains a covering which is almost always present and wliich is designated as the hernial sac. Regions of the Sac.—The portion of the sac most distant from the point through which the hernia escaped from the abdomen is desig- nated as its fundus; the orifice which communicates with the abdo- REDUCIBLE HERNIA. 641 men is known as its mouth, and the part constricted as the neck of the sac. Varieties in the Sac.—The sac, as first noticed, is a thin serous covering, formed of peritoneum, and in every way identical and continuous with the portion of this membrane yet left in the abdo- men ; but soon after the formation of a hernia the pressure to which it is exposed develops more or less inflammation, by which its structure is much thickened and its original appearance quite lost, becoming frequently several lines thick, whilst its transparency and vascularity are also much modified. But it sometimes happens that the distension of the sac results in a total destruction of the peritoneal covering of the hernia, and thus it happens that the con- tents of the tumor may be found protruded from the abdomen with- out a sac, though such a condition is very rare. Etiology of Hernia.—The causes of hernia may be arranged under two separate heads: 1. Those which are exciting, and 2. Those which are predisposing. The exciting causes are such as act violently upon the abdominal parietes, such as lifting heavy weights, blowing horns, jumping, and strains of every character. It is often excited by the tight lacing of corsets; whilst crying violently sometimes causes it in children. Pregnancy in the female is a common cause; whilst falls and blows, or any similar violence, may at any time induce the complaint. The predisposing causes are all such as result in a preternatural relaxation of the abdominal walls, or in a preternatural size of the various normal openings in the abdominal parietes for the passage of vessels. Thus, an unusually wide pelvis in the female is often a predisposing cause, because it creates a larger space beneath the crural arch, whilst the congenital deficiencies of the abdominal parietes, especially at the groin and umbilicus, greatly facilitate its production on the subsequent application of slight exciting causes. SECTION I. REDUCIBLE HERNIA. Symptoms;—The symptoms of reducible hernia are as follows: There is a tumor in the abdominal parietes or on the thigh which is well marked while the patient is standing up, but which disappears when 41 642 PRACTICE OF SURGERY. he lies down, and to which coughing generally communicates a dis- tinct impulse, as may be felt by placing the hand upon the tumor and directing the patient to cough, when the succussion will be readily noted. The tumor caused by a hernia is also very apt to be larger after a full meal than at any other time, and the patient experiences more or less of the evils of flatulence, as borborygmi or grumblings and roarings in the bowels, particularly in the neighborhood of the tumor, these being excited by the difficulty experienced by the flatus in passing through the protruded portion of the intestine. The hernial tumor generally commences above and extends down- wards, and, if it attains any size, is more or less pendulous in its character; the size attained finally being in some cases truly im- mense, reaching almost to the knees of the patient, and seeming to contain the whole of the contents of his abdomen. If the hernia be of the scrotal variety, as it increases in size the natural rugae of the scrotum disappear, and the skin becomes tense and shining, whilst the distension causes the penis to look like a depressed umbilicus. Whenever, however, a hernial tumor is either large or small, it can generally be told that it contains intestine both by the effect produced by the coughing, as well as by the fact that the tumor is more elastic and more springy than when it contains only omentum; besides which, rumbling can occasionally be felt in the intestinal tumor, but not in that which is omental. The tumor which contains only omentum is, on the contrary, more doughy and less elastic to the touch; gives less sensation upon coughing; has less tendency to tympanitis, and creates no borborygmus. Occasionally, such changes take place in the sac of a hernia as prevent the protruded portion from being returned to the abdo- men, and its contents are then said to be irreducible. SECTION II. IRREDUCIBLE HERNIA. Etiology.—The exciting causes of irreducible hernia are all such as are likely to produce adhesive inflammation between the peritoneal surface of the sac and that of the intestine, this occurring most fre- quently at the neck or near the mouth of the sac. Irreducible her- IRREDUCIBLE HERNIA. 643 nia may, therefore, at any time result from blows upon the tumor of a reducible hernia; from pressure upon the neck of the sac; from improper manipulation, such as the application of a truss when the tumor is not properly reduced; from too great an amount of violence in making taxis, &c. &c. Every irreducible hernia has usually been reducible in the first instance, and those which are found irreducible are, therefore, generally of some weeks or months' standing. Another change which takes place, commonly after a very short time, even in the reducible hernia, is the contraction of adhesions between the hernial sac and the surrounding parts, so that although the intestine can readily be passed up into the abdomen, the sac itself still remains outside. In this case, after the surgeon has re- duced any intestine or omentum which the sac may contain, further manipulation can do no possible good, and may do harm by bruis- ing the sac and exciting an inflammation in it that may create an abscess. After the hernia is reduced, however, it has been recom- mended, by many, to keep up a steady though moderate pressure for some time upon the neck of the sac, and it has been asserted that adhesive inflammation has thus been produced, and the oppo- site edges of the mouth of the sac so glued together that a hernia could no longer come down, a radical cure being thus effected; but surgeons differ in opinion in regard to the possibility of such cures being radical; my own personal observation being decidedly adverse to its practicability in the great majority of instances, except in children. Prognosis.—Either reducible or irreducible hernia may exist for years and not destroy life, and, beyond the mere inconvenience of bulk, do not seriously trouble the patient. But so long as a hernia exists in the irreducible form, or so long as it remains re- ducible and not properly kept up within the cavity of the abdo- men, so long is the patient exposed to strangulation and sudden death, living as if the sword of Damocles were constantly sus- pended over him, ready to fall without a moment's warning. In reducible hernia, the tumors containing intestine are generally much more readily reduced than those containing omentum, for the constriction at the neck of the sac, which is always more or less present, interferes so rapidly with the circulation in the omen- tum that effusions take place and it soon becomes very difficult to replace it in the abdomen. 644 PRACTICE OF SURGERY. SECTION III. STRANGULATED HERNIA. When an intestinal hernia is so constricted as to check the passage of food along the canal, or the circulation of the blood in the constricted intestine; or when an irreducible omental hernia has its circulation so interfered with as to set up an inflammation which, if unrelieved, will result in mortification, the patient is said to suffer from strangulated hernia. Symptoms.—The symptoms of strangulated hernia are as follows: The patient first complains of pain and uneasiness in the tumor, which pain continuing, gradually extends up into the abdomen; then he is conscious of a sense of constriction and uneasiness about his umbilicus, a sensation which he speaks of as resembling a cord tied around his stomach. This is followed by symptoms of dis- order of the stomach, as nausea and vomiting, the vomiting being either of bile or fecal matter, or sometimes even of blood. After this he usually begins to show great anxiety in the ex- pression of his face, his countenance becoming distressed and pre- senting a peculiarly haggard look, and there is marked constipation; such portions of feces being only passed as were in the intestines below the constricted part at the time of its strangulation, whilst subsequently he passes nothing by stool. While these symptoms are in progress, changes may be noticed in the state of the pulse which, as might be expected, shows clearly by its irritable condition that the circulation shares in the consti- tutional effects of the severe local constriction of a vital tissue. The patient, meanwhile, from excessive pain and debility falls into a profuse perspiration, and the vomiting returning, he begins to eject fecal matter, this being brought into his stomach by the reverse action of the peristaltic motion of the bowels above the seat of the constriction. As the irritation extends to the diaphragm he also suffers from hiccough, whilst gases accumulating in the intes- tines produce more or less tympanitis and general distension of the abdomen. These symptoms having continued for a variable period, the patient begins to show signs of prostration ; the perspiration be- comes more profuse, but is cold; the pulse becomes feeble, thready, windy, or like what is termed a "soap-bubble" pulse, which the STRANGULATED HERNIA. 645 slightest touch causes to disappear, when one of the most marked symptoms of the condition which is now coming on, shows itself in a sudden cessation of the pain in the tumor, which if pressed under the finger will crackle and give a crepitating sensation in conse- quence of the disengagement in the strangulated tissues of putrefac- tive gases. The tumor has now, moreover, ceased to exhibit the slightest tenderness on pressure, and changes its color, becoming brownish, or lead-colored, and livid. The abdominal tympanitis now rapidly becomes immense, the belly of the patient being sometimes as large as that of a pregnant woman in her ninth month. Then follow quickly the various symptoms of collapse and death; or in the smaller number of more fortunate cases the inflammation in the tumor is communicated to the skin, the latter ulcerates, the stran- gulated intestine sloughs—adhesive inflammation having already glued it fast to the side of the abdominal walls—and an opening or artificial anus is formed, through which the intestinal contents escape outwardly. Results.—Strangulated hernia may terminate in two ways: first, and more commonly, in death; and second, in artificial anus. This latter fact should always be borne in mind in forming a prognosis, as it will not do to tell a patient laboring under strangulated hernia that if he is not operated upon he will certainly die, although this will happen to him in the great majority of cases; for it may be that his case will take the second termination, and, sparing his life, result in the formation of an artificial anus. Diagnosis.—There are several conditions with which strangulated hernia may be confounded, and from which it is important to dis- tinguish it. Of these, that for which it is most likely to be mis- taken is ilius or intussusception, or the train of symptoms not unlike those of strangulated hernia, such as pain, constipation, stercora- ceous vomiting, &c., which ensue when a portion of the intestine is invaginated within itself, so as to create a diminution of its calibre, or a continued spasm of its muscular walls, so as to ob- struct the passage of the fecal matter towards the anus. But although the general symptoms in these cases are similar to those of hernia, yet a diagnosis can often be made with facility; because in hernia a careful examination will always show a tumor, whilst even in those cases which, from the difficulty of recognizing the tumor, have been named concealed hernia, the tumor may be found with more or less readiness by etherizing the patient and examining him carefully, when he is fully relaxed by the influence 646 PRACTICE OF SURGERY. of the anaesthetic. The history of the case will also materially aid the diagnosis; and if the patient be old enough or intelligent enough to give one, will generally leave no doubt as to the true state of the bowels. Pathology of Strangulated Hernia.—When, as a consequence of strangulated hernia, the patient dies, the post-mortem appearances are very marked, the tumor itself usually exhibiting all -the symptoms of mortification of a portion of the intestine. The latter, therefore, will be observed to be of a brown or chocolate color, resembling in this respect the color already described as belonging to moist gangrene. The hernial sac also usually presents a greater or less quantity of serum, which is generally tinged of a deep chocolate color by the altered haematin that has been effused as the result of the congestion that follows the constriction of delicate and vascular tissues. Prognosis.—The prognosis in strangulated hernia is always seri- ous, and should be very guarded, death being apt to ensue if the strangulation is not relieved by an operation, whilst the operation itself is frequently unsuccessful. Still, cases occur in which, as has been already stated, the patient will survive the strangulation with- out an operation in consequence of the formation of an artificial anus. As regards the prognosis of the different forms of strangu- lated hernia, it should be remembered that small hernia are more frequently the cause of danger and death than those of greater bulk, perhaps because they are more frequently overlooked or trifled with, and also because large tumors dilate the parts to such an extent that the strangulation is not so complete, and therefore by no means so dangerous as is the case in the small protrusions. The prognosis of intestinal hernia, when strangulated, is much more dangerous than that of strangulated omentum, as might readily be imagined, because in the latter the calibre of the intes- tine is not involved, and the passage of the faeces not interfered with, the danger in omental cases being chiefly from the develop- ment of peritoneal inflammation. The time in which death may occur from strangulated hernia, is various; thus it may happen in twenty-four hours, though, as a general rule, it will not take place until sufficient time has elapsed to permit the patient to pass through the symptoms above detailed, whilst not unfrequently to these will be added the more tedious symptoms of general peri- tonitis, this being not unfrequently the cause of death. The dura- STRANGULATED HERNIA. 647 tion of a strangulated hernia may, therefore, be stated as varying, according to circumstances, from twenty-four or forty-eight hours to eight or ten days, whilst the most frequent period may be set down as being from the fourth to the sixth day. In reducible hernia, the prognosis is altogether favorable, because, if proper means are adopted to keep the tumor up within the ab- dominal cavity, there will be no danger of constriction and stran- gulation. In irreducible hernia, the prognosis is less favorable, because at any moment it may become strangulated, when all the symptoms detailed in connection with the latter condition may ensue. Treatment.—The plain indication for the treatment of any variety of reducible hernia is to resort to such means as will restore the contents of the tumor to the abdominal cavity, and when there prevent them from again protruding. The manipulations by which the tumor is to be restored within the abdominal parietes, are de- signated as the taxis. In making taxis, attention should first be paid to the position of the patient. Thus, he should recline, and be so placed as to relax such of the abdominal or femoral muscles as might constrict the tumor. If the tumor is in the groin, the patient should therefore lie with his thighs flexed upon his body, and his shoulders so raised as to relax the abdominal muscles as much as possible, and if it is a femoral hernia, the position should be the same, but the -toes should also be turned sharply inwards, so as to relax the tis- sues about the femoral ring; but wherever the hernia is situated, the same general rule applies, to wit, to place the patient in that position which will relax as much as possible the parts concerned. Taxis is made by gently kneading the tumor alternately with the fingers of each hand, so as to press it back again into the abdomen, taking care to exercise the pressure in the line in which the hernia has descended. Having reduced the tumor, the next indication is to resort to such means as will prevent its reproduction, and these may be either palliative or radical. The palliative treatment con- sists in preventing the recurrence of the hernia by exercising a proper amount of pressure upon the orifice through which it has escaped; this pressure being generally produced by means of the instrument which is well known as a Truss. The radical cure of hernia has for its object the creating of such changes in the mouth of the hernial sac and in the ring as will close the latter, and thus permanently prevent the reproduction of the tumor. 648 PRACTICE OF SURGERY. Application of the Truss.—In taking the measure of a patient who is suffering from reducible hernia, with a view to the application of a truss, an annealed wire should be passed around his hips, just below the brim of the pelvis, so as to get his exact size and shape, if he is very thin; when in selecting the truss, the instrument-maker should allow about half an inch on each side, to compensate for the space occupied by the stuffing and covering of the instrument. If, however, the patient is fleshy, it will generally suffice simply to take his size around the hips with a string, which, with the above allowance for the stuffing of the truss, will be sufficiently accurate. A good truss should consist of a spring of sufficient strength to resist the descent of the diaphragm; this spring having upon one end of it a pad so shaped as to exercise a direct pressure upon the orifice through which the hernia has escaped, so as to counter- act the tendency of the intestine or omentum to come down again, and it is a matter of some importance that this should be accurately fitted to the part; for if the truss does not accomplish this, not only is it perfectly useless, but it may, by pressure upon the neck of the sac, when the hernia slips by the instrument out of the abdo- men, create such an amount of inflammation as will cause a pre- viously reducible hernia to become irreducible, or even strangu- lated. As the effect to be obtained by the application of a truss is generally understood, a great variety of instruments have been manufactured, each of which, it is usually claimed, accomplishes most accurately the end in view; besides which, many persons have the idea that the pressure upon the mouth of the sac should pro- duce a sufficient amount of adhesive inflammation to close it, and thus prevent the re-formation of the hernia. Certain of these trusses are therefore said so to act as to create a radical cure, a point which many surgeons regard as impracticable in adults, though it sometimes occurs in the case of children. The pad of the common old-fashioned truss, as it is now found all over the country, consists of an oval plate of sheet-iron covered with a compress of horsehair, over which buckskin is sewed. Trusses are also made with pads of wood, of glass, and of ivory; and there is even one made with a pad formed of a wire spring, like those of the seat of a chair or sofa. This truss presents one illustration of the evils which have arisen from the application of trusses having passed into the hands of unprofessional men, this truss, as well as many others, being often STRANGULATED HERNIA. 649 formed upon improper principles, and rather made by the dozen to expose for sale than shaped to suit the exigencies of each particular case, as a truss really ought to be. The surgeon is, therefore, liable to have offered to him all sorts of "patent trusses," "patent self-regulating, graduated, self-fitting trusses," " patent trusses for the radical cure of hernia," &o. &c, all which should be cast aside simply from the fact of their being patented, as this usually makes them unnecessarily costly, and in- duces apothecaries and others to meddle in a matter which should be strictly confined to medical men who are familiar with the anatomical relations of the parts concerned. All that is required in any truss is, that it should have a simple, well-shaped, firm pad; but whether this be formed of wood, glass, or ivory, matters little provided it is smooth, and properly formed to fit the region on which it is to be applied; the soft stuffing being liable to change its form, to absorb perspiration, to become offensive, and to irritate the part, so that the patient is induced to lay the truss aside until the skin becomes less sensitive. At one time it was supposed that young children could not bear the pressure of a truss, but they, on the contrary, bear it very well, if the strength of the spring is properly adapted to their age. The children's trusses of Messrs. Kolbe & Kumerle, for example, which are made of inflated caoutchouc, will do no injury, if properly fitted, to any child having a hernia, and as the period of childhood is that at which most benefit is to be derived from these instruments, a radical cure may be frequently accomplished at this period of life. The treatment of irreducible hernia resolves itself into attention to the general health, and the use of such means as will prevent the tumor from attaining any greater size. An excellent plan for accomplishing this is to use a hollow pad, or a suspensory bandage, or some similar apparatus, by which the tumor can be supported, and yet not compressed. A patient laboring under an irreducible hernia should, however, always be directed to pay particular atten- tion to the tumor, and to guard against any blows upon it, as well as to avoid pressure or any other causes which may set up inflam- mation, lest it become strangulated. The treatment of strangulated hernia consists, first in a judicious employment of the taxis with a view of ascertaining whether the hernia be really irreducible, but this taxis should be used with ex- treme caution, particularly if the tumor has been strangulated for 650 PRACTICE OF SURGERY. some time, as by violence or even by a too tedious employment of a degree of force which if but briefly exercised would not be improper, an amount of inflammation may be set up which will render the operation of herniotomy useless, or compel the surgeon to save the life of the patient by favoring the establishment of an artifi- cial anus, the protruded intestine being in such a condition that it would not be safe to restore it to the cavity of the abdomen. If a cautiously made taxis—say efforts continued for twenty minutes— fails to restore the intestine, it will be better to employ other means; thus a bladder filled with pounded ice may be made to touch the lowest end of the tumor so as to favor its retraction, though it should not be pressed on the protrusion or permitted to touch the neck of the sac. In consequence of the cold thus applied, the contraction of the tissues will often be such that the tumor will retract tho- roughly, and the hernia be reduced without much effort at taxis. Ice, however, should never be employed for such a length of time as would endanger freezing the parts, as might happen if care is not employed. If the strangulated hernia has been reducible up to a short period before its strangulation, it may sometimes be replaced by passing a stomach tube as far as possible up the rectum, and then distending the gut by injecting large quantities of water into the bowels, this acting both by its distension and by its exciting such a peristaltic action as will perhaps end in the reduction of the tumor. When these means fail, such measures may be resorted to as will produce complete relaxation of the tissues of the body, and thus favor the reduction of the tumor. Usually the best mode of pro- ducing this general relaxation is to put the patient into a perfect state of anassthesia, when the hernia will often readily pass back. But if he is so situated, in the country or elsewhere, that no ether can be obtained, resort may be had to venesection, which should be carried ad deliquium animi, when, in the total relaxation that fol- lows, the tumor will often be readily reduced. If the loss of blood be contra-indicated by the state of the patient's health, or by any other circumstances, an attempt may be made to obtain relaxation by the use of the warm bath, or by the administration of tartar emetic, given in sufficient doses to produce general prostration and relaxation of the muscular system. Another mode of obtaining a very complete state of relaxation is by the use of tobacco, which it was formerly recommended to STRANGULATED HERNIA. 651 employ in the form of infusion, a small portion of it being thrown into the rectum with a syringe. The relaxing effects of this article were thus very completely produced; but it sometimes happened that in the purgation that followed the injection was not thrown off, and as some of it thus continued to be absorbed, too much of the drug was introduced into the system, and a prostration ensued which was often serious if not fatal. This danger may now be avoided with tolerable certainty by using the tobacco in the form of a suppository instead of employ- ing it as an enema, the suppository being conveniently made by macerating a drachm of tobacco in an ounce of hot water until it is quite soft, and then tying it up in a piece of bobinet, when it should be put into the rectum so as to leave the string attached to it hanging out of the anus. As absorption quickly takes place, the constitutional effects of the tobacco will thus be induced, and when the depression has been carried to a sufficient extent, the suppository may be withdrawn simply by exercising traction on the string. If the efforts at taxis thus made do not succeed, then there will be a necessity for resorting to an operation for the purpose of re- lieving the constricted bowel and preventing mortification; this operation being a serious one, as the patient always incurs more or less danger, though it is one which is successful in very many instances if resorted to early, whilst it is not near so dangerous as the taxis, when rudely or improperly practised. In resorting to the operation of herniotomy, it is important to its success that the taxis previously made should have been of the gentlest kind, so as to diminish as much as possible the dangers of bruising and in- flaming the intestine, and that it should be early resorted to, in order that there may be as little time for the strangulated por- tion to become inflamed and mortified as possible. So frequently has this been noted, that Dessault, in the Hotel Dieu of Paris, would not permit the young residents of his hospital to touch a case of strangulated hernia until he saw it himself, and then if the hernia was not reducible on the gentlest taxis, he .proceeded at once to the operation. Statistics clearly show that by such a course fewer lives are lost than when more violent efforts at taxis are made before resorting to the operation. A similar result coin- cided with the experience of the late Dr. Parrish, of Philadelphia, 652 PRACTICE OF SURGERY. few surgeons having had more extensive opportunities than him- self of testing the value of any opinion respecting the treatment of hernia. It may therefore be laid down as a general rule, that if, under gentle but well-directed taxis, a strangulated hernia cannot be re- duced in a reasonable length of time—say an hour—it is best to proceed at once to an operation.1 The general preparation for the operation is very simple: thus the bowels should be emptied as far as possible by means of an injection, and the bladder voided, espe- cially if the hernia is at the lower portion of the abdomen. Then the parts adjacent to that through which it is intended to make the incision (Figs. 226, 228), should be shaved of their hair, in order to obtain a clean surface for the subsequent application of the adhesive strips. Proper assistants should also be selected, and their duties assigned to each, the instruments being laid on a table, or tray, in some convenient place, so that they may be within the surgeon's reach. After the operation has been performed, the after-treatment should consist in closing the wound so that the upper part of it Fig. 226. A view of the Tumor, showing the Line of the Incision through the Skin as shaved and prepared for the operation. (After Ferguson.) may unite by the first intention; but a mesh of lint should be introduced into the lower portion of the skin to keep it open and favor the escape of any pus which may form in the deeper tissues. After twelve, eighteen, or twenty-four hours, a gentle laxative 1 For Herniotomy, Taxis, &c, see Operative Surgery, vol. ii. p. 126, 2d edit. STRANGULATED HERNIA. 653 should also be administered, so as to get rid of any fecal matter which may have been left in the upper portion of the intestine, above the seat of strangulation; the patient being kept at perfect Fig. 227. A view of the Position of the Patient, Shape and Position of the Tumor, as well as the Line of the Incision in Femoral Hernia. (After Ferguson.) Fig. 228. rest until the wound has healed, any extra inflammation which may arise during the process of healing being actively combated on general principles. When strangulated inguinal hernia is ope- rated on in a case which is congenital, a much larger space will be found around the testicle in the scrotum (Fig. 228); or it may be that the original pouch of peritoneum pro- truded by the testicle in its descent has re- mained unclosed on the cord; consequently the hernia and the testicle will be found near to each other in the scrotum. As the greater portion of the subject of hernia involves a minute examination of the regional anatomy of the part through which it passes out of the abdomen, and as its treat- ment is almost entirely mechanical or opera- tive, the reader is referred to the Operative Surgery, vol. ii. p. 86, 2d edition, for the other details of this subject, as well as for the creation and treat- ment of artificial anus, all of which is amply illustrated in the plates of the same work. A diagram illustrative of the State of the Parts in the Scrotum in a case of Con- genital Scrotal Hernia. (After Liston.) PART XII. DISEASES OF THE GENITAL ORGANS. CHAPTER I. SYPHILIS. Syphilis, or the Venereal Disease, is the name ordinarily given to a disorder which commences in the organs of generation after an impure connection, and results in the production of certain changes which lead to the inoculation or poisoning of the blood. The origin of the term is unknown, though it has been variously ascribed; thus it has been said by some to be derivable from the Greek word jrj, a hog; and by others from otttahos, shameful, dirty. The general term Venereal Disease includes under it two dis- tinct forms; in the one, the mucous membranes of the genito- urinary apparatus are involved and give rise to an increased dis- charge from these passages mingled with pus, and accompanied with the ordinary symptoms and results of inflammation in mucous tissues elsewhere, which is known as Gonorrhoea; whilst in the other is noted a morbid inflammatory action that leads to suppuration and ulceration in some part of the organs, and which is strictly desig- nated as Syphilis. To the ulceration, which is the starting-point of the infection of the system in this latter disorder, the name of Chancre is applied; the transmission of the morbid matter from this chan- cre through the lymphatics of the part into the general circulation, giving rise subsequently to various constitutional symptoms which are noted in affections of the skin, mucous membranes, bones, &c. Origin of Syphilis.—The origin of the venereal disease was cer- tainly impure sexual intercourse, and the period of the world's history at which it first appeared, having been long and freely 656 PRACTICE OF SURGERY. discussed by surgical writers, is worthy of a brief reference, espe- cially as it will show to the young American student that neither the discovery of America by Columbus in 1492, nor the siege of Naples by Charles the Eighth of France in 1498, could have origin- ated this disorder. That the disease brought back by the followers of Columbus from the West Indies was without doubt that which still occurs there and is known as the Yaws or Frambcesia, is a point now regarded by many as settled, whilst it is more than probable that the soldiers of Charles the Eighth only contracted, as the result of the unbounded license and disorderly life of the camp, an exag- gerated form of a disease which previously existed. That the ve- nereal disease undoubtedly followed close upon the licentious habits of men at an early period of the history of our race is also believed by many to be proved by some of the allusions to the habits of the Israelites as made in Leviticus, where the rules of cleanliness are laid down and distinctions drawn between gonorrhoea and other results of the sins of the flesh. As violations of natural laws are always followed by disease, it is not improbable that this complaint was first originated by vicious intercourse between man and beast, to which allusion is also made by Moses, or arose from the frequent intercourse of one man with several women, which, with filthy habits and a warm climate, would doubtless prove sufficient for the creation of this disorder. But without discussing the signification assigned by able com- mentators to the expressions of the laws of the ancient Jews, there is yet evidence of the existence of syphilis in England and elsewhere, long before 1492, Hippocrates 460 B. C, and Celsus, who was the contemporary of Horace, Virgil, and Ovid, describing the disease and giving' many details of treatment which are noted as existing even at the present day. In the Acta Sanctorum, as quoted by Sir A. Cooper in his Lec- tures, by Lee, vol. iii. p. 19, it is stated that two cases were pub- lished in Great Britain in the year 1010. The disease is also, he says, mentioned by Bernard Gordon, Pro- fessor of Medicine at the University of Montpellier, in a work De Passionibus Virgae, published in 1305. In 1320, Dr. Gaddesden, of Oxford, published a work which he entitled Rosa Anglica, in which ulcers on the penis arising from sexual intercourse, are described. In 1347, brothels were established in Avignon, under Queen SYPHILIS. 657 Jane, and certain laws or regulations laid down for their manage- ment. Among these will be found certain regulations which are still extant in Paris, though in a modified form. Some of these rules were very singular, and may be here re- peated, as giving an idea of the sentiments upon this subject in those old times, rude and barbarous as they were. Thus the wenches were restricted in their walks, and were to wear upon their shoulder a red knot, by means of which they could readily be known. The third rule is so singular that it may be given more in full: " Our good Queen Jane doth further order that a brothel shall be located near the convent of the Augustine friars, and that no youth be admitted therein without permission first obtained from the abbess, or governess, who is to keep the keys, and counsel and advise them not to make a noise, or to frighten the wenches, which, if they disobey, they shall be laid under confinement by the beadles." The fourth rule clearly shows the existence of disease in those times, as it orders that once a week the wenches be examined by the abbess in company with a surgeon appointed by the directors, and those that are diseased separated from the rest, "lest the youths should catch their distempers." The Stews, in Southwark, London, had laws that date back as far as 1162, in the reign of Henry the 2d; these laws being modi- fied by Edward the 3d in 1345. These Stews were destroyed by Wat Tyler's mob in the time of Richard the 2d. They reappeared, however, and in the reign of Henry the 6th, were some eighteen in number, when they were again suppressed in 1546.1 As this brief allusion to these old laws shows that the venereal disease existed many years prior to the discovery of America, the history of syphilis may be left to the more minute investiga- tion of those who are interested in it. 1 The reader will find many other curious historical facts connected with this subject by referring to the Lectures of Lawrence, Cooper, and others among the English surgeons. 42 658 PRACTICE OF SURGERY. SECTION I. GONORRHCEA. Gonorrhoea is the name given to an affection of the lining mem- brane of the urethra of the male, and of the vagina and urethra of the female, which consists in inflammatory action, the effects and characters of which are strictly analogous to those of inflammation as seen in other mucous tissues, and which is to be treated and will be relieved by the same measures as would be applicable to an inflammation of any other mucous membrane. Gonorrhoea may be defined as a purulent discharge from the urethra of the male, or the vagina of the female, combined with inflammatory symptoms when the result of impure sexual congress. The derivation of the term shows some of the very erroneous notions that were entertained respecting this complaint in early times, as it is derived from two Greek words (y<*v*i), sperm, and (ps«), to flow, it being apparently regarded as connected with the secretion of the testicles. Synonyms.—This affection has various synonyms, such as blen- norrhagia, and blennorrhoea, from pxcwa (mucus), and *>«« (I flow), which is an equally erroneous term, for the disease does not con- sist of a flow of mucus, as this term would indicate. The English name for the complaint, Clap, is derived from the French word Clapier, a name applied to brothels in France, and was intended to designate it as the disease contracted in brothels. The French term Chaudepisse is derived from the fact that there is usually more or less sensation of scalding in urinating, or ardor urinse, as it is termed, at the commencement of the disorder. The disease is also spoken of as a running, and as the secret disease; the latter term being equally applicable to syphilis. Complications.—Some of the complications of the disease demand especial attention, and have received particular names. Thus, we have Balanitis (/3axavoj, glans), which is a term applied to an in- flamed condition of the mucous membrane of the head of the penis and prepuce, resulting in a purulent or muco-purulent dis- charge, this being also sometimes called the external clap. The inflammation of gonorrhoea sometimes affects the prepuce GONORRHEA. 659 so that it swells to such a degree as to prevent it from being re- tracted and exposing the glans, this condition being called phymosis (Fig. 229), though the same is also a congenital malformation. Fig. 229. Fig. 230. Fig. 229.—A side view of the manner in which the Prepuce covers the Penis in either Congenital or Acquired Phymosis. (After Miller.) Fig. 230.—A view of Paraphymosis, the dark portion heing the mucous membrane which lines the prepuce, and which is distended by serous infiltration of the submucous cellular tissue. (After Miller.) Sometimes the skin is retracted behind the glans, and swelling of the mucous membrane takes place to such a degree as to pre- vent the prepuce from being brought down over the head of the penis, and then this condition is known as paraphymosis. (Fig. 230.) Pathology.—In order to understand the pathology of gonorrhoea, it should be remembered that the glans penis is covered by a mucous membrane, which, after lining the prepuce, is reflected over the head of the penis, and enters the urethra, where it be- comes continuous with the lining membrane of the bladder and of the ureters. In the urethral mucous membrane are to be found a considerable number of follicles, which, when inflamed, are capable of pouring out a large amount of fluid, whilst they may continue in a state of iaflammation even after the surface of the mucous membrane itself has taken on healthy action. These follicles sometimes become enlarged in size, and occasionally allow a small catheter to lodge in them, which, refusing to pass further, may give rise to the erro- neous idea of a stricture existing at that point.1 Etiology.—As the sole origin of gonorrhoea is an impure con- 1 For an account of the treatment both of Phymosis and Paraphymosis, see the Operative Surgery, vol. ii. pp. 193 and 196, 2d edit. 660 PRACTICE OF SURGERY. nection, notwithstanding that many other sources are often charged with it by patients, it is evident that the male becomes infected by the discharge which collects upon the rugae of the mucous mem- brane of the vagina in the female—this being wiped off by the penis as it enters in a connection; the tension of the parts distend- ino- the aperture of the urethra, so that some of the matter is thus permitted to lodge within the fossa navicularis. This matter, if at all virulent, is quite sufficient to excite in a short time a purulent discharge from the whole of the male urethra; the inflammatory action, unless checked, rapidly extending itself throughout the entire canal. Symptoms.—In from three to six or eight days—though sometimes only a few hours may elapse—after an impure connection, the patient begins to experience a sense of tickling or tingling at the orifice of the urethra. On examining the parts, the lips of the urethra will now be found to be slightly swelled and inflamed, whilst the attempt to make water will create that peculiar sense of burning and smart- ing to which the name of ardor urinae has been applied. After a few hours, the part becomes moistened with a slight colorless dis- charge, which consists of serum mixed with the ordinary secretion of the urethra; but in a very short time this discharge becomes more or less yellow from the admixture of pus. In a few hours more, true yellow pus will be effused, while, as the inflammation becomes higher in grade, there will be seen all the modification of pus seen in other inflammations; thus it may become green, or pinkish, and streaked with blood from a rupture of some of the congested ves- sels of the lining membrane of the urethra. As the disease pro- gresses, effusions of lymph often take place into the corpus spongi- osum directly beneath the urethra, whilst there is a constant afflux of blood to the corpora cavernosa, in consequence of which there are frequent and violent erections of the penis, though the organ does not become completely erect, but bends downwards in conse- quence of the inflamed mucous membrane of the urethra acting as a string to a bow. To this condition the term chordee has been ap- plied—from the Latin word corda, a string. Chordee may occur at any period of an attack of gonorrhoea, though it seldom takes place until the inflammatory action has resulted in the secretion of pus, and there has been an opportunity for the thickening of the sub- mucous cellular tissue of the urethra. There is usually consider- able pain accompanying chordee, which is due to the extension of GONORRHOEA. 661 the inflamed mucous membrane, caused by the distension of the corpora cavernosa acting on the corpus spongiosum urethras. The progress of the inflammation now shows itself in its attacking the lymphatics of the penis, thus occasioning a sense of inconve- nience and fulness, if not of actual pain in the body of the organ, and as the irritation extends from these lymphatics, to the glands of the groin, heaviness and soreness are complained of in this region, as well as a sense of weight in the perineum or in the testicles, though the latter is not generally felt until the end of the second or third week, the enlargement of the testicles, which is the result of the extension of the inflammation along the vas deferens to the epididymis, seldom occurring before the end of the third week. If the inflammation continues and rises in grade, we may next notice its extension to the deeper-seated parts adjacent to the urethra, where it will be shown in abscesses of the prostate, cys- titis, or even nephritis. Varieties.—There are two forms of gonorrhoea, one of which is the virulent or true gonorrhoea, and the other the benignant or false gonorrhoea; the secretion of the menses, particularly if mixed with acrid fluor albus, or violent leucorrhcea, sometimes exciting a secre- tion of pus from the urethra of a delicate man if brought in contact with it in coition. Though the latter inflammation resembles the other, it differs in the violence of its symptoms as well as in its grade, and is therefore also designated as spurious gonorrhoea. The same condition has also sometimes resulted from the irritation created by the introduction of a bougie. True gonorrhoea, or the violent form of urethritis, only ensues on intercourse with a person who is at the time laboring under a similar purulent disorder. Diagnosis.—The best mode of diagnosis between these forms of urethritis is the color of the discharge, which, as true gonorrhoea is a higher grade of inflammation than the spurious, is greenish or pinkish in its tint, whilst that of the spurious form is white or yellowish. The ardor urinae, chordee, tendency to epididymitis, &c. also give evidence of the presence of a grade of mucous inflamma- tion in the true gonorrhoea, which is seldom or never seen in the spurious disorder, the inflammation in the latter case usually pass- in o- off in a few days, and creating little or no ardor urinas. Prognosis.—The prognosis in gonorrhoea will depend upon cir- cumstances. If the patient presents himself at the moment at which the swelling of the lips of the urethra and slight ardor urinae 662 PRACTICE OF SURGERY. are first noticed, he can often be cured in from three to five days. If, however, the disease has lasted for some days or weeks before he applies to the surgeon, and the inflammation has thus created considerable change in the tissue of the urethra, it will generally continue from three to five or seven weeks, or even as long as two or three months, particularly if from time to time the patient is guilty of indiscretions in food and drink. Treatment.—The treatment of gonorrhoea may be divided into three different stages: the prophylactic, the abortive, and the cura- tive. 1. Prophylactic Treatment—The best prophylactic measure is to abstain from exposure to the cause. But when the patient has had a suspicious connection he may do something to prevent the deve- lopment of gonorrhoea by washing thoroughly with soap and water, and urinating as soon as possible after the intercourse, in order to remove any irritating matter which may have collected in the urethra. 2. Abortive Treatment.—Should, however, the disease develop it- self, the abortive treatment may be resorted to under certain con- ditions; thus it is particularly applicable to the state of the parts found at the beginning of the complaint, when the thin serous discharge, or that resembling the white of an unboiled egg, first appears, and before inflammatory symptoms have developed them- selves ; in other words, during the first twenty-four or thirty-six hours of the disease. The abortive treatment consists in changing the action in the part, and substituting for the existing irritation or inflammation one which may be excited by means of the nitrate of silver applied either in the solid form or the strong solution. If used in its solid form, Lallemand's instrument for cauterizing the urethra may be employed.1 If the solution seems preferable, ten grains of the salt to the ounce of distilled water should be in- jected, but it should be thrown in by the surgeon himself with a glass syringe, care being taken not to bruise the orifice of the urethra with the instrument. When this solution is well injected it should be retained in the canal a few minutes by grasping the end of the urethra and penis with the thumb and forefinger, when it may be ejected by the patient making efforts as in urination. Before using this solution, the urethra should however be well washed out either 1 See Operative Surgery, vol. ii. p. 200, 2d edition. GONORRHEA. 663 by the patient urinating or by the surgeon injecting tepid water. The injection of the nitrate of silver, as thus practised, creates con- siderable pain, and acts by forming a white pellicle over the in- flamed surface, which protects it from the irritation of the urine for the next twelve or twenty-four hours, while in the meantime it sets up a new and healthy inflammatory action. The next day the parts will be found slightly swollen, and the discharge perhaps more copious and pinkish than it was previously, or it may even be streaked with blood. An injection of sulphate of zinc, from one to three grains to the ounce of water, should then be ordered, to be used four or five times a day by the patient himself, after special directions, when the cure will generally be effected in from three to five days, the patient abstaining from drinks of all kinds, in order to diminish the amount secreted by the kidneys, though he may take his usual food. The abortive treatment is, however, very seldom applicable to an attack of gonorrhoea, because patients do not apply to a surgeon at a sufficiently early period, but wait until pus is seen in the discharge, when it is too late to employ it advan- tageously. 3. Curative Treatment.—The curative treatment of gonorrhoea is that which is most frequently required, as it is applicable even to the highest inflammatory stage, and is very varied in the means to be employed. The indications to be observed are: 1, to combat and check the unhealthy inflammatory action; and 2, to relieve the weakness which is left in the parts. In carrying out the first indi- cation, and attempting to check inflammatory action, antiphlogistic measures should be employed both locally and generally, especially by taking blood locally. Thus, if the inflammation runs high, we may commence by abstracting blood freely from the perineum by means of leeches, directing the application of enough to take six or eight ounces, whilst immediately afterwards a free purge should be given. After this such articles may be employed as, by impreg- nating the urine, and being thus brought in contact with the surface of the urethra, will alter its character, as well as act on the inflam- mation. These articles are to be found in the balsams and tere- binthinates. That they act by coming directly in contact with the urethra, is proved by the fact that patients with gonorrhoea, who labor also under fistula in perineo, in consequence of which the urine passes out without touching the diseased urethra, are not benefited by these internal remedies, whilst so soon as the fistula 664 PRACTICE OF SURGERY. closes sufficiently to enable the urine to again pass through its pro- per canal, the patient begins to improve. We may also employ locally the large class of astringents with a view of checking the secretion. Some of the prescriptions that may be advantageously resorted to in the administration of the terebinthinates are as follows, the combinations being such as render them acceptable to the stomach. Many of them are used in Eicord's Hospital, or in some of the military hospitals of France, and have been tested in my own prac- tice. The following is an old prescription, which I have employed very largely in practice, and which I have given when the dis- charge was green and ichorous, and the ardor urinae quite marked, without finding it too stimulating:— R.—Pulv. cubebae Jss ; Bals. copaibae jjij; Ferri sulph. exsiccat. 3j ; Terebinth. Venetii 3iij. Divide into boluses of ten grains each, one to be taken three or five times daily. As there is a difficulty in making this formula into pills, Canada balsam may be substituted for the Venice tur- pentine. If the patient who is to take balsam, &c, prefers the form of mixture to that of pill, the following may be given:— Ii.—Bals. copaibae, Pulv. cubebae, aa ^j; Liq. potassae ^ij ; Pulv. acaciae gum ^ss ; Aquae rosar. f Jvj.—M. S.—A tablespoonful may be taken three times a day. The following is used by Eicord so frequently that it is called, in Paris, his favorite. It is particularly applicable to the weak and debilitated constitutions which are to be found in his wards, and which are also occasionally met with in our own cities, and espe- cially in those of the tuberculous diathesis. R.—Pulv. cubebae Jvj ; Ferri carb.JJiij. M. et ft. pulv. dein in chart, iij, dividend. S.—Take one powder three times a day. GONORRHOEA. 665 The following English formula contains an article not usual in these prescriptions (Potassae chloras), which, it is thought, exercises a peculiar influence in these complaints. It contains also a quan- tity of rhubarb, with a view of acting upon the bowels. R.—Pulv. rhei ^ss ; Liq. potas. giss; Potassae chlorat. sfiij - Aq. menth. pip. f^vj.—M. S.—Take a tablespoonful two or three times a day. In the early treatment of the gonorrhoea of high livers, whose diet, &c, has disordered their digestion, and created furred tongue, with highly acid urine, I have found this a useful combination. Injections.—Besides these internal remedies, great benefit will be derived from the use of alterative and astringent substances, as in- jections, as soon as the first violence of the inflammation has sub- sided. In connection with the use of injections it may be mentioned, that much needless fear sometimes exists in the minds of patients, lest the injecting material should get into the bladder and cause cystitis, but, as a general rule, there is no danger of throwing an injection, into an inflamed urethra, any farther than the accelerator urinae muscles or the bulb of the urethra, as the contraction of these muscles on the urethra will usually check its further progress. A simple precaution will, however, make such an accident impos- sible. Thus, if the patient sits down on the edge of the bed or of a chair, and places a roll of bandage, or a folded stocking, just be- hind the scrotum, in such a manner that his weight will make it press firmly upon his perineum, the urethra will be firmly closed. But when it is remembered that all attempts at injecting the bladder, except a catheter is first introduced, are usually very imperfect, it will be perceived that, under ordinary circumstances, cystitis is not likely to supervene on the use of an injection, and that when it supervenes it is, rather due to the extension of the original ure- thritis. As the chordee not only creates pain, but also produces a curva- ture of the penis, it not unfrequently—if the patient has had gonor- rhoea for some time, or has had several attacks of it—leaves an effusion of lymph in the cells of the corpora cavernosa, which will subsequently prevent their proper distension. In the treatment of chordee it will often be advisable. to caution the patient, particularly if he be of an irritable disposition, against 666 PRACTICE OF SURGERY. attempts at breaking the erection by bending the penis violently, as these efforts may do serious harm, and can certainly never give any relief. As the chordee is due to an irritation of the urethra, the proper means for its relief are such as are suitable to the relief of irritation elsewhere. A very simple plan of treatment consists in directing the patient, ap soon as he feels the erection, to spring out of bed and stand with his feet on a cold hearth; or to dip the penis and perineum into cold water by stooping over a basin; or to put his feet in the same, though the chordee will be very apt to recur as soon as he gets warm again in bed. The patient should also be directed to sleep with very light bed covering, and to take a cold hip-bath at night, whilst two grains of camphor and one grain of opium may be given in a pill at bed- time, the camphor being useful by acting directly upon the urine, as well as affecting the cerebellum as a sedative. As there are, however, many persons who are unable, or who imagine they are unable to swallow a pill, the same effects may be obtained by directing them to drop upon a lump of sugar forty drops of lauda- num, and twenty drops of the tincture of camphor. If the opium is for any reason contraindicated, extract of hyoscyamus, conium, or lupulin may be substituted for it. •In the treatment of gonorrhoea, it will be found that the anxiety with which the patient looks forward to his restoration to health, often arises not so much from the trouble of the running or the pain of chordee, as it does from the fact that the stains made upon his linen by the discharge are likely to lead to the discovery of the origin of his complaint. Even in those cases in which this is a matter of indifference, the soiling of the linen is unpleasant, and may readily be avoided by directing him to wear a proper sheath for the organ during the continuance of the disease. Such a sheath may be made—like a large finger-stall—of linen lined with oiled silk, or still better, of India-rubber cloth, which being attached to two tapes, and made to pass round his hips, may readily be drawn over the penis, so as to cover it entirely, and yet be slipped off for the purpose of urinating. When warmth and moisture are required to be applied to the penis, a very convenient and cleanly mode of accomplishing it is by means of a sheath made of spongio-piline and moistened with hot water before it is drawn over the penis. During the whole course of the treatment of gonorrhoea, the pa- GONORRHOEA. 667 tient should also be directed to wear a suspensory bandage, in order to guard against congestion of the scrotum and epididymitis or swelled testicle. There are various forms of astringent and alterative injections that prove useful in the treatment of gonorrhoea; thus, after the action of the parts has been changed in the abortive plan of treat- ment, we may not only use the sulphate of zinc as already recom- mended, but acetate of lead may be substituted for it, or the two may be used together in the proportion of one grain of each to the ounce of water. In fact, any of the mineral astringents may be employed in the proportion of one or two grains to the ounce of water, except the sulphate of copper, which should never be used stronger, at first, than half a grain to the ounce. There are some combinations of these articles which are very useful in cases that have lasted some time before being seen, or in those in which the abortive treatment has not been employed, as will be presently stated. The idea which was formerly prevalent, that it is necessary to wait till the inflammatory stage of the disease has entirely passed away before resorting to the use of stimulating injections, has, how- ever, been exploded by numerous observations, and my own plan of treatment is to employ injections in all cases where the ardor urinae is not very marked. It sometimes happens, however, that a patient will suffer extreme pain from their use, or that he cannot immediately bear the repeti- tion of them, particularly after the abortive injection of the nitrate of silver has been employed: and under these circumstances much comfort will be obtained from first resorting to the following injec- tion :— R.—Muc. sem. lini Oj ; Pulvis opii grs. x.—M. S.—Inject as often as may be necessary. Another injection which is exceedingly useful in those cases which suffer from chordee, contains camphor, and is as follows:— R.—Pulv. camphorae £ss; Vitellum ovi j; Aquae fontan. Oj.—M. 6.— Injeot frequently. 668 PRACTICE OF SURGERY. Should this not relieve the ardor urinae and chordee, the follow- ing may be substituted:— R.—Pulv. opii grs. xij ; Aq. font, f^ix; Liq. plumb, subacet. gtt. ix. Misce. This should be well shaken before being injected, and is an ex- cellent sedative and slightly astringent injection. Should the disease, from want of proper treatment, have con- tinued for some length of time, certain sequelae will be likely to appear and require attention. Thus the inflammation may travel down to the bulb of the urethra, and thence to the caput gallina- ginis and along the vas deferens, to the epididymis, so as to create epididymitis. Or, travelling still further, it may produce inflamma- tion and abscess of the prostate, or even invade the mucous coat of the bladder and create cystitis. § 1.—EPIDIDYMITIS. Synonyms.—Epididymitis has several synonyms: thus it was called by the old surgeons hernia humoralis and orchitis; whilst, by the people, it is known as swelled testicle. The term epididymitis, which is strictly correct, although the inflammation may extend from the epididymis to the testicle itself, indicates the true condi- tion of these parts when consequent on an attack of gonorrhoea. Etiology.—Epididymitis may result from other causes as well as from gonorrhoea, though the latter is its most common source. When consequent upon gonorrhoea it generally shows itself as follows:— Symptoms.—About the third, fourth or fifth week the patient notices a cessation or diminution of the discharge from the urethra, and at the same time begins to perceive a slight sensation of weight in the groin, when on pressing upon the cord it will be found to be slightly swelled and painful, thus showing the extension of the in- flammation along the vas deferens. These feelings of uneasiness are then propagated along the back of the cord towards the testis, and, producing heaviness in the scrotum, are soon followed by swelling of the epididymis, the globus major and minor beginning to enlarge, and continuing until they are sufficiently enlarged to EPIDIDYMITIS. 669 cover the whole testicle. As the inflammation goes on it may ex- tend to the tunica vaginalis testis, and produce true hydrocele, or to the scrotum, and produce oedema or inflammatory congestion; or, as already remarked, it may involve the tunica albuginea and the proper structure of the testis itself, though this is very rare. These symptoms, if sufficiently violent to create constitutional dis- turbance, will also give rise to the ordinary symptoms of irritative or inflammatory fever. As the discharge from the urethra gene- rally diminishes before the swelling in the testicle is noticed— owing to the metastasis of the inflammatory action—the idea was formerly held, and is still believed in by the vulgar, that the dis- charge causes the swelling; and hence we often hear the expression that "the clap has fallen into the testicles." Diagnosis.—In regard to the diagnosis of epididymitis there is generally but little difficulty in arriving at a correet conclusion, the history of the case and the accompanying symptoms generally referring the disorder to its true source. Should, however, the patient be disposed to deny the origin of the complaint, a very few days, by bringing back the discharge, will add considerably to the facility of diagnosis. Prognosis.—The prognosis of epididymitis is favorable, and under ordinary circumstances a cure may be expected in about nine days; this being a marked improvement upon the old plan of treatment, which seldom cured under three weeks. Treatment.—The treatment of epididymitis is based upon the gene- ral principles of the treatment of inflammation elsewhere; thus leeches should be at once applied to the cord or to the perineum, but not to the scrotum, where their irritation would only increase the existing inflammation. For the first three days the patient should also be kept in the recumbent position, with the testicle well sup- ported by a handkerchief suspensory (see Fig. 49, page 205), in order to prevent it from drawing upon the cord. At the same time warm cloths should be applied, and covered with oiled silk, as in the warm-water dressing; or, if it is more agreeable to the feel- ings of the patient, the cold-water dressing may be used. After twenty-four or forty-eight hours, or when the first violence of the inflammatory action has passed, means may be resorted to in order to relieve the parts of the effusions which ensue on the inflamma- tory action, and this may be accomplished by continuous and firm pressure of the affected testis, a plan first suggested by the late Dr. 670 PRACTICE OF SURGERY. Hartshorne, of Philadelphia, who applied it by means of a narrow bandage as early as the year 1800. About the year 1835, Frick, of Hamburg, recommended that the pressure should be made in these cases by means of strips of adhesive plaster, and suggested a firm and easily contrived dressing, which may be applied as follows: Shave the scrotum entirely free from hair, and force the testicle gently down to the bottom of it, where it should be held by surrounding the cord just above the testicle with the thumb and forefinger of the patient or an assistant. A strip of adhesive plaster about three-fourths of an inch wide being now warmed, should then be made to surround the cord, just below the thumb and finger, and when thus applied, will hold the tes- ticle firmly to the bottom of the scrotum, and prevent it from slipping away from the compression to which it is subsequently to be subjected. After thus steadying the testicle, begin in the centre of the oval tumor thus formed, and surround it with circular strips so tightly drawn that the patient will complain a little of the pain, and continue applying other circular strips from below upwards till the lower half of the tumor is covered, each strip being made to lap one-third of that which preceded it; after which cover in the remaining half in the same manner, whilst the small part at the bottom of the tumor, necessarily left uncovered by the circular strips, may be covered, and greater security given to the dressing °y applying a few vertical pieces of the plaster. These strips, if properly applied, should cause sufficient compression to create some pain at the moment of their application, but this usually passes off in an hour, and in the course of six, eight, or ten hours the dressing will be found quite loose, and no longer painful, but, on the con- trary, firm and comfortable. In forty-eight hours, as the swelling- will have rapidly diminished, the strips should be tightened by applying over the whole dressing a few more broad and circular pieces of the plaster; in three or four days more the strips may be removed, when the testicle will be found to be reduced very nearly to its former condition, except the thickening in the globus major, which will be no longer painful. Under this treatment it is aston- ishing how rapidly the swelling disappears, whilst the patient is often able to move about to a moderate extent within twenty-four hours after the application of the strips. Sometimes, however, owing to neglect of this treatment, there remains a certain amount of enlargement in the globus major, from EPIDIDYMITIS. 671 the effusion and organization of the lymph, which will leave an in- duration that will last some months. Sometimes, also, the testicle itself will continue slightly indurated, constituting one form of sar- cocele, or, as it has been designated, chronic orchitis. In such a con- dition the treatment pointed out for the treatment of chronic in- flammation, and induration of other structures, will be useful, as stimulating the action of the absorbents by local irritants, whilst such articles are given internally as will favor the liquefaction of the lymph. Locally, the use of iodine will be found highly bene- ficial, iodine ointment being rubbed upon the scrotum, after which the part may be covered with a piece of soap plaster, and the whole sustained by the use of a suspensory bandage; or frictions of mild mercurial ointment may be resorted to, care, however, being taken to carry none of these applications to such an extent as to inflame the skin, as this would only add to the existing inflamma- tion, instead of diminishing it. At the same time the administration of gentle doses of blue mass or calomel, given with the view of diminishing the plasticity of the lymph, will often expedite the cure. The gums should, there- fore, be touched very slightly, as may be safely done by the ad- ministration of the protiodide of mercury in the dose of half a grain three times a day. Any other mercurial preparation may likewise be given in the same way; but it should be remembered that any- thing like profuse salivation, under these circumstances, is posi- tively injurious to the patient, the object of the mercurial being merely to affect the lymph, and not to act as a revulsive. Sometimes, from improper treatment or neglect in the first in- stance, the inflammatory action will result in a true abscess of the testicle, which will subsequently open and discharge itself, or which the surgeon may open. But if he notices in the orifice thus made for the escape of the pus,- a white thready matter, which looks like a slough, it should be remembered that this is very often a por- tion of the rete testis, which, if pulled upon will come away in long shreds, and, thus destroying the structure of the organ, leave the patient completely emasculated, so far as that testicle is con- cerned. The general rule may, therefore, be laid down, that in any abscess about the testicle, all suspicious looking shreds of matter should be left untouched until fully thrown off by nature. The hydrocele resulting from epididymitis, as already mentioned, demands precisely the same treatment as hydrocele resulting from any other cause. 672 PRACTICE OF SURGERY. § 2.—GLEET. From improper treatment, or as a result of indiscretions on the part of the patient whilst laboring under an attack of gonorrhoea, it often happens that the disease is imperfectly cured, and the inflam- matory action not subdued, in consequence of which a slight dis- charge remains, which shows itself in the shape of a drop at the mouth of the urethra when the patient rises in the morning, or is seen occasionally through the day. This condition has been desig- nated as gleet, and occasionally as pin-head gleet, in order to indi- cate the size of the drop matter found at the orifice of the urethra. Occasionally this slight discharge is due to the inflammation con- tinuing to linger in the lacunae of the urethra; or it may be due to the formation of a stricture. Under any circumstances, however, it may be taken for granted that there will be no discharge of pus from the urethra, without there being some inflamed or ulcerated surface from which it can proceed. Under these circumstances a bougie should be introduced for the purpose of ascertaining whether any stricture exists, and, as the introduction of the bougie causes a slight stimulation of the mem- brane, it will very often suffice for the relief of the complaint. Should a stricture be detected, it is to be treated in the manner that will be detailed under the head of Stricture. If, however, the exa- mination shows that there is no stricture, some stimulating injec- tion, as that of the nitrate of silver, should be used with the view of modifying the chronically inflamed condition of the parts, and substituting for it an acute but more tractable inflammation, which will readily yield to treatment. In other words, gleet is to be treated on precisely the same general principles as an indolent ulcer. Several formulae for such injections may be given for the sake of illustration:— R.—Vin. oport. f§iv ; Acid, tannic. 9j.—M. S.—Inject three times daily. Another good injection in cases dependent upon simple debility, is the following:— R.—Decoct, cinchonae f^viij ; Liq. plumb, subacet. fjj.—M. S.—Inject three times daily. PROSTATITIS. 673 Another injection which is particularly useful when a spot that is tender upon pressure can be found by carrying the finger along the course of the urethra, is as follows:— R.—Hyd. chlor. mit. sjss ; Muc. gum acaciae fjxij.—M. S.—Inject twice daily. The following is particularly applicable to patients who are de- bilitated or of a scrofulous habit:— R.—Tr. iodini gtt. xxx ; Muc. gum acac. f|;ij ; Aq. font, f^vi.—M. S.—Inject twice daily. The following is useful in the case of old stagers:— R.—Vin. aromat. f^xiij ;—(of the French Codex. For formula, see page 118.) Acid, tannic. Qij; Ext. opii aquos. ^ss.—M. S.—Inject three times a day. Where many attacks of gonorrhoea have been experienced, the following may be borne by patients whose urethrae have become indurated:— R.—Zinci chloridi grs. viij; Aq. font, f^viij.—M. S.—Inject once daily. § 3.—PROSTATITIS. Another sequela of long-continued gonorrhoea is inflammation of the prostate, or prostatitis. Symptoms.—A sense of weight is experienced in the perineum, and, on passing the finger into the rectum, an enlargement of the prostate can be distinctly felt. Prostatitis generally involves the two lateral lobes of the gland, and, when abscesses form, they are usuallv found in this situation; but the third lobe also not unfre- quently enlarges, and that to such an extent as to obstruct the flow of urine. The period of the formation of pus is generally marked by distinct evidences of constitutional disturbance, as a chill, high fever, &c Treatment.'—The treatment of prostatitis consists in applying leeches to the perineum; in the use of the warm hip-bath, and in 43 674 PRACTICE OF SURGERY. the gentle employment of laxatives to keep the bowels in a soluble condition; but purgatives, particularly aloetic purges, should be avoided, as they are only likely to add to the local irritation. If abscesses form they must be left to nature, as they seldom point in the perineum, owing to the relations of the deep perineal fascia; hence they are apt either to open into the urethra, or to form rectal, perineal or urethral fistula. Should the enlargement of the third lobe of the prostate prevent the free evacuation of the urine, the use of a catheter will be demanded, as will be shown under the head of the retention of urine. § 4.—CYSTITIS AND IRRITABLE BLADDER. Another of the sequelae of gonorrhoea is irritable bladder, or sometimes the development of true inflammation of the vesical mucous membrane. Symptoms.—At a period varying from three to six weeks from the commencement of the attack, a patient with gonorrhoea will sometimes notice a cessation of the discharge, and at the same time become conscious of some irritation about the neck of the bladder, as indicated by a constant desire to urinate. There is also present that peculiar sensation in the head of the penis which is complained of in cases of stone; this being due to precisely the same cause, to wit, irritation of the nerves at the neck of the bladder, producing an impression which is referred to the peripheral extremity of the nerve, rather than to its origin. The disease progressing, the pa- tient experiences also uneasiness in the rectum, as is indicated by more or less tenesmus, which is very much like that seen in an ordinary case of dysentery. If the urine be examined under these circumstances it will be found to be variously affected. If the irritation is limited to the mucous coat of the bladder, there will be increased discharge from the mucous follicles, and the disorder of the urine will consist principally in the presence of a certain amount of muco-purulent or purulent matter, which will settle at the bottom of the chamber-pot, and which in marked cases, when the urine is decanted off, will be left behind in the shape of a tenacious jelly-like matter. Besides which, even in cases in which there is no apparent disorder of the kidneys, we are very likely to find in the CYSTITIS AND IRRITABLE BLADDER. 675 urine, when it has stood for some time, white phosphatic deposits, the amount of which will depend upon the extent to which the irrita- tion has gone, as well as on the constitution of the patient. These phosphatic deposits are not merely concomitants of vesical irrita- tion, but are also found in cases of irritation of the digestive appa- ratus, as after a too free indulgence in stimulating articles of diet, in wine, &c. They are found also after too great mental exertion of any kind. The character of these deposits may be tested in various ways, as by the specific gravity of the urine or the application of heat, or its reaction with nitric acid, &c. &c. Treatment.—The treatment of irritable bladder, or of cystitis, should it run so high as to deserve that name, will, of course, vary according to the grade of the" affection. Thus, should the inflam- mation be acute, severe antiphlogistic measures will be required, as the symptoms may be such as will demand free general blood- letting, or, perhaps, free local bleeding, such as may be obtained by leeches to the supra pubic region, or to the cord or perineum, or to all these points at once. After these preliminary measures, de- pletion may be carried still further by means of antimonials. But purgatives of a brisk character, particularly such as have a tend- ency to act specially on the rectum, as aloes, &c, are contra- indicated. Should, however, the disease have assumed a more chronic cha- racter, and present a lower grade of inflammatory action, such measures will be required as are likely to modify the neuralgic condition of the bladder. And this will be best accomplished by means of local applications; thus, cold water may be injected by means of a catheter into the bladder itself, or an alterative solution may be used containing one, two, three, or four grs. of the nitrate of silver to f I j of water, beginning with the weakest solution, and in- creasing its strength if the exigencies of the case seem to demand it, and the injection causes no pain. If there is much pain in the region of the bladder, or should the patient suffer much after his alterative injection, we may substitute the liq. morph. sulph. diluted with about one-half of water. Should either the disease itself, or the injections used produce tenesmus, as is not unfrequently the case, it should be treated pre- cisely like the tenesmus arising in a case of dysentery, by injecting into the rectum sixty drops, or, if that does not suffice, a teaspoonful 676 PRACTICE OF SURGERY. of laudanum mixed with about a tablespoonful of a thin solution of starch, the patient retaining the enema by means of pressure with warm cloths against the anus. Moderate purgatives will, however, be required from time to time, in order to keep the rectum empty, lest the weight and pressure of hardened feces should aid in keep- ing up the irritation. Saline cathartics, such as Eochelle salts or the citrate of magnesia, are particularly applicable, but drastic or aloetic purges should be avoided for the reasons already stated. The urine should also be tested from time to time and measures taken to make it as unirritating in its properties as possible; thus, if it is observed to be acid in its reaction, advantage may be ex- pected from a moderate course of alkalies, &c. Diuretics, as a general rule, should, however, be avoided through- out the complaint, and under this head may be included the free use of drinks of any kind, as anything that increases the quantity of the urine only adds to the vesical irritation. With regard to the manipulation necessary in injecting the blad- der, little need be said except to state that the use of the catheter is always advisable and generally absolutely necessary; it being most frequently impossible to inject a bladder except by its means. When the catheter has been passed into the bladder, a syringe should be adjusted to it and the injection carefully and slowly thrown in. The syringe for this purpose should be provided with two rings upon its cap, as well as one upon the piston rod, in order that it may be used with one hand while the other is employed in keeping the catheter in position. Sometimes the catheter employed for this purpose is a double one, so that the injection thrown in by one tube flows out by the other, which should be provided with a stopcock, that the injection may be retained for a short time if it be deemed necessary; but should it be inconvenient or impossible to obtain this instrument, a single catheter, with or without a stop- cock, may be employed, and answers a very good purpose. With regard to the form of the catheter itself, it may here be stated that the usual manner of making a number of perforations in the vesical extremity of a catheter in order to favor the escape of the urine is always objectionable, and particularly in these cases. In the first place, the numerous little orifices are liable to be blocked up with mucus, and thus prevent the flow of urine; and in the second, if the instrument is to be retained in the bladder for any length of time, particularly if the urine is acid, these various points are liable to WARTS. 677 oxidize, and thus becoming weakened, the point of the instrument may subsequently be broken off in the bladder. A much safer and more convenient form is that in which there is a large, round, or oval eye on each side of the instrument, as this eye can be polished to any degree of smoothness, whilst the instrument is firmer, and the orifice not so likely to be blocked up. When chronic cystitis shows itself in the muco-purulent or purulent discharge, which has been described as vesical catarrh, advantage may be derived from the employment of stimulating diuretics—such as balsam copaibae, cubebs, fluid extract of buchu and soda, &c. &c. An injection of the dilute nitric acid has also been recommended, and sometimes proved peculiarly successful. It may be used of a strength varying from two to three or four drops to the ounce of water, according to the irritability of the patient, but should not be strong enough to produce marked vesical tenesmus. § 5.—WARTS. Fig. 231. Another complaint, sometimes seen after gonorrhoea, is one in which certain growths are observed upon the prepuce or glans penis, which are de- signated as Warts, and sometimes as Vene- real Warts. They are generally the result of some external irritation, such as that pro- duced by a balanitis, want of cleanliness, &c, and form around the corona glandis, or on the reflected prepuce, or on the'head of the penis, and are, apparently, due to obstruction in the ducts of the follicles and to the distension and hypertrophy re- sulting from this. They are however gene- rally very amenable to treatment, and, if small, may be destroyed by touching them from time to time with the nitrate of silver or sul- phate of copper. If large, they may be snipped off with a pair of scissors, and the raw surface thus left freely cauterized with the lunar caustic. 67S PRACTICE OF SURGERY. SECTION II. GONORRHOEA IN THE FEMALE. Symptoms.—Gonorrhoea in the female is a discharge which is caused by active inflammation of the vaginal mucous membrane, and is not at first accompanied by that ardor urinae which dis- tinguishes the commencement of the disease in the male; the first symptoms noticed being usually an irritation about the vulva fol- lowed by an increase of the natural mucous secretions of the part. As the disease progresses this discharge becomes purulent in its character, then ichorous, and very irritating, so that as it runs down over the posterior commissure and fourchette it produces more or less excoriation, and gives rise to violent burning, with inflamma- tory swelling of the vulva. As the surface involved is very ex- tensive, the discharge is generally quite profuse, requiring often the use of a napkin to preserve a tolerable amount of cleanliness, and to prevent the excoriation which is so apt to result from the acrid character of the pus. As the disease continues the urethra becomes involved, and then there is more or less ardor urinae, as was the case with the male. On examining the parts carefully with a spe- culum, violent inflammation will now be seen in the labia minora and vagina, and sometimes excoriation and abrasion of the mucous membrane covering the os uteri, the whole vaginal canal being swollen and tender, so much so that the introduction of the specu- lum is sometimes intolerable from the pain. Diagnosis.—As regards the diagnosis, it is often a matter of great moment, so far as the feelings of the patient are concerned, yet it is a matter of very great difficulty in some instances. Leucorrhoea, which is a very common complaint, may, particularly in a bad con- stitution, or where there is want of cleanliness, simulate gonorrhoea so closely as to render it difficult, if not impossible to distinguish them, the discharge being first mucous, then thick and purulent, and becoming finally yellowish or greenish. As a general rule, however, the irritation produced by leucorrhcea is much less marked than that created by gonorrhoea, and if the patient has ardor urinaa, a profuse greenish or yellowish-green discharge, more or less swelling of the labia, particularly the labia majora, with sympathetic enlargement of the glands of the groin, it will GONORRHOEA IN THE FEMALE. 679 be quite right to look upon the disease as gonorrhoea, particularly if the patient is likely to have been exposed to the cause which alone can produce it. The uncertainty of diagnosis, however, should make the surgeon very careful in expressing an opinion, parti- cularly where medico-legal questions are involved, or where the ex- pression of the opinion would produce domestic unhappiness and distress, and it is often best not to criticize the symptoms rigidly, as the mental suffering in these cases is often much more severe than the bodily, a lady not unfrequently bearing uncomplainingly the bodily discomforts of the disease whilst believing that she has no virulent disorder, who would suffer exceedingly at the idea of contamination on the part of her husband. Treatment.—The cure of gonorrhoea in the female is generally much more readily accomplished than in the male. There is, it is true, a much larger extent of surface, and one more difficult to apply remedies to, than that of the male. As the urine also does not pass over much of the diseased surface, there is but little benefit to be derived from the use of those alterative diuretics which were recommended in the case of the male. The chief reliance, therefore, is to be placed in vaginal injections, and these, if judiciously ad- ministered, will rarely fail to accomplish a cure. When called to a case supposed to be gonorrhoea in a female, the first thing to be done is to examine the parts, and, if possible, by means of a speculum, as we can thus ascertain the extent of the trouble and learn how far the mucous lining of the vagina is involved in the disorder. The speculum used in these cases may be a simple bivalve, trivalve, or quadrivalve, though a much better instrument is the fenestrated speculum recently made in Paris, but now for sale by most of our cutlers, by means of which the whole vaginal mucous membrane can be very thoroughly ex- posed, as it can be readily introduced without causing pain. Being satisfied of the condition, of the vagina, some astringent injection may be ordered proportioned in strength to the grade of the dis- ease. As a general rule, however, much stronger injections are advisable in the female than could be employed for a similar con- dition in the male. In the use of an injection, special directions should be given that the parts be first thoroughly cleansed by means of an injection of soap and water, when a strong infusion of white-oak bark, or a strong solution of alum, of sulphate of zinc, or some similar substance may be thrown into the vagina whilst 680 PRACTICE OF SURGERY. the female is reclining in a horizontal posture, with the hips raised by a pillow placed beneath the pelvis. The injection may be thoroughly introduced and held in the vagina by means of Chased , syringe, as this will permit the patient to retain it for some little time by pressing the shield against the vulva; or she may use the self-injecting apparatus, or clyso-pompe of the cutlers, or some similar means. The ordinary glass syringe, with little holes in the side, is of no use, being too small, and not bringing the injecting material in contact with the whole of the canal. A very excellent plan of treatment is that suggested by Eicord This consists in distending the vagina by means of charpie which has been soaked in some astringent or alterative solution, such as the sulphate of zinc, acetate of lead, nitrate of silver, etc. The vagina may be packed full of the lint thus prepared by means of the fenestrated speculum, and the solution be thus kept in contact with every portion of the walls of the canal for some time, so that its full effect can be obtained, the charpie being retained, if neces- sary, by means of a T bandage or napkin applied against the peri- neum. After forty-eight hours this packing may be removed, and a second or even a third or fourth application may be necessary; but usually the disease is said to be cured by this plan in a very short time. The surgeon will sometimes be called upon to express an opinion in cases of what is supposed to be gonorrhoea in young females under ten years of age, on whom it will be asserted, or feared, per- haps, by the mother of the patient, that a rape has been attempted by a person laboring under gonorrhoea. Now it is important, under these circumstances, that the young surgeon should be acquainted with the fact that female children are not unfrequently attacked by a mere leucorrhceal discharge, which, in the irritable or un- cleanly, may simulate ordinary gonorrhoea, worms, irritation in the rectum, scrofulous disease, want of cleanliness, and many other causes, giving rise to such a complaint; and there are many instances on record, in which men have been tried, and convicted, —most unjustly—of attempts to commit rape where there is no doubt that the discharge arose from perfectly natural causes. It should be remembered, therefore, in the investigation of such a case of supposed rape, that anything like an attempt at coition, fairly made upon a child of less than ten years of age, would produce STRICTURE OF THE URETHRA. 681 such an amount of bruising and laceration of the vulva as would be readily recognizable, and that in the great majority of cases of this sort there is not the slightest ground for the charge. § 1.—CONSTITUTIONAL RESULTS OF GONORRHOEA. Eheumatism has been spoken of by some as being among the sequelae of gonorrhoea; but this is an error, as there is nothing even in virulent urethritis in any way liable to affect the fibrous tissues. Eheumatism may coexist with gonorrhoea, or it may fol- low after it in those predisposed to such attacks, but there is no reason to believe that it is in any way connected with gonorrhoea, this disorder being a local and not a constitutional affection. In the same manner, it has been said that a papular eruption sometimes follows gonorrhoea, and such is undoubtedly sometimes seen, a well-marked papular eruption sometimes ensuing in these cases, not, however, as the result of a constitutional contamination from the gonorrhoea, but as the consequence of the measures taken to relieve the discharge, it being entirely due to the too free use of the balsam of copaiba, which, by disordering the digestion, reacts on the skin. It is, therefore, a very simple matter, and may readily be checked by stopping the use of the balsam, and purging the patient thoroughly. SECTION III. STRICTURE OF THE URETHRA. Another complaint, frequently a result of gonorrhoea, but very often arising from other causes, is an inconvenience resulting from the inflammation acting upon the submucous cellular tissue, and producing effusions of lymph. This lymph may simply involve the submucous cellular tissue, or may go further, and affect the corpus spongiosum, or the corpora cavernosa, creating an obstruction that is designated as a stricture. By the term stricture is usually meant an obstruction of any of the canals in the body, which is either the result of inflammatory action, or created by spasm of the muscles, 682 PRACTICE OF SURGERY. the latter creating such a contraction of the canal as will tempora- rily obliterate it. Etiology—-The same causes acting upon any of the mucous canals of the body will result in stricture, precisely similar to that often seen in the urethra as the result of gonorrhoeal inflammation; thus the oesophagus, for example, or the rectum, when inflamed, may become the seat of stricture. Varieties.—Stricture of the urethra, for the purposes of method- ical study, may be divided into three kinds. 1. Spasmodic stricture, or that resulting from mere spasmodic contraction of the muscles of the penis or of the perineum. 2. Acute.inflammatory stricture. 3. Chronic or permanent stricture, or that due to effusion of various kinds into the adjacent parts. Permanent stricture has also been subdivided into several forms, according to its extent. Thus, if the obstruction is extremely narrow, it is called a thread-like stricture; if a little wider, it is designated as a ribbon-like stricture; whilst the term cartilaginous stricture is sometimes employed to indicate the density of the obstruction. General Prognosis.—Stricture of the urethra is usually a tedious complaint, and is not often seen until long after the exciting cause, if it be a gonorrhoea, has passed away. It therefore not unfre- quently shows itself in men, many years after they have had gonorrhoea, because the morbid action in the urethra progresses so slowly that it is a long time after its commencement before it begins to attract attention. Etiology of Stricture.—1. Of spasmodic stricture. When an in- dividual has been living rather freely, indulging too much in eat- ing and drinking, or has been to a ball, and partaken plentifully of stimulating articles of food or drink, and then walked home through the snow, or has been on a sleighing party, or on a frolic; in either case, on his return home, or before he enters a house, he will often have a desire to urinate, and find it impossible to void his bladder. The same condition is also found in certain fevers, and in accidents requiring the supine position, as fractures of the leg, &c, the patient frequently finding it difficult or impossible to void his urine for the first few days that he is confined on his back. 2. An inflammatory stricture is usually the result of irritation or inflammation in the urethra itself, which, by effusion, diminishes PERMANENT STRICTURE. 683 the caliber of the canal. It is frequently combined with paralysis of the muscles of the vesical triangle, a striking example of which is often seen in gonorrhoea; where, when the patient urinates and suffers intensely from ardor urinae, he is induced to hold his urine as long as possible, until when he again attempts to pass it, he finds he has lost the power of doing so. 3. Permanent stricture may be the result of repeated attacks of the spasmodic stricture, in consequence of the muscular fibres compressing the urethra, as is especially the case near the bulb; or it may ensue upon the inflammatory stricture, or on gonorrhoea, or blows, or ulceration, &c, which by creating an effusion of lymph in the submucous cellular tissue, diminishes the capacity of the canal to the extent of the deposit. This lymph, as originally effused as the product of inflammatory action, may subsequently become organized, and passing through the various grades of induration, sometimes creates a substance as dense as cartilage, which cuts like it, this stricture being hence often spoken of as the cartilagi- nous stricture. As the permanent stricture is the most serious of these varieties, the symptoms, &c, of all strictures may be best studied under this head. § 1.—PERMANENT STRICTURE. Symptoms.—The symptoms of permanent stricture are as fol- lows : The first thing that calls the patient's attention to the parts, is the experience of some slight irregularity in the stream, or diffi- culty in urinating, or he may feel a certain amount of irritation at some one point which excites his attention; after which he will notice the presence of a slight muco-purulent discharge, which resembles that of pin-head gleet, and is often the origin of the latter disorder. As this discharge comes in contact with his linen it will make a stain, which is thick and somewhat like the spot caused by a little melted tallow. The urine itself, in certain conditions, is also capable of staining the linen, but this stain is a simple discoloration, while the stain produced by gonorrheal matter, by gleet, by the discharge from stricture, and other purulent discharges not only produces a discoloration, but communicates to the linen a certain amount of stiffness. After this the desire for urination becomes more frequent, and is shown by the patient urinating once, twice, or thrice, nightly, 684 PRACTICE OF SURGERY. oftener than usual, and even more so during the day, whilst the evacuation of the bladder is not complete, being often unsatisfactory and creating more or less disposition to strain. The stream of urine is also irregular, being diminished in thickness, so that it may become as fine as a thin wire, whilst it not unfrequently takes a spiral direction, or becomes twisted and spatters as it escapes from the urethra. Owing to the varying caliber of the urethra at differ- ent points, and other irregularities in its size, the natural stream, it should be remembered, is itself always more or less spiral; but in stricture it is positively irregular and often forked, the spiral twist being a short one, and the coils separate, like those in a corkscrew. After urinating the patient also often finds that he has not entirely emptied his urethra, but that a few drops more dribble away, soiling his shirt, or even soaking through and discoloring his clothes if their color is such that the urine can act upon the dye. An hour or two after this he again finds he desires to urinate, and in this effort is again only partially successful. In this manner the patient may work along for some time, experiencing more or less discomfort, but no actual suffering until on some occasion when he has been on a party, or become slightly intoxicated, or used for some time high seasoned stimulating food, or been exposed to cold and mois- ture, he suddenly finds that he cannot pass his water, or can only do so with great effort, and in small quantities at a time. This difficulty may, after a time, be partially relieved, but usually con- tinues to some extent, the urine accumulating behind the stricture and producing dilatation which may even result in rupture of the urethra, when, as the urine is bound down by the perineal fascia it will burrow forward and escape into the scrotum, resulting in ab- scess, sloughing, mortification, and the establishment of fistulous orifices in the perineum (Fig. 232); or the entire scrotum may be- come enormously distended and slough so as to leave the testicle quite exposed. If the dilatation does not go so far as to result in rupture of the canal, it may yet create very serious consequences, as abscess of the prostate, &c, or the irritation may travel along the vas deferens to the epididymis, and epididymitis or swelled testicle result, or create numerous ulcerated openings behind the scrotum and before the anus, as before alluded to. Seat of Stricture.—The seat of stricture varies very considerably, though it is generally found at those points at which the canal is bent or pressed upon by any cause. Thus, it is sometimes met PERMANENT STRICTURE. 685 with at the point at which the canal first narrows, just behind the fossa navicularis, next at the point where the penis is bent when Fig. 232. A front view of the numerous Orifices sometimes present in Fistula in Perineo. (After Liston.) hanging in its natural undistended condition, or when attacked by chordee, or at the bulb where the canal is compressed by the con- traction of the accelerator urinae muscle, or at the membranous por- tion of the urethra, where it is exposed to pressure from the perineal muscles, from hardened faeces, &c. Stricture is, moreover, found at times in the true prostatic portion of the urethra, but this is due rather to a change in the prostate gland, than to any derangement connected immediately with the lining of the canal itself. Diagnosis.—In regard to the diagnosis of stricture of the urethra, great caution will be required. The patient may have the pain, the frequent desire to make water, the dribbling of urine, etc. etc., and yet his canal be in a perfectly normal condition. Thus, many of the symptoms described may result from the presence of stone in the bladder, or the peculiar corkscrew-like stream of urine may be simulated by the compression of the urethra caused by the muscles when the penis is in a state of semi-erection, &c, so that the surgeon might readily be deceived were he to judge simply from the rational symptoms of the complaint as detailed by the patient, whilst if not careful in the introduction of the catheter or bougie, he may also be deceived even with the use of a bougie. Under ordinary circumstances, however, nothing is more certain as a means of diagnosis in a case supposed to be one of stricture than the introduction of an instrument, it being passed down the 686 PRACTICE OF SURGERY. urethra like a catheter.1 But if the instrument is small, and the surgeon careless, he may engage its point in an enlarged lacuna, and suppose that spot to be the seat of a stricture. If, however, he will partially withdraw the instrument, and stretch the penis so as to make the urethra tense, he will, on disengaging its point, be able to pass it on. At the triangular ligament in the natural condition of the parts the inexperienced surgeon will also often imagine that he has found a stricture because he does not sufficiently depress the handle of the instrument to cause the point to pass up over the triangular ligament. A little manipulation will, however, readily avoid this difficulty; but if it should occur, and be troublesome, as it will sometimes prove even in the hands of a skilful operator, a finger introduced into the rectum will guide the instrument suc- cessfully into the bladder, unless there is a stricture in the mem- branous portion of the canal. Sometimes, and especially in old men, a difficulty will be found in the introduction of an ordinary bougie or catheter, which is not due to stricture, but is owing to an enlargement of the third lobe of the prostate gland, in consequence of which it rises into the ori- fice of the canal, and opposes the entrance of the catheter. This may be obviated by giving the catheter such a curve at its point as would be created by passing it for a quarter of an inch into the barrel of a desk key, and then bending the body of the catheter gently downwards, so that when the catheter is held upright the point as far back as the end of the eye (Fig. 233) will be horizon- tal—or by introducing a gum elastic catheter with its stylet until the obstruction is reached, when the stylet being withdrawn a quarter of an inch the point of the catheter will be raised above the obstruction, and may then be readily made to pass into the bladder. When a stricture truly exists, however, it will be found that none of these manipulations will enable the instrument to pass it until, as the surgeon diminishes the size of the instrument, he is enabled to carry a small one through the obstruction, or is com- pelled to overcome it by caustic or incision. Prognosis.—The prognosis of permanent stricture will, of course, depend upon the history of the case, the duration of the disease, and the character and habits of the patient. It will be favorable 1 For the operation of Catheterism see Op. Surg., vol. ii. p. 202, 2d edit.- PERMANENT STRICTURE. 687 if the stricture has existed but a short time, if the patient is of temperate habits, and is faithful in following out the directions of Fig. 233 l f Fig. 234. Fig. 233.__A side view of the Curvature of the Point of a Prostatic Catheter of half the natural size of the instrument. (After Miller.) Fig. 234.__A side view of the ordinary Curve of the Catheter. (After Miller.) 688 PRACTICE OF SURGERY. his surgeon. If he is intemperate, or has had the stricture for some months, and particularly if it has acquired the cartilaginous consistency, the prognosis should be guarded. Treatment—The treatment will, of course, vary according to the character of the stricture. 1. If it is of the spasmodic kind, and pro- duced by the causes already given, seat the patient by the fire, and warm him through, or seat him, if convenient, in a tub of hot water, give him a moderate amount of some warm tea and some anodyne, or direct an anodyne injection to be thrown into the rectum, and then, if he is yet unable to void his urine, pass the catheter.1 After having evacuated the bladder, the patient will be relieved for the time, when diluent drinks, low diet, and other means calculated to make the urine as unirritating as possible, should be resorted to with a view of preventing a recurrence of the inconvenience. 2. Inflammatory stricture is to be relieved by combating the inflammation that causes it. When it is so perfect as to cause a retention of the urine, it will be necessary to employ the same local treatment as that just detailed in the spasmodic variety, except that greater care in anointing and warming the instrument and greater gentleness in its introduction will be required. 3. The treatment of permanent stricture is very varied, but may be classified under three general heads:— 1. Dilatation.—Permanent stricture may be treated by means of dilatation, the surgeon commencing by introducing a bougie of cat- gut, wax, or metal of such a size that he can pass it through the stricture, where he should allow it to remain five or ten minutes, as this is quite sufficient for one day, and will not unfrequently produce a slight chill, and be followed by more or less febrile reac- tion. The next day a bougie of the same size as that last employed should be introduced, and allowed to remain the same length of time, and the next day a larger one, and so on until the canal is sufficiently dilated. There are, however, cases principally of cartilaginous stricture, which cannot be overcome by means of dilatation; this treatment being only likely to prove successful in cases of thin, ribbon or thread-like strictures. A cartilaginous stricture will, therefore, usually require such measures as will change the action of the part 1 See Op. Surgery, vol. ii. p. 202, 2d edit. SYPHILIS. 689 completely, either by cuting through it or overcoming it by means of caustic, the details of each method being given in the Operative Surgery, vol. ii. p. 206, 2d edition. CHAPTEE II. SECTION I. SYPHILIS. Syphilis may be defined as a specific disease which affects the whole system, but which, at its commencement, is characterized by a peculiar ulcer, that takes the French name of chancre, and is capable of being propagated—though this name was originally ap- plied by the French to any sore with hardened edges. In studying the peculiarities of a chancre, we should first consider the character of its pus. As this is the origin of syphilis, being specific or pecu- liar in its nature, and capable, when introduced beneath the skin in another part or in another person, of reproducing a sore precisely similar to itself, or, if absorbed into the blood, of creating consti- tutional effects which will result in the formation of other sores similar or analogous to the primary one, just as the pus of cow- " pox introduced beneath the skin reproduces exactly the original vesicle or scab, and then goes on to the production of a constitu- tional affection. The sore thus produced by inoculation of the pus from a chancre, being the starting-point of syphilis, is often designated as the primary sore, the attack as primary syphilis, whilst those which result from the constitutional infection, or the absorp- tion of the pus of the primary ulcer, are called secondary sores, being noted subsequently as ulcers of the skin and mucous membranes; the disorders of these tissues from this source being often desig- nated as secondary syphilis. When the constitutional disease goes still further, and produces changes in the ligaments, in the fibrous tissues, in the bones, &c, the affection is called tertiary syphilis. Seat of Chancre.—In order to produce the primary sore or chancre, it is necessary that the pus should pass beneath the cuticle; hence we find the most common seats of the disease are points where the cuticle is the thinnest and most likely to crack or be ruptured; 44 690 PRACTICE OF SURGERY. such as the frsenum of the prepuce, which is often so violently dis- tended during coition as to create a rupture of the cuticle covering the part. The frasnum is, perhaps, the most frequent seat of chancre, whilst next we have the corona glandis, or the part just behind it, Fig. 235. Fig. 236. The common seat of Chancre—thesore Chancre of the acute Phagedenic presenting the characters of that with variety, seated around the Corona an indurated base, and which is desig- Glandis. (After Acton.) nated as the Hunterian Chancre. (Af- ter Acton.) where the mucous membrane is reflected from the penis upon the prepuce, this being also very apt to be stretched during copulation, in consequence of which it becomes abraded or cracked. The next most frequent seats of chancre are outside of the body of the penis; upon the nipple of the female, or upon the lips and tongue. It is also to be found in the eyelids, from rubbing the eyes with the hands, on which there may be chancerous pus. In the female it is found upon the labia minora, near the meatus urinarius, upon the fourchette, within the vagina, upon the os uteri, &c. Symptoms.—The symptoms of primary syphilis and of chancre are as follows: In from two to four days, after an impure connec- tion, there is seen on the prepuce, or corona, or on the body of the penis, or upon the labia minora or majora, or within the vagina, a red inflamed spot; which is combined with a certain amount of smarting or stinging, sufficient in the penis to give rise to an afflux of blood to the part, and cause a marked irritation and disposition to an erection, this erection, by stretching the parts, aiding in the extension of the sore, the little red inflamed spot, at this early period, exhibiting only the ordinary characters of unhealthy inflam- matory action. The cuticle covering it, however, soon becomes elevated by the effusion of serum beneath it so as to make a little vesicle, the serum of which shortly assumes a yellow color from an admixture of pus, and finally becomes quite purulent. The dis- SYPHILIS. 691 tended vesicle then bursts, and discharging itself, leaves a slight superficial abrasion or ulcer. In this condition this ulcer is a sim- ple ulcerated surface, secreting, it is true, a specific pus, but yet susceptible, after a light cauterization, of being healed by the ordi- nary treatment of inflammation elsewhere. After the ulcer has progressed for a few hours it however becomes changed in its appearance, owing to the efforts of nature to prevent the absorp- tion of pus, this being accomplished by m'eans of an effusion of lymph; in consequence of which the sore acquires defined edges, and more or less induration around its borders. In the course of twenty-four or thirty-six hours after the first ap- pearance of the abraded surface it will be found that the chancre has changed its early characters, and, instead of presenting a super- ficial abraded surface, secreting pus, has now taken on the cha- racter of a superficial slough, and is covered by a soft, pulpy struc- ture, of various depths, this death of the tissue being in proportion to the virulence of the disorder. The efforts of nature to limit the extension of the disease now become more marked, the edges of the chancre become thicker and more rounded, and the sore acquires a greater apparent depth, owing to the effusion of lymph on its edges, whilst it obtains a hardened base, which can be distinctly felt by pinching the parts between the fingers, this base presenting the con- dition to which the term Hunterian chancre has been applied from the fact that this sore was first accurately described by the celebrated John Hunter. It should, however, be remembered that such a chan- cre commences precisely like the simple sore first described, it having become deeper and more rounded on its edge, precisely as the edge of an ordinary indolent ulcer is created from that of a simple healthy nicer of the leg. As long as a chancre has not created a bubo it should also be recollected that it is perfectly amenable to proper treatment, and that it may be healed without the disorder contami- nating the patient's system. But if the primary sore is allowed to progress unchecked, inflammation in the lymphatic glands of the tfegion will next be noticed, a red line being observed to extend along the back of the penis in a line corresponding with the course of the lymphatics. The lymphatic glands will now become in- volved, and begin to enlarge either in the groin, constituting what is ordinarily designated as a bubo, or the lymphatics of the penis itself may enlarge and thus create a true abscess of the penis. When a bubo forms in the groin it will often run on to suppuration, when 692 PRACTICE OF SURGERY. the pus thus formed will prove to be precisely like that originally obtained from the woman, and if introduced beneath the skin of some other part, as upon the thigh of the patient, will produce another chancre precisely similar in all respects to the first one. The pus from a chancre will usually stain the linen as did that of stricture, but, perhaps, in a more marked manner, producing a heavier tallow-like stain. This pus, moreover, has certain proper- ties which may be described under the head of the Laws of Chancre which have been established chiefly by the talents and industry of M. Eicord, of Paris. 1. The pus from a chancre, or from its consequent bubo, whether upon the penis or the groin, will always reproduce a chancre wher- ever it may be inoculated. 2. It will produce an irritation that will travel along the lym- phatics and create inflammation and suppuration in the first lymphatic gland. 3. It will develop irritation and suppuration in each gland that is involved, and the bubo thus formed will produce a pus of pre- cisely the same characteristics as that formed in the original sore; that is, the pus from such a bubo, if introduced on the point of a lancet, beneath the sound skin of any portion of the body, will in three days create precisely such a condition as was seen in the for- mation of the original chancre. Diagnosis.—From the description of the primary sore just given it will readily be seen that there are many conditions which a careless observer might confound with the earliest stage or the commencement of chancre. Thus, a man may have connection with a filthy woman, or he may himself be of filthy habits, in con- sequence of which, the mucous membrane covering his glans penis will become abraded, or the irritation produced by mere contact with the acrid matters of the female vagina, may produce a little vesicle, or a number of little vesicles, and these will be found upon the fraenum and behind the corona, which, it should be re- membered, are the most frequent seats of the primary sore; but these sores are nothing more than the vesicles of eczema. Then, again, it should be remembered that there is a true herpes of the glans penis, or of the prepuce, the vesicles of which are not unlike those seen in the commencement of chancre, these, when they burst, also creating a little superficial excoriation which may readily be confounded with chancre by an inexperienced observer. But the SYPHILIS. 693 surgeon may always make a correct diagnosis by noticing that the sore left by herpes never runs on to a deep ulceration like chancre; that it does not form a thick gummy pus; is not covered by a thick pultaceous slough, and does not produce a suppurating bubo, although at times it results in a mere sympathetic one, which generally disappears in a few days; or if these facts are not suffi- cient, the diagnosis can always be definitely settled by Eicord's ex- periment of inoculation; thus if the pus from a supposed chancre does not reproduce a chancre, it may be safely asserted that it is not a specific sore. Although, then, the diagnosis in the early stages of the primary sore is difficult, that between other sores and the Ilunterian chancre may be readily made. Treatment of Syphilis.—The treatment of a simple chancre, be- fore it has become Ilunterian, or before it has acquired an indu- rated base, is to be conducted upon general principles, the great danger being from the absorption of the virus from the surface of the sore. The indications for treatment, therefore, are clearly : — 1. To check or modify the secretion of pus from the chancre. 2. To prevent its absorption into the system. 3. To heal the ulcer left behind after the first two indications have been fulfilled. With regard to the first indication, or the modification of the secretion of pus, it is to be accomplished by such means as will change the whole character of the sore, such, for example, as the application of caustic, a gentle cauterization with the nitrate of silver being generally found sufficient to answer that purpose, this being repeated the next day, or every other day, if necessary, until the sore is healed; the chemical action of the caustic and the healthy inflammation it develops being generally sufficient to alter completely the specific nature of this sore. But it should be re- membered that the nitrate of silver is to be applied with a view to its alterative effects, and not in order to create a deep eschar and burn out the sore, as this is not required in this stage of the complaint, and creates an amount of irritation which the circum- stances do not demand. If we have the Hunterian chancre to treat a more powerful caustic will be demanded, as will be ex- plained when considering the treatment of this sore. If the nitrate of silver is not at hand, an alterative effect may sometimes be produced upon the surface of the sore by means of a solution of some one of the milder chlorides, such, for example, as 694 PRACTICE OF SURGERY. black wash, which may be made in the proportion of 3j Hyd. chl. mit. (calomel) to Aq. calcis f|iv, lint saturated with the above solution being kept upon the sore. As regards the second indication, it is best carried out by such means as will remove the pus from the sore as rapidly as it is formed, and this is to be found in a frequent change of dressings, the lint which is placed next in contact with the chancre being changed every two or three hours, whilst anything like the forma- tion of crusts or scabs is to be studiously prevented, lest the pus accumulate beneath them and thus become absorbed. As the inflammation produced by chancre is always of an un- healthy character, it will be found advantageous to moisten the lint with which the sore is to be dressed with some stimulating article, and a very excellent one is to be found in the aromatic wine of the French codex,1 a preparation formed by the macera- tion of various aromatic herbs in claret wine. Lint, wet with this solution, and applied to the sore, should there- fore be changed at least every three hours until the application becomes too stimulating, as will be shown by its smarting, when the wine should be diluted with a little water. If the secretion of pus is very profuse, a small quantity of tannic acid may be added to the aromatic wine with a view of diminishing it, about ten grains of tannic acid being added to each ounce of the wine. But it should be remembered that it is possible to apply an astringent to such an extent as to prevent the development of granulations, and thus interfere with the perfect cicatrization of the sore, and any such accident should be guarded against by diminishing the quantity of the tannic acid. The third indication—to heal the sore—is to be accomplished in precisely the same manner as the healing of any other ulcer, except that ointments and greasy applications do not seem to answer as good a purpose in the treatment of chancre as simple washes. If the sore does not heal with sufficient rapidity, it may be lightly touched from time to time with the solid stick, or with a solution of thirty grains of the nitrate of silver to the ounce of water. Before applying these articles, however, the surface of the ulcer should be gently wiped dry by pressing upon it a little piece of lint, and after the caustic has been applied the application of the 1 See page 118. SYPHILIS. 695 lint should be repeated in order that it may remove any excess of caustic, which might otherwise spread and affect the sound tissues. Thus far syphilis requires little or no constitutional treatment, a slight purge, attention to the condition of the digestive organs, &c. &c, being generally quite sufficient, the primary ulcer, after it has been cauterized, being treated precisely as if it had been pro- duced by any other cause. The simple chancre thus early seen and properly treated is therefore a very simple affair, and much less troublesome than gonorrhoea. But if the patient allows the ulcera- tive process to progress, as he is very apt to do, on account of mis- taken notions of the purity of the woman from whom, in truth, he has received it, a true Hunterian chancre may be developed, which will present the characters already described. The treatment of this indurated or Hunterian chancre is more troublesome than that of the simple sore just described, as it does not yield to the simple stimulating applications which will heal a simple chancre, owing to the induration of its base by the effused lymph. Sometimes, on account of the bad constitution of the pa- tient, or other causes, marked signs of unhealthy inflammation also develop themselves, and there is no longer a disposition to the effusion of lymph; hence as the inflammation is not limited, the ulcer spreads with greater or less rapidity. Such a condition is described as the phagedenic chancre, or if it sloughs with great rapidity, as the sloughing phagedena. This sloughing chancre will sometimes progress to such an extent as completely to surround the head of the penis with deep ulcerations, so as nearly to remove it, thus creating a loss of structure which is never afterwards re- placed. Sometimes instead of an external chancre we may notice a chancre which is within the urethra, in consequence of which it is designated as a concealed chancre, though it can generally be seen at the edge of the fossa navicularis of the urethra, by opening the lips of this canal. It is said that this chancre may be found further in- but if this is true, it must be extremely rare, as it is a difficult matter for the inoculating pus to travel much further into the urethra than the fossa navicularis, and find an abrasion. The treatment of the concealed chancre is the same as that of the simple chancre when it is external to the urethra, its cauterization being accomplished by the introduction of the solid stick of caustic within the urethra, or by throwing in a strong solution, taking care to 696 PRACTICE OF SURGERY. limit its action by constricting the urethra behind the corona glandis. The Hunterian chancre will require a more powerful caustic than that directed in the case of the simple chancre, as it is necessary not only that the sore itself, but its indurated base and edges should also slough out. In these cases the use of the caustic potash, or of the strong acid nitrate of mercury is preferable, as after the slough resulting from such an application has come away, it will leave a clean healthy ulcer without induration, and the treatment will be precisely the same as that detailed under the head of simple chancre. The treatment of the phagedenic chancre, like that of other phagedenas, must be prompt and active, as it is worse than useless to attempt to palliate it, or to reduce the unhealthy inflammation which is here present, by the use of the ordinary antiphlogistic measures. Such efforts, particularly if actively carried out by weakening the patient, always result in a more rapid spread of the disease, and there is, therefore, but one course to pursue, and that is to destroy the whole unhealthy surface, by cauterizing it with strong acid nitrate of mercury, as this is more certain, and pene- trates more deeply into the ulcer than any other caustic. The ap- plication of caustic potash may accomplish the same thing, but it is not so well adapted to this purpose as the strong nitric acid. In the application of the acid, care should be taken to limit its action by the prompt application of sweet oil, or of the bicarbonate of soda, in solution. Occasionally it will happen that the inflammatory action de- veloped by the presence of a chancre leads to an effusion of serum or of lymph into the prepuce to such an extent as to produce phy- mosis. In such a case we should not operate until the chancre is healed, this being accomplished by means of appropriate injec- tions beneath the prepuce, when the swelling will often be so much diminished that the phymosis can be overcome by mere manipula- tion ; or if this is not the case, the operation can be safely performed without the risk of inoculating the edges of the incision. The cicatrix left by a chancre upon the mucous membrane is a peculiar one, and one which never thoroughly disappears, whilst as it is depressed it always shows clearly that there has been a loss of substance. Sometimes this cicatrix is observed to have a thick- ened edge, or when felt gives the sensation of a little cartilaginous BUBO. 697 induration beneath the mucous membrane or the skin, and it should be remembered that whenever such a cicatrix exists the lymph may contain the nidus of the disorder, and that the patient is liable to suffer from constitutional symptoms. The best plan that can be followed to prevent this, is again to apply caustic to the cicatrix, and, if possible, compel the entire induration to slough out. § 1.—BUBO. The term bubo, which is generally applied to the syphilitic affec- tion of the glands of the groin, is one also employed indiscrimi- nately to designate all enlargements of the lymphatic glands, whether caused by syphilis or not, as the term means merely a swelling in the groin. Symptoms.—The symptoms of bubo are as follows: There is fulness in the groin with pain, tenderness upon pressure, and swell- ing. As these symptoms increase and the swelling progresses, the pain becomes quite severe, because the enlargement is limited by the dense superficial fascia of the part, and when suppuration is established, the pus, owing to the same cause, has a disposition to burrow and travel in various directions. At last, the enlargement distends the skin to such an extent that it ulcerates and gives way; the pus is evacuated, and then an ulcer is left similar to the primary sore, though on a larger scale, presenting an ulcer with elevated rounded edges, with a kind of a slough at the bottom, consisting of the structure of the degenerated lymphatic gland, this being also capable of secreting a pus which, by inoculation, will reproduce another chancre. Diagnosis.—As it sometimes happens that a bubo occurs in a case of simple gonorrhoea, it may become a question whether it is of syphilitic origin or merely a sympathetic enlargement pro- duced by the irritation of the gonorrhoea, and this question can generally be determined with tolerable certainty by remembering the following facts :— The gonorrhoeal bubo generally presents us with an enlargement of several glands at the same time, because the irritation from urethritis is not sufficiently great to develop suppuration in one gland before another enlarges; whilst in the syphilitic bubo the inflammation so rapidly develops pus that one gland suppurates 698 PRACTICE OF SURGERY. before the next is attacked, and thus the syphilitic bubo generally involves but one gland at a time. Sometimes there will be enlargement of the glands of the groin from a very simple cause, as when th.e patient stumps his toe, or cuts his corns too closely, or has a toe-nail ulcer, these causes being often quite sufficient to develop a sympathetic enlargement of the glands in the groin; but this bubo corresponds with that described as the result of gonorrhoea, two, three, or several glands being attacked at the same time. It has also not the same tendency to run on to suppuration that is found in the syphilitic bubo. A more difficult matter is to diagnose between the syphilitic bubo and that which is occasionally found resulting from mere irritation produced by cauterizing the chancre in its earlier stages with nitrate of silver. But the delay of a single day will enable the diagnosis to be readily made, as in that time the bubo produced by the irritation of the caustic will be much better, while that pro- duced by the syphilitic virus will be worse. When a patient has a sympathetic bubo at the same time that he is suffering from both concealed chancre and from gonorrhoea, it will, however, be diffi- cult to decide whether the bubo is produced by the gonorrhoea or the chancre, except by a careful inspection of the orifice of the urethra, on the edge of which the chancre will generally be found, as the pus from the urethritis under these circumstances may create a chancre if employed for inoculation. Treatment.—The treatment of the simple sympathetic bubo, or that due to a virulent gonorrhoea uncombined with chancre, is to be based on the general principles of inflammation, the irritation in the gland being checked by soothing applications to the source from whence it came; whilst leeches around the bubo, cold cloths, &c, may, and probably will, check its further progress and prevent its suppuration. When its enlargement is slow, and the skin over it has not reddened, benefit may also be derived from the application of a blister for two or three hours as a revulsive, though this should not be allowed to vesicate, but simply to redden the part on which it is applied. But when the bubo is certainly syphilitic, when it fol- lows the development of chancre, when one gland alone enlarges and is disposed to suppuration, no time should be lost in getting rid of the pus or of the entire gland, so as to prevent the absorption of the matter into the blood and the contamination of the patient's con- stitution. If the least point of suppuration can be detected, the bubo bubo. 699 should therefore be at once freely lanced, the pus discharged, and then the entire cavity cauterized, by rubbing in it caustic potash, the action of the potash being immediately checked by injecting olive oil, But if the bubo has not suppurated but is of some size, with the skin reddened and swollen, whilst at the same time an indurated Hunterian chancre exists on the penis, the entire gland should be made to slough out by the following prompt though painful means, so that the patient may be secured from constitu- tional taint. Give the patient a full dose of anodyne; then shave the groin free from hair, and apply a blister over the bubo for six or twelve hours, or until it vesicates sufficiently to remove the cuticle, after which apply to the denuded surface a compress of patent lint of the size of the bubo, wet with a strong solution of the sulphate of copper, say two drachms of the salt to the ounce of water; lay over this another compress of dry lint and bind the whole firmly to the part by means of a spica bandage. In between twenty-four and thirty-six hours, this dressing may be removed and poultices or g' '" the warm-water dressing applied so as to favor the separation of the slough; these dressings being retained by the spica handkerchief of the groin suggested by Mayor (Fig. 237). If preferred, instead of the sulphate of copper the acid nitrate of mercury may be used; but, in this case, it is not neces- sary to remove the cuticle. "In ap- plying the acid, surround the part with a little elevated line of Basili- con Ointment, and then Spread the A front view of the Handkerchief Band- ' l age of the Groin, as suggested by Mayor, acid Well OVer the part, allowing it for the retention of poultices, Ac, to this _ . •, region. When a change of dressing is de- tO remain for a tew minutes, WUen sired, it is only necessary to unpin the ends it Should be neutralized with SWeet Jf t^k^and J^emby^ Oil Some Surgeons prefer for the round the back of the hips, and carrying ° r . the ends in the line of each groin pass Same purpose the USe Of the CaUStiC them around and beneath the thigh so . i . i xi u „ .„- +U~ that they may be pinned as shown in the potash, which they rub over the figure '(After Mayor.) bubo until the whole is converted into an eschar. In either case, the slough should be deep enough to involve the entire gland, so that when the dead portion comes 700 PRACTICE OF SURGERY. away the diseased gland may be removed, and a simple ulcer left which will be amenable to the ordinary treatment of ulcers. The simple bubo from gonorrhoea requires a very different and much milder treatment—as applications of cold water; pressure, leeches, &c., to check the inflammatory action; or if it runs on to suppuration, an early evacuation of the pus should be practised, and then the sore cauterized lightly. If, however, the inflamma- tory action becomes chronic without going to such an extent as to induce suppuration, and an indolent induration of the glands is esta- blished, these should be treated by such means as will diminish the plasticity of the lymph, precisely as a chronic induration from in- flammation would be treated in any other part, or arising from any other cause, as by the application of small and repeated blisters, inunctions with mercurial ointment, whilst some one of the prepa- rations of mercury may be given in alterative doses in order to facilitate the removal of the lymph. The local use of iodine will also sometimes prove highly useful. § 2.—SYPHILIS IN THE FEMALE. When syphilis shows itself in the female, it obeys the same general laws, and is amenable to the same treatment as when it manifests itself in the male. Seat.—The most frequent seat of chancre in the female is around the meatus urinarius; upon the labia minora; upon the os uteri and upon the fourchette. It is, however, found at times upon other places, both upon the organs of generation and elsewhere. Symptoms.—The symptoms of chancre are more marked, and the ulcers more apt to become phagedenic in the woman than in the man, from the fact that the healthy or diseased discharges of the bladder, the uterus, and the vagina flow over and still further in- flame the ulcerated surface. As a consequence of this, large chan- cres are very apt to form upon the posterior parts of the perineum; or two chancres, one on each side, may unite at the fourchette, and constitute what is known as the horseshoe chancre. Treatment.—Chancre in the female, if simple, is to be treated pre- cisely like the simple chancre in the man, and if phagedenic or Hunterian, after the manner just alluded to; the treatment above given being equally applicable to both sexes. SECONDARY SYPHILIS. 701 SECTION II. SECONDARY SYPHILIS. Thus far we have considered syphilis simply as a local disease, but should the virus enter the system, should the bubo or chancre Be improperly treated, should such an indurated cicatrix as has been just described be allowed to remain, or even when the sore has been well treated, and has apparently healed in the most favorable manner, but yet been attended by an enlarged gland, symptoms of blood poisoning may present themselves a few weeks subsequently. In this case certain constitutional symptoms will appear and pre- sent examples of the affections of the skin, of the mucous mem- branes, of the iris, &c, which have been designated as secondary symptoms, or as secondary syphilis. Besides these, which are the constitutional symptoms of syphilis, there are other affections which are no less constitutional, but which are merely such as would be expected to arise from the irritation of a healthy local inflammation, and which are frequently seen in cases of ordinary ulcers upon the legs and elsewhere, such as disorder of the digestive organs, and consequent malaise, restlessness, want of sleep, emaciation, &c. Symptoms.—About six weeks after the appearance of a chancre, sometimes even where the chancre has been healed, the bubo sloughed out, or even where there has been no marked bubo, the patient will begin to notice some little feebleness in his digestive organs, accompanied by a loss of appetite, and by a disposition to emaciation. This emaciation is often very marked, making the patient look older than he is, and producing in young persons an appearance of old age, the eyes being sunken from absorption of the fat of the orbit, the cheeks depressed from the loss of the fat beneath the malar bone, and the skin sallow and wrinkled. At the same time the eyes will be heavy, and the patient will sleep badly, be irritable and dispirited, and have a quick pulse, while night-sweats will often be exceedingly profuse, thus resembling the condition which has been alluded to in the symptoms of hectic fever. These symptoms will, moreover, be much augmented if the pa- 702 PRACTICE OF SURGERY. tient has been salivated, because then, in addition to the constitu- tional irritation produced by the disease, we have that created by the mercurial. At a period which varies, sometimes preceding, sometimes following, sometimes coincident with, and sometimes without any accompanying disturbance of the digestive organs, there will be noticed affections of the skin and throat, which are usually regarded as the efforts of nature to get rid of the virus of the blood, precisely as the eruption in smallpox is due to the efforts to throw off the blood poison which has produced the constitutional disturbance. § 1.—AFFECTIONS OF THE MUCOUS MEMBRANES. The affections of the mucous tissues, as a consequence of primary syphilis, usually begin as a slight irritation in the pharynx, of which the patient complains, and which he compares to the irritation of or- dinary sore throat; thus he will have some little hoarseness, and, per- haps, some little stoppage of the nose, precisely resembling that of an ordinary catarrh; the secretion produced by these irritated sur- faces being so thick and gluey that he experiences a constant incli- nation to hawk in order to get rid of it. At the same time, or soon after he begins to experience difficulty in deglutition, and, upon looking into the mouth, the uvula and tonsils will be observed to be swollen, and the back of the pharynx to have a peculiar dark mot- tled appearance, more or less of the tint of copper, which is quite characteristic. These mottled spots rapidly take on ulceration, and then present many of the characteristics of the primary sore; thus they are unhealthy in their character, and are disposed to spread, sometimes rapidly becoming phagedenic, and speedily destroying not only the uvula, but the whole soft palate, or travelling for- wards and making oftentimes a direct communication in the roof of the mouth, between the mouth and nose. Symptoms of inflamma- tion in the mucous membrane of the nostril may also present them- selves, and be shown by an increased discharge from the nose, which is acrid, and excoriates the sound skin with which it comes in con- tact. As the inflammation progresses, it next attacks the perios- teum of the spongy bones of the nose, so that caries of these and the neighboring bones is often induced, from which proceeds the usual stinking discharge of diseased bone, thus creating the affection AFFECTIONS OF THE SKIN. 703 which has been already designated as ozaena. As the caries pro- gresses, portions of the spongy bones are discharged with the pus, the nose becomes flattened, the soft parts become involved, and ulcer- ate, and are completely destroyed, so as to create a horrible defor- mity. With these symptoms conjunctivitis and iritis are frequently observed, the changes produced by which have been already de- tailed under the head of Diseases of the Eye. § 2.—AFFECTIONS OF THE SKIN. At various periods after the creation of a chancre, say about six or eight weeks, but often independent of any affection of the throat and nose, affections of the skin begin to be noticed, and these are first exhibited as spots or taches of various kinds, like those of measles. These are reddish in their color and about the size of a split pea or larger, appearing first, as a general rule, on the palms of the hand, on the skin of the face, and then upon the skin of the front of the chest, following in this respect the laws of eruptions generally. The light red color which they present at first, speedily becomes darker, and finally assumes that copper color which is regarded as characteristic of syphilitic eruptions. After this various other skin diseases may appear; these corresponding with ordinary skin dis- eases in their general characters, though they are modified by their syphilitic source, and are hence called syphilides. Thus we may have eczema or any other vesicular eruption; or any one of the papu- lar affections; or those of the pustular class, these pustula^feyphi- lides being extremely characteristic, as they contain an amount of pus greater than usual, and are more disposed to dry and form crusts which are very prominent, being formed of scabs of several layers. When these crusts separate from the skin, a deeper ulcera- tion is also left than is commonly found after the separation of a crust in the ordinary pustular affections. Sometimes a tubercular disease of the skin is seen, by which term (tubercular) is here to be understood an affection presenting large pimples, from the size of the end of the little finger to the size of the end of the thumb, these being caused by a deposition of lymph beneath the skin. These pass, among the unprofessional, under the name of bumps, and are not unfrequently found upon the face. The pustular affections are also very apt to attack the face, 704 PRACTICE OF SURGERY. where they assume the shape of the circle, thus resembling some of the forms of porrigo, and when found around the forehead re- ceive the appellation of the corona veneris. These various skin affections need not be here described in de- tail ; suffice it to say that they are more marked in character than the ordinary skin affections, and are darker in color. In addition to affections of the skin we may also have affections of the append- ages of the skin, as the hairs and nails, the follicles of the hairs be- coming impaired in their vitality and the hairs dropping out, so that the individual becomes bald. His eyebrows also not unfrequently fall off and he presents the condition known as alopecia. Occasionally the growth of warts will also be noticed as a result of venereal contamination, these warts being precisely similar to those which follow gonorrhoea, and requiring the same treatment. Condylomatous tumors (Fig. 238) are also found upon various por- tions of the skin, presenting true elevations of the skin or mucous A full view of numerous Condylomatous Tumors as seated around the Anus and Genitals of the Male, though found also in the Female. (After Acton.) membrane. A very common seat of these condylomatous tumors is around the anus, where they show themselves frequently quite numerously, and in sizes varying from the tip of the finger to that of the thumb, or even larger. Treatment of Secondary Syphilis.—■When a patient presents him- AFFECTIONS OF THE SKIN. 705 self laboring under the catarrhal affection, which, so far as the throat is concerned, is the first evidence of constitutional infection from the syphilitic poison, he might be supposed to be suffering under a simple pharyngeal irritation as the result of cold, or of the excessive use of tobacco. But the history of the complaint will gene- rally undeceive the surgeon. Besides the history of the disorder, the diagnosis will also be influenced by the fact that these simple inflam- matory affections produce a diffused redness, which, although it may be dark, has not the peculiar mottled appearance of the syphilitic complaint. In this stage, however, the local treatment of both forms is precisely similar, and the surgeon may therefore direct the use of some astringent gargle; such, for example, as sage tea and honey, with the addition of a little borax or alum; or a much better application may be found in a strong solution of nitrate of silver, fifteen or twenty grains to the ounce of water, well put on with a camel's hair pencil. If the disease has progressed still further and resulted in ulceration, so that the back of the pharynx or uvula, or the sides of the tonsils are affected, they should be frequently touched with the solid stick of the nitrate of silver, or with what is better, a camel's-hair pencil dipped in a strong solution, 3j of nitrate of silver to f3j of water. Between the cauterizations the patient may also use a gargle of vinegar and water, of alum water, or some similar article, and should be put under appropriate con- stitutional treatment, the details of which will be referred to pre- sently. The ulcers upon the tonsil or uvula should not, however, be confounded with the little adherent patches of lymph or mucus which are sometimes seen as the result of an ordinary pharyngitis, and which can be wiped off by means of a dry camel's hair pencil, a manipulation which should always be practised upon an ulcer in this situation before cauterizing it. If the disease has progressed still further, and ozama is presented, it is to be treated so far as local applications are concerned, as ozaena produced by any other cause. Some detergent and astringent wash may, therefore, be used as an injection, and when the odor of the discharge is very offensive, it may be corrected by means of some of the mild chlorides, 3ss of chloride of lime, or the same quantity of Labarraque's solution of the chloride of soda, being put into four ounces of water, and gradually increased in strength as it is used until, when injected into the nostril, it creates smarting. 45 706 PRACTICE OF SURGERY. The local treatment of the affections of the skin is to be con- ducted upon the same general principles as are applicable to them when they proceed from other causes. In cases of vesicular erup- tion if there is evidence of inflammatory action in the part, it must be overcome by warm mucilaginous baths, some alterative being given and an astringent ointment applied, such as the following:— R.—Hyd. chl. mit. £ij ; Plumb, acet. grs. xv ; Axungiae ^j.—M. S.—Anoint the part. A similar plan is to be followed in the papular eruptions, but here, instead of the warm baths, vapor baths can often be advan- tageously used; and, if no more convenient mode of obtaining it is at hand, a vapor bath may always be prepared extemporaneously by wrapping the patient in a blanket, within which hot bricks covered with wet towels are placed. This may be repeated four or five times weekly. If the patient has one of the pustular diseases alluded to above, or any of the scaly affections, such as psoriasis or lepra, or even ichthyosis, they should be treated upon general principles. The scales or scabs may always be removed by means of some alkaline ointment, and a very good one is as follows:— R.—Sodae carb. sjss ; Axungiae ^j. M. et ft. unguentum. The ulcer left after the scab or scale is removed may then be treated with weak red precipitate ointment, or with the alterative ointment of calomel, as given above. As regards the constitutional treatment of secondary syphilis, it should ever be borne in mind that it is to be conducted upon ge- neral principles. Let us at once get rid of the pernicious idea that in syphilis it is necessary, in order to remove one poison from the blood, to introduce into it another. General principles are here all that is essential, and when alteratives seem necessary, let them be prescribed precisely as though the disease arose from any other cause, such means being employed to diminish the plasticity of the lymph as would be resorted to in other complaints. When a gentle alterative is indicated to modify the condition of the blood, as well as the capillary action, as, for example, when the skin diseases begin to appear, or when the throat is first affected, the most judicious article that can be employed is the AFFECTIONS OF THE SKIN. 707 iodide of potassium, in doses of from three to eight grains, three times a day, and given in solution in water, in syrup, or in the compound syrup of sarsaparilla, according to the fancy of the pa- tient or the practitioner. I say according to their fancy, for it is a mere matter of taste, the compound syrup of sarsaparilla as found in the shops being generally inert, and often containing no sarsa- parilla at all. But it should be remembered that the iodide of potash itself will, if carried to some excess, produce an eruption or sore throat, and an enlargement of the salivary glands, which looks not unlike that which is the result of salivation. For this reason, large doses, and a too persevering use of the drug, should be avoided. But although the use of the iodide of potash, particularly when combined with diaphoretics, such as Zitman's decoction, or the de- coction of guaiacum, will in many cases suffice, yet there is a class of affections in which it is not sufficiently potent to remove the disorder, and especially where an effusion of lymph threatens to destroy important organs (as in the case of syphilitic iritis), unless some measures be speedily taken to diminish its plasticity. Under these circumstances we should not hesitate to employ mercurials. Some of the special circumstances under which we should be justi- fied in administering mercury are cases of Hunterian chancres with indurated bases, which remain indurated notwithstanding the appli- cation of the strong caustics which have been directed; or cases of dry scaly eruptions in the skin, with chronic ulcerations of the throat, not disposed to phagedena; acute iritis, nodes, &c. The question whether mercury could judiciously be directed in syphilis is one which, in former times, excited much discussion, and which is still debated at the present day. But at present it is the opinion of many surgeons, and it is certainly my own, that in the cases just detailed, alterative doses of mercury may be given with advantage, these being, however, always suspended so soon as the patient experiences a slight disposition to tenderness about the gums. The idea of the necessity of salivation in syphilis has long since been exploded, though formerly such a course was considered essential to its cure, and many can doubtless recall the horrors of some of the public institutions of Philadelphia, when mercury was given for the purpose of salivation in the syphilitic wards. Then it was not uncommon to see patients leaning out of their beds, with 708 PRACTICE OF SURGERY. their heads over basins, their tongues lolling out, parotids swollen, and the saliva running in a stream, simply because they had syphi- lis; thus literally carrying out the idea of old Boerhaave, that "unless the patient could be made to spit four pounds a day, he could not be cured." When, then, it is desired to obtain simply the alterative effects of mercury in the cases detailed, it should be very cautiously given, and stopped the moment there is a moderate amount of redness or irritation about the gums. The best preparation for obtaining these alterative effects without profuse salivation is Donovan's solution, or the Liq. Hydrargyri et Arsenici Iodidi of the Pharmacopoeia (solu- tion of the iodides of mercury and arsenic). This may be given in doses of five drops twice a day at first. If it is found to produce irritation of the digestive organs, as shown in diarrhoea, &c, it may be omitted for a day or two, and recommenced when the system has recovered from its bad effects. At the same time, diaphoretics should be steadily given; or the protiodide of mercury may be administered in doses of ^ to £ gr. twice or three times a day. By these means, we will generally get rid of all the symptoms; whilst, if the patient is salivated, the constitutional effects of mercury will be superadded to those of the syphilitic disease, and the patient suffer for years, particularly if he has a tendency to the tubercular diathesis. The indiscriminate use of mercury in syphilis is there- fore objectionable, but there are cases in which its judicious use is the only means of regulating the progress of the affection. If the mercury has, however, been incautiously given, the best way of checking the excessive salivation thus produced, is by the use of the iodide of potash, which will eliminate the mercury from the system. At the same time, the alterative effect of the iodide will be obtained. SECTION III. TERTIARY SYPHILIS. Symptoms.—The tertiary symptoms of syphilis are those which are shown in the affections of the fibrous tissues and bones, as in rheumatism, in enlargement of the joints, in periostitis, in enlarge- ments of the bones themselves, in nodes, in neuralgic pains in the SPERMATORRHEA. 709 bones, osteoscopes, &c, the effects of the diseases of the bones being necrosis or caries, all of which should be treated upon the general principles laid down in connection with the diseases of the bones. CHAPTEE III. SPERMATORRHOEA. After studying the evils resulting from improper sexual inter- course, we may now pass to the consideration of a complaint which is a great annoyance both to the patient and surgeon, which causes an immense deal of unhappiness, and the treatment of which has been very empirical, as its true pathological condition is apparently unknown, owing to the fact that it seldom or never causes death. Much obscurity has also been thrown around this subject by the misapprehension of honest observers and the mental distress of patients created by the duplicity of quacks. Spermatorrhoea is a term the derivation of which—antpiia, sperm, and ps«, I flow—points out one of the most marked symptoms of the complaint, to wit, a flow of semen, which shows itself at fre- quent and short intervals, and is the result evidently of a morbid irritability of the organs. To understand readily some of the con- ditions which may create emissions, it should be remembered that the rectum passes directly in contact with the vesiculae seminales and the prostate; the latter, when enlarged, not unfrequently en- croaching upon its cavity, so that hardened faeces passing along the rectum, and pressing upon the prostate and vesiculae, may lead, particularly when those organs are enlarged, irritable, and full of semen, to a seminal discharge, which, accordingly, in persons of costive habit, &c, is not unfrequently found to take place during efforts at stool. The complaint is a very ancient one, and not, as has been asserted in some works upon the subject, a disease of modern origin. It is distinctly alluded to in Leviticus in contradistinction to gonorrhoea, and is also described by Hippocrates. In more modern times, we find mention of it made by Wiseman in 1782, and by Frank, and others. 710 PRACTICE OF SURGERY. It has, however, been recently very minutely studied by Lalle- mand, of Montpellier, in France, and his name, with that of Curling, of England, is at present closely associated with the subject. Lallemand describes the complaint as existing in two forms; one in which the emissions take place during the night, which he desig- nates as nocturnal emissions, or nocturnal spermatorrhoea, and one in which they take place during the day, which he designates as diurnal spermatorrhoea. Now either of these conditions may exist to a certain extent without constituting a diseased action or creating any results which are injurious to the patient, and if this fact could only be im- pressed upon the minds of the latter, a great deal of mental distress and one of the most marked evils of the disorder would be avoided, as it is very common for patients to labor under the greatest distress on account of their belief that they have spermatorrhoea, who have nothing more than a perfectly natural emission; and it is easy to see how this may happen: A healthy man, in whom the vesiculae seminales are full, and who has no sexual intercourse, will not unfre- quently suffer from more or less turgescence of the organs of generation, accompanied with some dulness of the ordinary train of thought, whilst there will be more or less tendency to thoughts about coition. Under these circumstances nature will frequently relieve him by creating a seminal discharge during the progress of a lascivious dream; or during the day, he may go to stool, and his bowels being constipated, the pressure of the hardened faeces upon the vesiculae and prostate gland will lead to an emission, accompanied by an erection more or less complete. This emission under these circumstances generally contains a large quantity of prostatic fluid and a smaller number of spermatozoa than that which is perfectly natural, and so far from being evidence of dis- ease is really a proof of vigorous health and a full performance of the functions of the testicle and its adjacent organs. That such a diurnal discharge is perfectly natural, may, I think, be inferred from the fact that a similar emission not unfrequently occurs under the same circumstances in the dog, this animal being often seen when straining at stool to have a discharge from the urethra; whilst the same thing takes place under certain circum- stances of excitement in the stallion and in the bull. Such emis- sions, therefore, if occurring but occasionally, say once a week, should be looked upon merely as an effort of nature to get rid of the surplus of a secretion, and not as in any way injurious to the SPERMATORRHEA. 711 patient, but on the contrary a wise provision for the relief of his brain. With regard to nocturnal emissions, when they are not more fre- quent than once in two or three weeks, they also, if the individual is otherwise in good health, should be regarded as a perfectly natural result; but if the discharge occurs two or three times in a night, without erection or with very imperfect erections, then the condition should be looked upon as a morbid one requiring treatment, lest in the sequel it lead to serious consequences, and result in a loss of nervous power, in paralysis of the muscles of the part, in impotence, &c. In these cases the discharge, as first seen, will present under the microscope many of the characteristics of natural or healthy sperm; though soon a diminution will be observed in the number of the spermatozoa, whilst an increase in the watery elements of the dis- charge will be simultaneously noted. Etiology.—The causes which may result in the production of the complaint are very varied, and may act directly upon the brain and spinal cord, or be purely local in their character; thus, it may be produced by excessive coition; by masturbation; by stricture of the urethra; by the presence of worms in the alimentary canal, particularly of ascarides; by congenital phymosis; by irritation in the prostate and vesiculae; or by the congestion of these parts, which may be caused by too long sitting, as in the case of students and others leading sedentary lives; or it may be due to excessive exercise on horseback. Of these the most common cause is certainly masturbation. An irritable condition of the urethra and vesiculae seminales being t"hus once established, emissions may be brought on by reading lascivious books, by loose conversation, and by indulging in lascivi- ous ideas; or they may occur totally independent of any such causes. In investigating the symptoms of spermatorrhoea, some light will be thrown upon their etiology if we remember that the irritation which is at first local from the excitement created in the genital organs, is soon extended to the spinal marrow from whence these organs derive their nerves, as well as to the brain; whence it is communicated to the sympathetic system, and creates all that train of phenomena which may be described as follows:— Symptoms.—At various periods after the establishment of the efficient cause (masturbation) and the occurrence of the emissions, 712 PRACTICE OF SURGERY. the latter become more frequent, and the patient experiences a sense of fatigue, particularly in the morning, when he awakes from a sleep which has been broken by a nocturnal discharge. At night he also becomes restless, and in the day is sleepy and heavy; is melancholy, cowardly, and anxious about his health, often so much so that the suro-eon will be astonished at the accuracy and minuteness of his observations upon his own condition. In addition to this, he not unfrequently has a dogged downcast look, and is unable to look any one in the face, whilst his features become emaciated, and his eyes sunken, and with dark lines beneath them. At the same time symp- toms of nervous disturbance will be observed, the patient complain- ing of irregular pains in the back, stomach and limbs. There is also irritation felt during micturition, and when derangement of the di- gestive organs appears, a train of symptoms is developed which very much resembles those produced in the female by prolapsus uteri, or by irritable uterus; the patient suffering from loss of appetite, whilst he is troubled with flatulence and hears the wind rumbling about in his bowels; has a suffocating sense of stricture in his oesophagus, often amounting to a true globus hystericus, and has a true salivation resembling the condition of the pregnant woman, and described as "spitting fips," that is spitting small pieces of thick, tenacious mu- cus or lymph mixed in the saliva, which assume, when they strike the floor, the appearance of a small coin. To get rid of this matter the patient keeps up-a continual hawking, which resembles that which occurs in secondary syphilis, whilst he suffers from water- brash, and has not unfrequently a true morning sickness resembling that which occurs in the female during the first months of preg. nancy. The pulse is quick, irritable, and peculiar—so much so that, after some experience, the surgeon will frequently guess at the disease simply from the pulse, as it resembles no other pulse except that resulting from the excessive use of tobacco, being a quick, irritable, windy sort of pulse. There is often dyspnoea, which is sometimes quite severe, espe- cially after ascending a flight of stairs; there is pain in the chest, and a tickling in the palate, which is not unfrequently due to elon- gation of the uvula; whilst he expectorates freely, and imagines that he is going into a consumption. All these symptoms, though annoying to the patient, are in no way dangerous to life, and should be looked on simply as due to nervous derangement. That the SPERMATORRHEA. 713 cerebral functions are deranged, is evinced by various symptoms; thus, the patient does not sleep soundly, and is subject to night- mare ; cries out in his sleep, is restless, and has troubled dreams. He also suffers from vertigo, ringing in the ears, deafness, and irregular action of the optic nerves; vision being impaired, and motes floating before the eyes, &c. As evidence of the mental dis- turbance, a change in his disposition will be noticed, particularly if the disease is the result of masturbation, the passions in this latter case being misdirected; as he is no longer satisfied with the female, but turns aside from the most attractive and prefers the practice of masturbation to the pleasures of the sex. He, therefore, usually shuns the society of women, prefers solitude, and is melancholy and reserved. The nervous derangement is also shown by its effects upon the other functions; thus, the urine presents abundantly those phosphatic deposits which are generally found in any case of irrita- tion of the digestive organs, whilst it also contains more or less mucus, and a few spermatozoa. Prognosis.—The prognosis of this complaint must necessarily be guarded, as there is no disease so difficult to cure, or one which presents less certainty as regards the result of the treatment. This uncertainty is necessarily the result of our want of know- ledge of the true pathology of the complaint; post-mortem examina- tions having shown nothing very definite, ulceration or even irritation of the urethra having been rarely observed; while inflam- mation of the vesiculae seminales, and inflammation and abscesses of the prostate gland, with congestion of the spinal marrow, conges- tion of the cerebellum, irritations of the mucous membranes of the throat and stomach, have been noted when there was no sperma- torrhoea. Treatment.—The treatment of spermatorrhoea may be divided into three heads—1. The moral treatment; 2. The local; 3. The con- stitutional treatment. In the moral treatment, the physician must be aided by all the knowledge that he can gain of the character of his patient. If he is depressed in spirits, or if he is anxious about his health, he must be freed from the idea that the discharge from which he suffers is acting as a drain upon the system; an idea which always alarms and depresses him, and one of which he should be promptly disabused, by telling him that the loss of a drachm or two of semen, daily, cannot possibly be attended with such terrible consequences as are attributed to it, though he generally thinks he 71-4 PRACTICE OF SURGERY. is fully posted on this subject from having read the accounts of those who prey on society by magnifying the evils of this disorder, and forwarding their lying pages to all sections of the United States. Having thus consoled him as much as possible, and in a measure relieved the mental derangement, all causes competent to produce a disordered condition of the parts should be removed ; and if he has been practising masturbation, it must be given up. Let him be convinced of the impropriety of the practice; let him endeavor to check every unchaste thought; let him abstain from reading las- civious books, etc. etc., and much will be gained towards the cure of this most annoying mental and physical malady, by means which have been correctly designated as the moral treatment. The local treatment consists in such measures as would be adapted to local congestion, or neuralgic irritations elsewhere. When the condition of the parts is simply a congestion along the canal of the urethra, as will be shown by the pain caused on passing a bougie into the bladder, it may often be very much, if not entirely, removed by the occasional distension which results from frequently carrying a bougie of wax throughout the canal, and especially through its vesical portion. When the instrument is introduced under such cir- cumstances, a considerable degree of tenderness will often be noticed between the bulb and the membranous portion of the urethra, or in the neighborhood of the prostate gland, this tenderness being there greater than it is at any other point. When it is excessive, inflamma- tion in that region may be suspected; and if this suspicion is con- firmed by the fact that the simple passage of the bougie rather in- creases than relieves the irritation, Lallemand's instrument may be resorted to, for the purpose of lightly cauterizing the seat of the supposed inflammation, or ulceration. In these patients, cauteriza- tion of the urethra is really beneficial; and there are also cases of supposed impotence in which the local stimulation of the caustic proves highly useful, by creating an irritation which is transmitted to the spinal cord, and results in erections; but I am satisfied, from considerable experience, that the universal and indiscriminate appli- cation of the nitrate of silver to cases of spermatorrhoea has done much harm. If the discharge is the result of congestion and enlargement of the prostate gland, as is not unfrequently the case, it will contain much mucus, but few spermatozoa, showing that it comes chiefly from this gland. This derangement should, therefore, be treated SPERMATORRHEA. 715 precisely as it would be under any other circumstances. If the ex- citing cause is constipation, it must be overcome by laxatives and by injections of cold water into the rectum, which will not only aid in overcoming the want of action in the bowels, but serve to allay the irritation in the vesiculae seminales and prostate gland. In lunatic asylums, or among young lads, in whom masturbation is not uncommon, and whose mental condition is often such that we cannot control the practice by moral means, benefit will often be derived from a blister applied to the penis, which will make the organ sufficiently sore to compel the patient to let it alone. Advantage will also sometimes be derived from the use of the stimulating diuretics, such as cubebs, copaiva, &c, whilst injections into the urethra of calomel and mucilage are sometimes beneficial. The following formula, for example, may be employed:— R.—Hyd. chl. mit. gss ; Muc. g. acac. f^viij.—M. S.—Inject once a day. But this, like the caustic, is only applicable to those cases in which there is marked irritability of the lining membrane in the course of the urethra, the emissions ensuing on imperfect erections. The constitutional treatment of this complaint is, however, the most important, and is to be found in the use of such means as are calculated to relieve congestion of the spinal marrow and cerebel- lum ; and in tonics and other means calculated to remove the diges- tive derangement, as quassia and iron, whilst cold douches may be applied to the spine, or blisters to the region of the cerebellum, &c. Should the progress of the disease result in impotence, advan- tage will sometimes be found from the use of nux vomica, accord- ing to the plan of Tissot, of Paris, from g^th to ^gth of a grain of strychnia being given twice a day, and pushed till it begins to produce slight muscular twitchings precisely as would be done in an ordinary case of paraplegia, but using, if possible, greater cau- tion. As regards the use of stimulating articles with a view of producing erections in these cases of impotence, they may be set down as of little or no value, and may sometimes prove positively injurious. The muriated tincture of iron is occasionally beneficial, but merely as any other preparation of iron would be by improving the condition of the blood; upon cantharides or upon phosphorus no reliance can be placed. This idea of impotency—for it is usually only an idea—is the most annoying symptom in the complaint; as 716 PRACTICE OF SURGERY. individuals will not unfrequently be found who have had more or less of seminal emissions for years without giving it a thought; until having read some vile advertisement, or unprincipled book, and, perhaps, formed a contract of marriage, they become alarmed and consult a surgeon in regard to their powers. Under such cir- cumstances, no one need hesitate about advising the completion of the contract, as a few weeks will then certainly cure the patient. PART XIII. AFFECTIONS OF THE KIDNEYS AND BLADDER. CHAPTEE I. STONE AND GRAVEL. The next of the affections of the genito-urinary organs to which attention may be directed, is that known as Gravel or Stone, terms used to designate the formation in the kidneys, and the lodging in various parts of the urinary passages, of certain particles of calcu- lous matter which, when arrested in these passages, are liable to accumulate from fresh particles being added to them, and thus pre- sent themselves in the form of gravel, or attain such size and solidity as justly entitle them to the name of stone. SECTION I. OF GRAVEL. 4 Varieties.—The sabulous matters found in the urinary passages have been variously classified; in the first place they are divided according to their size, being, when finely pulverulent, spoken of as sand, sediment, or deposit, the last two terms being, however, objectionable, because there may be a sediment or deposit in the urine, which does not consist of calcareous matters, it being caused by the presence of blood, mucus, pus, or semen. The term sand, as expressive of the general character of the disorder, is therefore preferable. When sand aggregates to a moderate extent it is called gravel, the larger masses resulting from still further aggregation, receiving the name of stone or calculus. 718 PRACTICE OF SURGERY. Etiology.—The disposition to the formation of gravel in the urine is to be found in connection with a state of the kidneys by no means precisely understood. Very often it is hereditary, father and son for many generations laboring under the complaint. As the disease consists essentially in a vitiated action on the part of the kidney, any cause capable of producing or sustaining this disordered action may become the cause of the complaint. Thus, it will be found that among the predisposing causes are certain kinds of food, especially those which abound in the nitrogenized elements, whilst certain drinks are also said to aid the diathesis in favoring the formation of stone; persons who use much hard cider being said to suffer, whilst the disorder is more common in districts where the water is highly impregnated with limestone than else- where. Climate, clothing, or any change of circumstances which, by modifying the action of the exhalants of the skin, throw an increased burden upon the kidney, may also become the cause of stone. These facts are important, because after a stone has been removed from the bladder by operative interference, if the patient be not watched, and the exciting causes removed, or the tendency of the diathesis carefully counteracted, it may be reproduced. It should, therefore, be borne in mind that the kidney is the source from which the mischief comes, pathological observations having often revealed the fact that, under these circumstances, this gland is diseased to a considerable extent, every possible variety of disordered action being seen in it that could be the result of inflammation. Chemical Composition.—The chemical composition of gravel is varied, though it generally consists of the combination of uric, lithic, oxalic, or phosphoric acids with certain bases, such as lime, ammonia, magnesia, soda, silica, iron, &c, or with a peculiar sub- stance, recently described, under the name of Cystine. To that peculiar state of the constitution which predisposes to the formation of these compounds in the urine, the term Lithogenesis or stone producing diathesis, is applied; and in speaking of the specific deposit which the diathesis induces, the name of the acid that predominates in the gravel is usually prefixed to it; thus we have the uric or lithic acid gravel, as well as that of oxalic and phosphatic acid. Uric and Lithic Acids.—The most common of all the varieties of gravel are those composed of the uric or lithic acids, these gene- OF GRAVEL. 719 rally occurring in combination with ammonia, and constituting a urate of ammonia, or one to which the term ammoniaco-uric or lithic sediment has been applied. Sometimes, when the ammonia is extracted by some abnor- mal acid in the urine, a pure deposit of uric acid is thrown down which looks, when examined by the naked eye, very much like grains of Cayenne pepper; whilst, under the microscope, it presents various crystalline forms, which are generally some modification of the rhombic prism (Fig. 239). When the deposit consists almost purely of lithic acid, it is designated as the crys- tallized lithic or uric acid deposits, and generally presents itself in the form of what is known as red gravel. Of the urate of ammonia, or amor- phous lithic acid deposits, there are two forms. The first consists of the urate of ammonia (Fig. 240), combined simply with the coloring matter of the urine, and constituting the yellow sediment which is found in the urine, particularly in connection with gastric or intestinal irritation, the sediment depositing generally after the urine has cooled; whilst in the second form, the urate of ammonia is intermingled or combined with more or less of a substance called purpurine, this sub- stance being derived by chemical change from the coloring matter of the blood. This combination forms the lateritious sediment of fevers, rheu- matism, gout, &c, and the pink sedi- ment of certain organic diseases. Fig. 239. Crystals of Uric Acid. (After Bird.) Fig. 240. **■ ffjj* -& Urate of Ammonia under the Micro- scope. (After Bird.) 720 PRACTICE OF SURGERY. Fig. 241. Treatment—The lithic acid diathesis is to be combated by atten- tion to diet, exercise, the. state of the skin, and the condition of the general health; there being perhaps no class of remedies more ser- viceable than those which will relieve the kidneys by keeping up a proper action in the skin. Phosphatic Gravel.— Perhaps the next in frequency to the gravel of uric acid are those of the various phosphates. These deposits may be the triple, or ammoniaco-magnesian phosphates; or they may consist—though more rarely—of phosphate of lime, or of the combinations of the two (Fig. 241). These deposits have a peculiar white appearance, which is easily recogniza- ble, and when they consist simply of the triple phosphate, present beautiful, minute, brilliant white crystals, which assume various forms. The urine in these cases is pale, and of a low specific gravity, and the depo- sits are frequently found in the urine of healthy persons after severe mental exercise. Treatment.—The treatment consists in abstaining from mental ex- ertion, and in building up the system by means of tonics and gentle stimulants, with the use of nitric or nitro-muriatic acids, internally. Oxalic Acid Gravel.—The oxalic acid constitutes another variety of gravel, and generally presents itself under the form of the oxalate of lime (Fig. 242). The particles of this compound have a great tendency to agglutinate, and a patient laboring under this diathesis generally suffers, sooner or later, from the symptoms of stone. The urine is usually clear, and of a pale yellow or citron color, of moderate specific gravity, inclined perhaps rather to be high than otherwise; and if it be allowed Crystals of the Ammoniaco-magne- sian Phosphates. (After Bird.) Fig. 242. Oxalate of Lime under the Microscope. (After Bird.) to cool, will throw down oxalic acid crystals, which, if examined under the microscope, present various forms, which are generally some modification of the cuboidal prism, though there is a dumb- bell-shaped crystal sometimes met with that is exceedingly charac- CALCULUS, OR STONE. 721 teristic. The causes, or perhaps it would be better to say the con- ditions often accompanying this diathesis, are gout, rheumatism, &e. &c; irregular habits of life, and exposure to depressing agents of any kind, being very liable to terminate in the production of this diathesis. Treatment.—The treatment of the oxalic acid gravel consists in the employment of measures calculated to prevent the formation of the acid, or to destroy it when formed. For this purpose, the in- ternal administration of benzoic acid was once supposed to be a specific, and nitric acid has also been recommended. Alkalies should be carefully avoided. SECTION II. CALCULUS, OR STONE. When any of these sabulous deposits find in the bladder a nu- cleus, such as a drop of blood or of mucus, or a grain of wheat, a bit of straw, or any substance which the morbid imagination of a patient *may have led him to introduce, or which has entered accidentally, they accumulate upon it, and go on to such an extent as to result in the formation of a true stony mass or calculus. The calculi thus formed are to be regarded as foreign bodies, and act as such, producing irritation of a serious character in the mucous membrane of the bladder, the effects of which are felt by the whole system. The vesical irritation and inflammation thus resulting may even be so severe as to cause the death of the patient, post-mortem examinations showing pathological changes in the coats of the bladder caused by this irritation; they being sometimes enormously thickened, whilst the ureter is distended and sacculated, and the whole urinary apparatus presents appearances which almost prevent the recognition of its original structure. Varieties of Calculi.—The various kinds of calculi may be thus briefly described:— That of uric or lithic acid, and its compounds, is the most com- mon, constituting two-thirds of all calculi. They are seen of various colors, often presenting a fawn or yellowish hue, though sometimes they are so dark as to deserve the appellation of a mahogany color. In shape, they are generally of a flattened oval, and if a section is made, they will be observed to consist of concentric laminae, arranged 46 722 PRACTICE OF SURGERY. Fig. 243. around a central nucleus; each layer showing its distinct character by a variation in the color. (Fig. 249.) The surface is either faintly tuberculated (Fig. 243), or more often smooth. In size they vary from the circumference of a hazelnut to that of a hen's-egg. The oxalic acid calculus is next in frequency, and generally presents it- self in a form which, from the cha- racter of its surface, is described as the mulberry calculus. It is tubercu- lated, but irregularly spherical, and is nearly always single. In its formation it has generally a nucleus of some foreign substance, or of some other variety of urinary concretion. (Fig. 244.) The tuberculated surface is often rough and sharp-pointed, and therefore it is that the symptoms of this variety are generally more severe, in proportion to the size of the calculus, than those of any other class. (Fig. 246.) Uric Acid Calculus, showing its finely tuberculated surface. (After Gross.) Fig. 244. Fig. 245. Fig. 246. Fig. 244—Nucleus surrounded by Oxalate of Lime, and this covered by concentric layers of Urate of Ammonia. (After Gross.) Fig. 245.—Triple Phosphate surrounding a Mulberry Calculus. (After Gross.) Fig. 246.—Oxalate of Lime, or Mulberry Calculus. (After Gross.) In size, these calculi are seldom larger than that of a walnut, or of a small egg. In texture, they are extremely hard, and are sus- ceptible of polish. The stone formed by the phosphates (Fig. 245) has a grayish-white CALCULUS, OR STONE. 723 color, and is quite soft; and it may, therefore, generally be very readily crushed. The appearances of some of the other varieties are shown in Figs. 247, 248, 249, the details of which must be sought in Mono- graphs.1 Fig. 247. Fig. 249. Fig. 247.—Calculus of Ammoniaco-Magnesian Phosphate, entire, exhibiting its shining crystalline surface. (After Gross.) Fig. 248.—Cystic Oxide Calculus. (After Gross.) Fig. 249.—Section of an Alternating Calculus, chiefly composed of uric acid. (After Gross.) Symptoms.—As it is apparent that calculi originate in the kid- ney, the earliest symptoms of the tendency to the formation of these bodies will usually be found in connection with this gland; thus there will be pain in the loins, this pain being at times much more severe than at others, and resembling, when at its height, the pain of colic, for which it may.be mistaken, particularly when accom- panied, as it sometimes is, with vomiting, and a peculiar sense of constriction in the epigastric region, as if the patient was bound around the stomach with a cord, the urine being scanty, high- colored, and often mixed with blood. There is also very apt to be a burning sensation in the urethra, due to sympathetic irritation. When gravel or a pebble passes into the ureter, if its size is such as to present any obstacle to its free passage, a new train of painful 1 See a Practical Treatise on the Diseases, Injuries, and Malformations of the Urinary Bladder, the Prostate Gland, and the Urethra. By Samuel D. Gross, M. D. Philad., 1855. 724 PRACTICE OF SURGERY. symptoms are rapidly developed; thus there will be pain in the course of the ureter, violent spasmodic contraction of the cremaster muscle, the testicle being often drawn quite up to the external ab- dominal ring, a fact which is of much value as a means of diag- nosis, whilst if these symptoms continue for from twenty-four to forty-eight hours, there will very often be present more or less febrile reaction, heat of skin and diminished secretion, this condition being usually terminated by sudden relief. The suddenness of the relief experienced by the patient is another diagnostic sign of importance, and is caused by the passage of the stone from the ureter into the bladder. All these symptoms are sometimes so severe as well to deserve the name which is often applied to them of nephritic colic. Treatment of Gravel, or Nephritic Colic.—As the passage of a pebble through the ureter is very painful, it requires prompt and efficient treatment, the indications of which are to allay the pain and favor the passage of the pebble by such means as will induce relaxation of the system, the quickest mode of doing which is by the adminis- tration of anaesthetics, the best being the mixture of ether and chlo- roform, one part of the latter to three of the former, which is now generally resorted to for the purposes of etherization both in the clinical service of the University of Pennsylvania as well as in that of the Philadelphia Hospital, Blockley. In the relaxation induced by partial anaesthesia—for it is not necessary to carry it to the fullest extent—the passage of the calculus will be favored both by gra- vity and by the action of the urine. If, however, anaesthetics are not at hand, or are from any cause contraindicated, the same thing may be accomplished, though not quite so efficiently, by the use of opiates: and if in spite of these measures the calculus lingers in its passage through the ureter, the effect of an active purgative may be tried. One point in the treatment is of great importance, and yet is often overlooked, and that is, until the pebble has passed completely from the kidney into the bladder, and the patient is entirely relieved for the time, the use of diuretics should be carefully abstained from, for it will readily be understood that the great danger in the passage of the pebble through the ureter is that it may cut through it, and thus give rise to urinary infiltration into the abdominal cavity, or that, blocking up the ureter, it may dam up the urine, which, accumulating behind it, may produce distension and rup- ture of the canal, the latter danger being greatly increased by the increased secretion of the kidney while the pebble is in the ureter; CALCULUS, OR STONE. 725 but after the pebble has passed into the bladder, mild diuretics and diluents will often be useful by allaying pain and irritation. Having reached the bladder, the pebble may afterwards, if not too large, be passed by the urethra, and to favor this the mild diu- retics and diluents above spoken of are also serviceable. But most frequently it remains in the bladder without causing any incon- venience until attention is directed to it by the gradual setting in of all the symptoms of stone in the bladder. Stone in the bladder may be found in all ages, in all climates, in patients of all habits and temperaments, and in both sexes, though more frequent in the male than in the female, on account of the larger size and shorter length of the female urethra, which therefore permits an incipient calculus to escape. Stone has also been found in children at birth of such a size as proved that it must have existed for some time in the foetus in the womb, whilst it has been found in old men—as well as in all in- termediate ages. Children, however, are rather in the majority, as of 5376 cases recorded by Civiale, 2416 were in children, 2167 in adults, and 793 in very old persons. Of the children, 1946 were under 10 years of age. This complaint also prevails in all climates, though some seem more favorable than others, owing to a variety of causes, among which the character of the waters of certain streams perhaps plays an important part. Among our own States, according to the work of Dr. Gross, of Louisville,1 the disease is most common in Ken- tucky, Ohio, Tennessee, and Alabama; less frequent in Pennsyl- vania, Delaware, Maryland, Virginia, North and South Carolina, Louisiana, and Arkansas; while Missouri, Iowa, Michigan, New York, &c, are comparatively exempt. In New England, Canada, Texas, Mexico, and California, it is much more rare. As regards the color of the patients, the white man suffers more than the black, and it is said to be a rare thing to see a negro affected with stone. Out of a very large number of cases seen by me in this country and in Europe, including a close observation of Civiale's wards for many months, I do not remember to have noticed more than two cases in the negro. Symptoms.—The symptoms which generally accompany the pre- 1 A Practical Treatise on the Diseases, Injuries, and Malformations of the Uri- nary Bladder, the Prostate Gland, and the Urethra. By Samuel D. Gross, M. D. Philad., 1855. 726 PRACTICE OF SURGERY. sence of stone in the bladder are as follows: There is a difference to be observed in the manner of urinating, the stream being frequently and suddenly arrested by the stone coming over the orifice at the neck of the bladder and closing it. In a few moments after, the stream will again begin to flow freely, as the stone has rolled away. The patient now begins to complain of pain, and this pain—which is due to the irritation about the neck of the bladder, like many other irritations upon the course of nerves which are referred to their peripheral extremities—is noted at the head of the penis. This pain at the head of the penis, due to irritation in the neck of the bladder, is not merely one of the symptoms of stone; but is generally found to accompany any irritation of the neck of the bladder produced by other causes. Thus, it is often found accom- panying the neuralgia of the neck of the bladder, which sometimes occurs in connection with spermatorrhoea; and is also found as one of the symptoms of cystitis. The pain at the head of the penis, is, however, more marked in cases of stone than in the other disorders, owing to the permanency of the cause, and leads the patient, parti- cularly if a child, to handle the penis, and pull upon the prepuce constantly. As a result, the prepuce becomes very much elongated, and phymosis is induced, so much so that it is sometimes difficult to introduce a sound, whilst the fingers of the little patient, from the constant dribbling of urine, have the cuticle macerated, and the finger-tips shrivelled, so as to resemble a washerwoman's fingers. As the rectum is closely in contact with the bladder, it shares in the vesical irritation, and there is tenesmus, this tenesmus being not unfrequently accompanied with prolapsus ani. The urine at first is clear, and may or may not present, when allowed to cool, characteristic deposits. But by and by it becomes muddier or dark-colored from an admixture of mucus or of blood, and may contain little particles of stone, which have been broken off and escaped. All these symptoms are liable to be much aggravated in spells, there being then intense pain and great constitutional disturbance, accompanied sometimes by more or less febrile reaction. Under these circumstances, the patient is said to be laboring under a fit of the stone. The symptoms of stone in tne bladder, though often very marked, are sometimes quite obscure, and the surgeon has occasionally no reason to suspect in the least the presence of a stone, until it is CALCULUS, OR STONE. 727 Fig. 250. accidentally discovered by an instrument passed into the bladder for some other purpose. Very often, although the symptoms are such as fully to justify a belief in the presence of stone, and the " fits of the stone," so called, are frequent and severe, the general health of the patient does not appear to suffer; the bloom still rests on the cheek of the child, and the frame of the adult preserves its strength, whilst in other cases the constitution suffers greatly) and the patient emaciates and sinks rapidly. Diagnosis.—A patient being suspected, from the symptoms which have been described, to be laboring under stone in the bladder, its pre- sence may be positively recognized by means of sounding. Sounding consists in introducing a sound or solid instrument shaped like a ca- theter, but made of steel, into the bladder until it touches the stone, when the presence of the latter can be detected by the sensation caused by the contact of the sound with the stone, as well as by the click or sound emitted, this sound being sometimes made audi- ble over a large room by means of a sounding-board which can be attached at pleasure to the top of the sound. The sound should not be more curved than that represented in Fig. 250, lest, as the stone lies in the basfond of the blad- der, the instrument may ride up over it, and escape it altogether; nor should the surgeon be satisfied that there is no stone present, when the patient is laboring under the ordinary symptoms, until the examination has been made several different times, and with instruments of differ- ent curves. Prognosis.—The prognosis in a case of stone will depend very much upon the circumstances of the case; thus, if the health of the patient is good, the stone moderate in size, and the case one suitable for lithotrity, the prognosis will be favorable; while, if the general health of the patient is exhausted and broken down, the prognosis will be grave. If lithotomy is required, the dangers of the opera- tion must always be taken into consideration in giving a prognosis; whilst in both operations it should be recollected, that after the re- moval of the stone, if the diathesis is not combated and overcome, the stone will be reproduced. A diagram showing the ordinary Position of the Calculus, with the sound entering the bladder. (After Liston.) 728 PRACTICE OF SURGERY. Treatment—The treatment of stone is of two kinds—the first, being palliative, and the second radical. As the irritation of a fit of the stone is very great, a palliative plan of treatment becomes necessary to relieve its violence. Thus an attempt may be made to render the surface of the stone smooth if it is rugged, by the injection of mucilages into the bladder, or the free administration by the mouth of alkalies and diuretics. When the patient is suffering acutely, resort may be had to various other plans of obtaining relief. Of these the simplest is to seat him in a warm hip-bath, which is generally useful by relaxing the spasmodic contractions of the bladder. If this is not sufficient, an anodyne injection, consisting of a teaspoonful of laudanum in a little starch- water, may be given, or resort may be had to a moderate use of anaesthetics. In the radical treatment, besides the operations of lithotripsy, or of lithotomy,1 various methods of effecting the removal of the stone have been proposed; thus it has been suggested to disintegrate it by means of chemical substances injected into the bladder when they are diluted to a proper degree. Instruments have also been in- vented to pass into the bladder, and expand and surround the stone, which is then to be disintegrated by means of stronger chemical agents injected into the cavity of the instrument. But all these modes are purely theoretical, and have never attained any marked results. 1 See Operative Surgery, vol. ii. p. 243 et supra, 2d edit. PART XIY. AFFECTIONS OF THE TESTICLE AND CORD. CHAPTER I. AFFECTIONS OF THE TESTICLE. SECTION I. HYDROCELE. Hydrocele is a collection of serous fluid within the cavity of the tunica vaginalis testis, the term being derived from two Greek words, £6"wp, water, and xij\ij, a tumor, signifying, therefore, a watery tumor. Anatomical Relations.—The tunica vaginalis testis, as was men- tioned in connection with the subject of hernia, is that portion of the peritoneum which was originally pushed before the testicle in its descent from the abdomen into the scrotum. In its new position this portion forms, therefore, a double envelop for the testicle, and its connection with the abdomen having been obliterated, it con- stitutes a closed sac, as is the case with the other serous membranes. Like these, the tunica vaginalis testis also secretes a certain amount of halitus in the natural condition of the parts, which serves to lubricate and facilitate the motion of the testicle; as without this the delicate structure of the testicle would be exposed to contusion whenever the patient crossed his thighs. Etiology.—Various disorders may cause this natural secretion of the tunica vaginalis testis to become inordinate in quantity. Thus, inflammatory action may produce it, as is the case in those hydro- celes which ensue upon epididymitis, orchitis, or blows. Sometimes it occurs suddenly after great muscular exertion; and in one case a 730 PRACTICE OF SURGERY. very considerable hydrocele resulted in the course of half an hour after the individual had lifted a barrel of flour from the ground into a wagon;1 other cases are also on record, and should be borne in mind, lest a tumor from hydrocele, of sudden occurrence, be con- founded with hernia. Generally, however, the causes of hydrocele may be stated to be those which are likely to develop chronic in- flammatory action in a serous membrane. When such causes exist, and fluid accumulates in the tunica vaginalis testis, a tumor is formed, which, beginning at the bottom of the scrotum, gradually rises upwards, until it may extend all along the cord, as high as the external abdominal ring. It sometimes happens that a part of that portion of peritoneum which was pushed down before the testicle, remains around the cord, and having contracted adhesions both above and below, forms a closed sac, communicating neither with the abdomen nor with the tunica vaginalis testis. When in such a state of affairs an effusion occurs, a condition is presented which is described by writers as hydrocele of the cord, a tumor being formed along the course of the cord, which fluctuates, is translucent, and presents the other symptoms hereafter detailed. Symptoms.—When the effusion is limited to the proper tunica vaginalis testis, the tumor begins below, and gradually ascends, becoming larger and larger, but it does not enter the external abdo- minal ring, and unless it is complicated with hydrocele of the cord, produces no thickening of the cord itself. To the touch, hydro- cele presents generally a sense of fluctuation, such as would be expected from any collection of fluid. But if the parts are ex- cessively distended, or if, as sometimes happens, the tunica vaginalis has become dense, and more or less ossified, the sense of fluctuation may be partially or entirely absent; a fact which should be borne in mind, in order to prevent the confounding of such a case of hydrocele with other hard tumors of the scrotum. As a general rule, then, the symptoms of a hydrocele may be stated to be: 1. The formation of a tumor at the bottom of the scrotum. 2. The sense of fluctuation; and 3, the translucency of the tumor. The last is the most positive sign, and may be employed to facilitate the diag- nosis by the following arrangements: Let the room be darkened, and seat the patient upon a table, chair, or edge of the bed; then grasping the tumor in the hand, so as to force the fluid well down into the scrotum, hold a candle or a lamp upon the opposite side 1 See Am. Journ. of Med. Sci., vol. xiii., N. S., p. 85, 1847. HYDROCELE. 731 from the eye of the surgeon; when, if the tumor is a hydrocele, it will appear sufficiently translucent to enable the surgeon to recog- nize the position of the testicle, as a dark mass, this being gene- rally of the normal size, and in the posterior part of the scrotum. Still, however, this test is not an infallible one; as it may happen that the tunica vaginalis testis is thickened by disease, or the fluid distending it may be rendered opaque, either by the presence of blood in consequence of the rupture of some small bloodvessel, or from some other cause. In this case, the tumor will not be trans- lucent. As a general rule, however, the fluid in hydrocele is of a pale straw color, and the test of transmitted light is an exceedingly satisfactory one. Diagnosis.—It has been already mentioned that hydrocele may be confounded with scrotal hernia. The latter, however, begins at the external abdominal and descends, and creates, moreover, a tumor, to which a certain amount of succussion is communicated when the patient coughs, which is not the case with hydrocele, except in congenital hydrocele, in which, as was stated in connec- tion with the subject of hernia, the communication between the peritoneum and the tunica vaginalis testis is not closed, and in which, therefore, the same succussion is perceptible. If the hernia is reducible, its reduction by the taxis will dispel any doubts which may exist as to the nature of the case. Haematocele, or a collection of blood within the scrotum, will, at times, present a train of symptoms which might be confounded with hydrocele. Generally, however, a diagnosis can be made by means of transmitted light. The fluctuation of haematocele, more- over, is usually much less distinct than that of hydrocele; but obscure cases will sometimes present themselves in which it be- comes necessary to resort to an acupuncture needle, or to a small trocar and canula, by means of which a diagnosis may certainly be made; as, if the tumor is a haematocele, nothing but blood will escape from the puncture. Should it, however, be a hydrocele, the escape of the characteristic straw-colored fluid will at once reveal the nature of the case. Should it happen, as it sometimes does, that a hernia is present, and is punctured with the little trocar or needle, the trifling wound thus made will generally heal without doing any serious mischief, but such an event should be avoided. When the hydrocele is complicated with hernia, the difficulty in the diagnosis is increased. . If the hernia is reducible, this 732 PRACTICE OF SURGERY. fact will at once insure a diagnosis, whilst, after the reduction of the hernia, the patient should be treated for hydrocele, as if no such complication had existed. If, however, the hernia be irre- ducible, the difficulties of the diagnosis will be materially increased; though transmitted light in such cases will usually show the hernia as a dark mass in the upper part of the tumor, while the hydrocele will appear translucent below. The tumor formed by a hydrocele, if of any extent, is usually smooth, the distension having com- pletely obliterated all the wrinkles of the scrotum, though this con- dition is also produced by other tumors, as well as by hydrocele. A hydrocele is often of such size as to bury the penis completely, the position of the organ being only marked by an irregular de- pression, similar to that made by the umbilicus. Prognosis.—The prognosis of hydrocele will depend upon cir- cumstances. As it is generally possible to evacuate the fluid which distends the tunica vaginalis, the prognosis, in most cases, will be favorable as regards the result of the operation. But, unless some means be resorted to for producing inflammatory action, and thus gluing together the walls of the cavity in which the accumulation of fluid has taken place, after the manner directed in some one of the operations for a radical cure,1 a fresh accumulation will occur, and all the inconvenience of the disease be reproduced. The prog- nosis of the operations for the radical cure is generally favorable; the dangers being either of the inflammation going too far and producing sloughing, or that it shall not go far enough, when a' reproduction of the disease will follow. If the disease be not treated at all, yet is its prognosis favorable so far as the mere question of mortality is concerned; though it produces inconve- nience from its size, and often interferes materially with the proper performance of the generative functions; otherwise it is compara- tively harmless. The treatment may be either palliative or radical. The palliative treatment consists in the puncture of the tumor with a bistoury, a trocar and canula, or some similar instrument, and the evacuation of its contents. Such a puncture should be boldly made so as to penetrate the tunica vaginalis testis. After the operation the patient will at once be enabled, with the aid of a suspensory bandage, to resume his ordinary avocations; and, in some few cases, may go a year or even eighteen months before 1 See Operative Surgery, vol. ii. p. 234, 2d edition. HEMATOCELE. 733 another operation will be required ; but, in Xhe great majority of instances, the disease will be reproduced in from ten days to three months. The operation for the radical cure, therefore, is much the more satisfactory mode of procedure, and should be resorted to whenever the circumstances of the case will permit it.1 SECTION II. HEMATOCELE. Hozmatocele (atfia, blood, and xrfkr}, a tumor) is, as its name imports, a collection of blood within the cavity of the tunica vaginalis, this being generally the result of some sudden injury. As its diagnosis has been pointed out in connection with hydrocele, it is unneces- sary to recapitulate it. Treatment.—In the treatment of haematocele, the same general principles are to be observed as would be applicable to the man- agement of an effusion of blood elsewhere. Thus, the action of the absorbents should be stimulated, and efforts made to produce con- traction of the tissues; leeches should also be applied to the cord, but not to the testicle itself, where the bite of the leech, by de- veloping a certain amount of inflammation, would only add to the mischief, a remark which is true in most other conditions of the testicle for which leeches are required. After local depletion, much may be done by stimulating and irritating frictions, such as those of iodine ointment, or of iodine ointment and the oil of tobacco mingled as in the following formula:— £.—Ung. iodinii |j ; 01. tabac. gtt. xx.—M. S.'—Apply to the tumor once or twice a day. The quantity of the oil of tobacco may be increased to thirty or forty drops if required, where there is not much susceptibility, as in the case of the scrotum of a laboring man. Care must, however, be taken not to carry this application far enough to vesicate, as the local inflammation thus developed would do mischief instead of good. > For the account of the operation see Operative Surgery, vol. ii. p. 342, 2d edit. 731 PRACTICE OF SURGERY. SECTION III. VARICOCELE. Varicocele (vapiz, a distended vein, and x^y, a tumor), or, as it is sometimes called, circocele (xtpjoj, a varix, and x^, a tumor) are terms which are often indiscriminately employed to designate a varicose enlargement and distension of the spermatic veins; but the term varicocele is that which is most expressive of the character of the disorder. Etiology.—The causes of varicocele are varied, being any that will induce congestion of the veins by interrupting the circulation through them. Among these may be mentioned ligatures around the abdomen, it being not uncommon in young men who wear very tight waistbands to their pantaloons, and avoid suspenders; or it may be due to the congestion of the testicles occasionally induced by extreme continence, or it may follow the improper application of a truss, or result from constipation. As it more frequently affects the veins of the left than those of the right testicle, various reasons have been assigned for this peculiarity, but the most cor- rect is that advanced1 by Dr. Brinton, of Philadelphia, who found it to be due to the fact "that a very perfect valve exists at the en- trance of the right spermatic vein into the cava, whilst there is no valve at the termination of the left spermatic in the emulgent vein." Symptoms.—Varicocele is generally attended by a sense of fulness in the scrotum; with a dull heavy pain in the back, and in the line of the cord when the patient is erect, but which is relieved by hold- ing up the scrotum, or when he lies down, whilst the patient is often depressed in spirits, and fearful of losing his virile powers; the scrotum also becomes much relaxed, and the nutrition of the testicle may become so imperfect as to cause its atrophy. On feeling the scrotum or cord between the thumb and forefinger, a collection of enlarged vessels will be noticed which give a sensation that has been compared to that caused by a number of earth-worms in a bladder. Diagnosis.—Varicocele is not unfrequently confounded with hernia and especially omental hernia, as it may, when large, be acted on 1 Am. Journ. Med. Sciences, xxxii., N. S., p. Ill, July, 1856. SPERMATOCELE. 735 by the patient's coughing, owing to the action of the diaphragm upon the abdominal contents. But a diagnosis may be made simply by placing the patient in the horizontal position, when both a re- ducible omental hernia and a varicocele will disappear; then press- ing firmly on the external abdominal ring, direct the patient to stand up, when the hernia will be prevented from escaping, though the veins will gradually fill and become distended notwithstanding the pressure. Prognosis.—The prognosis of varicocele is favorable. When due to engorgement of the testicle, sexual intercourse removes all diffi- culty, whilst various operative measures will accomplish a cure and enable the testicle, if wasted, to recover its former condition. Treatment.—The treatment consists in removing all pressure from the abdominal veins, as by avoiding tight pantaloons and keeping the bowels free; in supporting the scrotum by the use of a sus- pensory bandage; by bathing the parts night and morning in lead water, and by never applying an inguinal truss to the external ring, there being comparatively few cases of varicocele which will not be relieved by these means, though they are often designated simply as "the palliative cure." A more thorough change in the condition of the veins may, however, be effected by operative inter- ference, as by ligating the veins, excising a piece of the scrotum, or compressing the veins by an instrument.1 SECTION IV. SPERMATOCELE. Spermatocele (s*w*> sperm, and x^rj, a tumor) was the term by which the older surgeons designated the enlarged condition of the scrotal contents that has just been alluded to as varicocele. There is however occasionally met with a true spermatocele, in which the tumor is formed by the globus major and minor of the epididymis, enlarging to a moderate extent from accumulated secretion. Symptoms.—Spermatocele creates a violent pain in the testes of a neuralgic character, but unaccompanied by any evidences of in- flammatory action, the patient, though unable to touch the part, 1 See Operative Surgery, vol. ii. p. 228, 2d edition. 736 PRACTICE OF SURGERY. not suffering from heat or redness of the scrotum, or effusions around the tunica vaginalis testis. At the same time he is more or less troubled with erections, but is not the subject of spermatic discharges. Etiology.—This condition, which I have more than once met with, is apparently due to an engorgement of the rete testis and epidi- dymis, and is apparently caused by an obstruction of the spermatic secretion in those who have formerly been accustomed to constant sexual intercourse, though it may also be noted in vigorous men who have practised perfect continence, and in whom the moment- ary cause has been a slight contusion of the testicle, either whilst riding on horseback, or from other blows. Diagnosis.—The simple enlargement of the globus major unac- companied by the inflammatory symptoms, &c, of gonorrhoeal epididymitis, usually suffices for the establishment of a correct diag- nosis. Prognosis.—The prognosis is favorable, relief being promptly afforded by appropriate treatment. Treatment.—As the suffering is acute, and the disorder might result in acute orchitis, or inflammation of the testicle proper, the treatment should be prompt, and may be best carried out by seat- ing the patient at once in hot water, by applying leeches to the cord, by supporting the testicle by a suspensory bandage, and by administering an active purge of ten grains of calomel and ten of jalap with a half grain of tartarized antimony, which in twelve hours will usually relieve the pain, though the enlargement of the globus major may continue for some days, or until relieved by seminal emissions. SECTION V. TUBERCLES OF THE TESTIS. Under the title of scrofulous disease of the testicle, surgeons formerly described an affection which more thorough investigation showed to be due to the deposit and softening of tubercles in the affected structure. Having, when in Paris, in the year 1839, had my attention specially directed to this disorder, I published in the TUBERCLES OF THE TESTIS. 737 Medical Examiner1 a paper on the subject, which is now offered as affording a fair summary of the professional views on this com- plaint, most of the article being reprinted as originally published. Pathology.—" In the testicle, as in other organs of the economy, tubercles present themselves under two forms, either as isolated masses, forming the disseminated tubercles, or as infiltrated, and generally spread throughout the testis, epididymis, vasa deferentia or prostate gland. In the disseminated form, we sometimes find only a single tubercle, which presents the characters common to these bodies, but it is more usual to see four or five existing at the same time, under the form of little tumors, more or less regularly rounded, hard, almost insensible to pressure, movable under the scrotum, and firmly imbedded in the portion where they have been discovered, and of a size varying from a buckshot to a cherry-stone, or even a chestnut. When small, they lodge in the cellular sub- stance between the tubuli seminiferae without appearing to affect these tubes; but when of greater size, they invade the filaments of the testicle and destroy more or less of its substance. The infil- trated tubercles generally occupy the body of the testis, taking the place of its true substance, or when deposited in the epididymis, completely change the appearance of the part, presenting to the touch masses of different sizes, with a hardness altogether different from the usual elastic feel of the tube. In some instances, the epididymis is enlarged to triple its ordinary size, and seems to be completely injected with the tuberculous matter in a semiliquid state. This disease rarely confines itself to one testicle, though it is unusual to see both in the same state of development; but whether this arises from their proximity or from both being exposed to the same exciting cause, it is difficult to say. In a case reported by Be- rard, the left testicle, which was in the scrotum, had been attacked with the disease for two years, whilst the right, which had remained in the inguinal canal, had only commenced to suffer six weeks pre- vious to his seeing it. When the epididymis is the portion affected, the tubercles commence most frequently in the globus major, and, in a majority of the cases, will be found to be formed by the isolated tubercles, and to be of easy diagnosis. Patients.—Tubercles of the testis rarely attack children, at least till the years near to the period of puberty, as these organs are ' Medical Examiner, 1st series, vol. iii. No. 17, p. 261. Philad., 1840. 47 738 PRACTICE OF SURGERY. generally too little developed previous to this time, to admit of their deposition. In adults, they are found generally between the ages of sixteen and forty, attack, in preference, those of a lymph- atic temperament, or in whom we might suspect tubercles elsewhere, and frequently follow the suppression of a gonorrhoea. Etiology.—-Many of the cases reported by Cruveilhier had had syphilis without gonorrhoea; others had received a contusion; others had suffered from repeated attacks of gonorrhoea, the last of which, however, had generally preceded by some months the appearance of the disease, and in others, the causes were unknown. In the few cases I have seen, the disease could generally be referred to the constitution of the patient, as a predisposing cause, though, in every instance, the exciting one was an external injury received in riding, climbing, &c, or from the rudeness and want of care in the treatment of a gonorrhoea. In one case, the commencement could be traced to a blow given by the fist of the patient whilst in a paroxysm of anger at the duration of a chordee, which he thought to conquer in this manner. Symptoms.—The changes occurring in the development of the tubercles are seldom perceived by the patient at an early period, as the tumefaction of the scrotum commences without pain or change in the color of the skin, increases slowly, and can exist for months without other inconvenience than that resulting from the extra size of the part, and it is not until the tubercles are numerous, or reach an advanced state, that the signs of their existence become sensible to him. At this time the scrotum presents, frequently, a thickness and size double that which it has in the healthy state, and the tu- bercles present to the touch a well rounded form, with some little irregularities, also more or less rounded, and of the firm texture so well recognized when felt in the lungs. But after a certain time, which varies considerably, but is always tedious, the tubercles com- mence to soften and to pursue the changes so well known from the works of Bayle and Laennec; the scrotum, immediately over the tubercle, becoming of a more or less livid red color, or sometimes even bluish, and thinner and thinner till it terminates in ulceration, when the tubercle escapes in a yellowish pus like liquid—generally fur- nished at the expense of the cellular substance—in which it is easy to recognize the caseous particles formed by the tubercle. If, in- stead of permitting the ulceration of the skin, and the escape of the tubercle by suppuration, it is cut into soon after its formation, TUBERCLES OF THE TESTIS. 739 the matter will be found in a concrete form, and will escape, of itself, through the artificial opening, by the simple contraction of the surrounding parts. The course of these bodies to suppuration is not the same in all cases, as regards the duration; and in the same case, one nearly always progresses more rapidly than another, so that it is not uncommon to see in the same testicle, one abscess opened and discharged, and find newly developed tubercles still in a hard state within a few lines of it. When seated in the epididy- mis, their course to a discharge externally is always more rapid than when situated in the body of the testicle, the fibrous coat of the latter always opposing, strongly, a suppuration towards the surface. After the discharge of the matter, the scrotum presents an appearance highly characteristic of the disease. At this time we find one or more cavities or depressions, externally of an un- equal surface, communicating with the cavities internally by a course more or less direct, but most frequently tortuous and fistu- lous. The internal cavities are points caused by the inflammation consequent on the suppuration of the tubercle, and are divided sometimes into little cells, by irregular partitions, the sides of which are filled with a softened tuberculous matter, which preserves the discharge for a long period. As these close—a termination much to be desired, but very difficult to obtain—there is left an irregularly depressed cicatrix, of the size of a small shot or pea, which always shows more or less loss of substance, and marks, forever, the fis- tulous opening caused by a softened tubercle. But most frequently these openings constitute the most annoyiDg symptom in the case, as, after the tubercle is discharged, we do not find it easy to cause adhesion, owing to the movable nature of the parts, the constant discharge and the hardness of the parietes of the fistulas. In some cases the difficulty is increased by the discharge of the seminal fluid, especially during dreams or the venereal orgasm. After the opening has remained a few days, nature attempts the cure by the formation of granulations about the fistulae. Should the case be presented to us at this moment, it would not be difficult, at first sight, to mistake it for an ulcerated cancer of the testicle, from the tint of the skin, the increased size and hardness of the parts, and the fungous granulations; but a little reflection will solve the diffi- culty, and render clear the diagnosis. Diagnosis.—Tubercles are never the seat of lancinating pains; their compression does not cause pain, at least till the surrounding 740 PRACTICE OF SURGERY. tissue is inflamed; their hardness is less than that of scirrhus, and greater than that of the encephaloid tissue; they are almost always numerous, and developed in the epididymis in preference to the testicle. Cancer, on the contrary, prefers the body of the testis. Tubercles also go through peculiar well marked changes from depo- sition to softening, their surface being smoothly rounded and circum- scribed to the touch. Scirrhus on the contrary is generally irregu- lar, is found in lobulated masses of an irregular shape, and seldom in its commencement prevents our feeling the healthy portions of the testis at a point distinct from its seat. Tubercles most fre- quently are developed indiscriminately, and if we feel the testis, it is in the intervals between each tumor, and when they reach the period of softening, their course is indolent, the discharge is pecu- liar, the lymphatic ganglions undergo no change, and the general health is not seriously affected. When, on the other hand, cancer ulcerates, its course is rapid, there is great sensibility even in the granulations, and the discharge is often colored with blood. In tubercles the matter is like pus, contains portions of the tubercle in a majority of the cases, and never is colored with blood, unless produced by accidental causes. Prognosis.—Should the substance of the testicle have not been affected, we can generally distinguish its usual size and figure, and its functions will not be sensibly changed. But should the tuber- cles originate in its body, the affection is much more serious, as the seminiferous ducts can escape from the openings, as in the cases reported by Swediaur,1 a consequent weakness or atrophy being produced. Dupuytren has remarked that in some cases where the disease existed a long time, " the testicle became softened, and fungous, and similar to the tissue found around the articulations attacked with white swelling."2 Such is the usual course of the isolated tubercles to a cure by suppuration, and the question naturally presents itself, as to whether there are cases which can happily terminate by resolution ? Many surgeons deny entirely the possibility of such a termination, but Mons. Berard affirms that it can. Delpech also states, that he has seen cases " in which tubercles already softened have caused ulcera- tions, whilst new tumors, presenting the same characters and appear- ance as the former at a like period, have disappeared completely, 1 Dictionnaire des Sciences Medicales. Lecons Orales. TUBERCLES OF THE TESTIS. 741 either under a proper treatment or by the increased action in the parts consequent on sexual intercourse or the changes of puberty." He further says, "that there are even facts to prove that this true resolution of subcutaneous tubercles, can be favored or decided by the continued action of cantharides over the part corresponding to the organic lesion."1 In the infiltrated tubercles, the case is more serious and more difficult of diagnosis, as the matter is very generally deposited throughout the whole body of the testis and epididymis. It differs, however, from the isolated, in the changes which it produces, being more general and less sensible to the touch, as in the body of the testis the matter is developed in its very substance, radiating the whole length of the fibrous prolongations of the corpus Highmo- rianum, and penetrating to the centre. In this state the whole body of the testis enlarges gradually, has a variable hardness, according as the matter is near or far from the surface, and an insensibility to pressure entirely different from the natural state, little or no pain being produced by firm compression when the matter is in a crude state, and has filled a large portion of the testicle. When it is in the epididymis, we find the whole or large portions of it engorged and knotted, affording to the touch the sensation of their being filled with caseous matter in which some portions remain harder than others. In a case of infiltration of tuberculous matter in the epi- didymis, seen by Mons. Cruveilhier, the tunica albuginea was thickened so as to separate it from the body of the testis, the former of which was one tuberculous mass, so much enlarged, that it was almost impossible to find any sign of the primitive tissue, and the matter had softened in spots, the largest of which was in the globus major. In the isolated tubercles, dissection generally reveals a portion of the structure untouched by the disease, but on the whole the diagnosis is difficult between these and the infiltrated, the great difference being that the isolated form numerous globular tumors, distinct and salient at the surface, whilst in infiltration there is a general increase of the part in size and density without there being much alteration in form. Tuberculous infiltration frequently destroys a part or the whole of the functions of the organ, and its cure is always difficult. As 1 Maladies Chirurgicales, tome iii. pages 633 and 635. 742 PRACTICE OF SURGERY. a tuberculous affection, three questions of considerable interest pre- sent themselves:— 1st. Has the patient, affected with tubercles of the testis, neces- sarily the same bodies developed in the lungs? When we consider that tubercles of the testis most frequently affect persons of a lymphatic temperament, and that they are de- veloped at an age when phthisis pulmonalis is most common, we might reasonably fear that this complication would exist, at least in a great number of cases. Mons. Berard, however, cites but few where the disease invaded the lungs and the testicle at the same time; in all the others, the testicle alone appeared to be affected, and the patient offered no sign of a pulmonary affection, even some time after their cure. 2d. Ought the presence of tubercles in these organs to author- ize the operation of castration, in order to prevent their develop- ment in the more important parts ? As we know nothing to prove that tuberculous matter when ab- sorbed has the power of provoking the formation of these tumors in other organs, we might readily answer in the negative. Cruveil- hier, however, regards this question as depending on the seat of the tubercles; and says, that when the tuberculous matter exists in the epididymis, we ought not to have recourse to castration, but that when it is in the body of the testis, the operation may be necessary to relieve the existing symptoms. Yet, as castration is sometimes fatal to happiness, he advises the attempt to cure the affection, even if obtained at the expense of an atrophied testicle, and the consump- tion of a long period in the treatment. Berard also opposes de- cidedly the operation of extirpation, preferring the cutting into and removal of the portion affected, to the entire removal of the gland. It ought, however, to be noted as an observation on the part of Cruveilhier, that where the tuberculous testis has been removed, the success has been nearly constant, and without a reappearance of the disease in other parts; whereas, the reverse is the case in the extir- pation practised for cancer, the success being much less, and the relapses much more frequent. 3d. Can the tuberculous testis pass readily to a cancerous state ? The opinions on this point seem to be very much divided, many believing that it can. Nevertheless, Berard denies it entirely, and says that, in cases where the cancer has appeared to succeed tuber- cles, there has existed a complication of the two diseases. Cruveil- TUBERCLES OF THE TESTIS. 743 hier likewise reports one or two cases of a similar complication, and one case under my own observation in the wards of Mons. Vel- peau, at La Charite, supported the same opinion. Salle St. Augustin. No. 38.—Pimber, cabinet-maker, aged 36 years, entered February 19, 1840, with an enlargement of the right testis. The testicle was of the size of an egg, oblong, irregular in shape, being larger at its upper portion, lobulated, and presenting different degrees of consistence. At the lowest part it is elastic, soft, painful on pressure, and evidently belongs to a sound part of the testicle ; above this, on the inner portion towards the raphe", is a small fluctuating point, external to which is a harder portion, connected apparently with the firm lobulated structure, forming the enlargement at the upper extremity. The epididymis is readily felt at the lower part, in a healthy state, but at the upper is not to be distinguished from the mass of the testis; the cord is natural, the scrotum soft, relaxed, movable over the tumor, and exhibits two cicatrices, from which the patient says matter escaped nearly eight months ago. General health excellent; complexion good; has had both chancres and gonorrhoea, but was never mercurialized; he dates the disease back to 1838, two years since; does not recollect how it commenced, but believes the cause to have been a blow re- ceived in mounting a horse; the scrotum he states was always long, and wearing loose pantaloons, the parts were caught under him as he sprung from the ground to the horse's back. He was in the hospital eighteen months since, but left it, being unwilling to sub- mit to treatment. Since that period, has undergone every remedy, as leeches, scarification, hydriod. potass., iodide of mercury, fumiga- tions, &c, but without any change in the tumor, which has con- tinued to increase, and progressed rapidly within eight or ten weeks. The operation of castration was performed on him, by Velpeau, February 24,1840, by means of an incision in the scrotum, turning out the testicle and cord, the latter of which, with all its vessels, &c, was included in a ligature and divided by the bistoury. On opening the testicle longitudinally, several structures were presented. The upper portion was composed of an encephaloid tissue which occupied nearly the .whole of the shell of the testis; near the middle was one large tuberculous mass, the size and shape of a chestnut, with one or two smaller ones near it. The cyst contained a fluid not recognized as peculiar to any of these portions, and the lower part of the testis was unaltered, with the exception of a small 744 PRACTICE OF SURGERY. tubercle near its centre; the epididymis was sound throughout. The wound was healed by granulation, and the patient is now, March 17, nearly recovered, having had no bad symptoms. The other testicle is perfectly healthy. Treatment—The constitutional means likely to counteract the lymphatic temperament of the individual, constitute the most im- portant part of the treatment during the whole course of the disease, such as the use of mild tonics, especially the ferruginous prepara- tions, and all those remedies which the knowledge of the predis- posing cause of the disease would indicate. The avoidance of all means likely to produce a contusion of the scrotum, or an inflam- mation of the parts, ought also, it is hardly necessary to say, to be strictly enjoined. The local remedies will vary according to the state of development of the tubercles; thus, during their crude state, the employment of means likely to produce their resolution, as irritating friction, which, by increasing the circulation, may change the vitality of the part, as preparations of iodine, of mer- cury, or of cantharides, continued for some time, and afterwards covering the parts with a soap plaster and the constant use of a suspensory truss. Nevertheless, we must watch carefully the action of these substances, lest the inflammation should go too far, and produce a suppuration of the tubercle, a termination always to be avoided. The complaint of pain on the part of the patient ought, therefore, to be the signal for the use of emollients. But in most cases it will be in vain to attempt a resolution, as the natural tend- ency of tubercles here, as of other foreign bodies, is to an escape by suppuration, the tubercle not only producing an inflammation of the parts around it, but this inflammation causing suppuration, which will sooner or later terminate in ulceration. When the matter is once formed, ought we to wait till fluctua- tion be perfectly distinct before opening it, or ought we rather to give a prompt issue to the softened portions? Berard advises strongly an early opening, as tending to prevent any considerable thinning of the skin, and the formation of fistulae or even a true abscess between the softened tubercle and the scro- tum. The effect of allowing the natural discharge of this matter by ulceration cannot be better shown than by the following case:— Salle St Ferdinand. No. 10.—Paquier, aged 41 years, carter, entered the wards of Velpeau, on the 28th of January, for an affec- tion of the testicle. In May, 1839, whilst loading his cart, he re- TUBERCLES OF THE TESTIS. 745 ceived a blow on the testicle, from a bar of iron, which produced the pain and faintness usual immediately after an injury to this organ. It did not, however, prevent his continuing his work till towards September, when the swelling and hardness of the parts induced him to consult a physician, by whom he was leeched, kept in bed, and had ointments rubbed on the scrotum. After a continu- ance of this treatment, he was again obliged to resume his work, and continued at it without noticing particularly the parts, till the 8th of Nov., 1839, when it became painful and inflamed externally. This obliged him again to consult his physician, by whom he was leeched and afterwards poulticed, but was obliged to continue at his work till the end of December, when he was confined to his bed, and again submitted to treatment of a similar nature till an abscess opened in the lower part of the scrotum, when he was sent to the hospital from want of funds. On his entrance, the left testis was the size of a large egg; the scrotum very much relaxed; of the natural color, at the upper part, but below of a deep bluish-red, especially at the sides of the abscess, where the skin was very thin, ragged, and disposed to sloughing. The cavity made by the abscess would admit the end of the forefinger, and the matter had extended under the integuments of the perineum, where a second abscess had formed. This was freely opened by Velpeau, and gave exit to a pus-like matter, mixed with a little blood. A further examination of the testicle showed the epididymis to contain tu- bercles throughout its whole extent, presenting hardened masses, which I cannot better describe than by saying as if filled with peas, some of which had been mashed. The testicle also was enlarged, but seemed to be more the result of the inflammation near it than of disease in its substance, its sensibility and elasticity being pre- served. The right testicle is perfectly natural, as is also the scro- tum on this side of the raphe", but several tubercles in a crude state can be felt in the upper part of the epididymis, of which the pa- tient is not aware, as he complains of nothing unnatural in this gland. His general health has always been good, and he has never before had an affection of the testicle, though he suffered from chancres when young. After the opening of the abscess, Velpeau directed the use of cataplasms to the part, and good diet, under which treatment he continued for some time; the edges of the scrotum having sloughed off, and showed a tendency to granulation, when a change took 746 PRACTICE OF SURGERY. place, the ulceration seemed to have recommenced, and he has had several hemorrhages from the part, without it being possible to distinguish the point from whence it. comes. He is now, March 26, 1840, still under treatment, with the prospect of having to sub- mit to castration. It hardly admits of a doubt that had this case been differently treated, previous to its entrance into the hospital, much of these results could have been prevented, as a free incision would have prevented the burrowing of the matter, and ulceration of the skin, and left the parts in a state more favorable to cicatrization. If, however, fistulae are formed by the natural discharge of the matter, we must, after giving free vent to the discharge, attempt to provoke adhesion by stimulating injections, of which those of port wine, lime-water, a solution of sulphate of copper, of the nitrate of silver, or of tinct. cantharid. are those most constantly employed. Should the fistulae still continue, the treatment must be persevered in, varying the injections, or adding thereto, as recommended by Berard, douches of sulphurous, saline, saponaceous or chalybeate waters. The removal of the hardened sides of the fistulae by the knife, or by caustics, as the acid nitrate of mercury, will fre- quently hasten their adhesion. Notwithstanding, sometimes, the employment of all these means successively, the duration of the fistulae will be tedious, but they will heal sometimes of themselves, though after a long period. In the case of a sailor, who entered La Charitd, in October, 1839, for a contraction of the tendons of his feet, numerous tubercles of the testis in a crude state were found in the right testicle, whilst several cicatrices remained in the scro- tum, from which, according to his account, matter resembling shreds of beef had escaped for a long time. He stated that when in Africa, nearly three years previous, he had bruised his testicles by falling on some rocks, but had never been treated for it. Some months after, matter was discharged from the scrotum, without his suffering very acute pain, and this matter continued to escape by different openings from time to time, during two years, when the fistulae closed without treatment, and he thought so little of their existence, that he had said nothing of it on his entrance to the hospital. The great difficulty of obtaining the resolution of tubercles, makes us foresee that their softening will bring on ulcerations in the scrotum, and fistulous openings, difficult to cure. Would it TUBERCLES OF THE TESTIS. 747 not, therefore, be better to anticipate this termination, and incise at an early period the hardened and encysted tubercle? Would not also the wounds resulting from this operation be more disposed to a prompt cicatrization? In one case, where the brother of Berard recognized the presence of large tubercles in the testicle, a large incision made on the part caused the exit of the mass by means similar to the extraction of a kernel from a nut, and the cure was radical and prompt: but the testicle rested completely atrophied. Perhaps it would have been possible to have prevented this atrophy by incising the tubercle alone, and avoiding any injury to the sub- stance of the testis, whilst in the epididymis it would most proba- bly be always successful. It would, however, be only applicable to cases where the*tubercles were isolated, when, as has been shown, the seminiferous tubes are rarely affected by their existence. PART XY. AFFECTIONS OF THE ANUS AND RECTUM. The connection of the rectum with the process of defecation, and the daily recurrence of this act, render the disorders of this portion, of the alimentary canal a subject of interest, not only to the patient, as involving his comfort and general health, but also to the surgeon, owing to the difficulty sometimes encountered in removing the results of diseased action in a part which, besides being very liable to all the ordinary results of inflammation, is also exposed to the risks of a free hemorrhage, that cannot be readily controlled when the tissues have been incised. Anatomical Relations.—Without entering into a detailed account of the structure of the rectum, it must suffice, at present, to call attention to the fact that the different coats which form this bowel are loosely applied to each other; that the rectum itself is sur- rounded by a free cellular tissue, which is more or less filled with fat, especially near the anus; and that, in addition to the arteries which supply it with blood, it is freely furnished with veins that anastomose in all directions, and form, at its inferior end, near the margin of the anus, a plexus, or network, that is designated as the hemorrhoidal plexus. This venous plexus lies in the cellular coat of the rectum, immediately beneath its mucous coat, and when enlarged by disease, also encroaches on the muscular coat. The internal sphincter muscle, it should also be remembered, is so freely traversed by this plexus of veins that, when hemorrhoidal tumors are formed the muscular fibres are sometimes spread around the pile, and, in some instances, appear to constitute a small portion of the tumor, or are so incorporated with it, as to render it difficult to separate them. The hemorrhoidal plexus of veins communicates 750 PRACTICE OF SURGERY. directly with the inferior mesenteric vein, as well as with the hypo- gastric; hence, whatever compresses the abdominal contents, is liable to produce congestion of the hemorrhoidal plexus. The disorders of the rectum may be briefly alluded to as those affecting the anus, or its external orifice; those affecting the adja- cent cellular tissues; those which involve its coats, and those which develop changes in its veins. SECTION I. AFFECTIONS OF THE ANUS. The skin covering the margin of the anus is liable, like the skin of other portions of the body, to the development of inflammatory action, which is here aggravated both by the friction of the cheek of one buttock against the other, as well as by the constant passage of the faeces over it. In addition to the ordinary results of inflam- mation of the skin, as congestion, suppuration, and ulceration, the integuments of the anus are especially liable to a form of vesicular disease that constitutes a true eczema—is the source of great annoy- ance to the patient, and is not unfrequently regarded as due to dis- ease within the rectum, instead of being, as it frequently is, purely an external disorder of this region, though perhaps first excited by irritating discharges from the rectum. § 1.—ECZEMA OF THE ANUS. Symptoms.—Eczema of the anus, like the eczema of other regions, is seen either as an acute, or, more frequently, as a chronic disorder. When acute, it is preceded by a constant sense of burning and itching, which the patient assigns to the chafing of the parts, and the continued itching of which usually continues to be one of the most annoying features of the disorder. A close examination will now show the edge of the fold of the buttock, as well as the margin of the anus, to be red, hot, moist, and abraded of cuticle, whilst at other points, minute vesicles, filled with serum, will be seen scattered around, as in the ordinary form of acute eczema of other parts. As ECZEMA OF THE ANUS. /ol the fluid escapes by the rupture of these vesicles, it may be either clear, like serum, or slightly yellowish in its tint, staining the linen of the patient, and forming on the skin around the anus, when it dries, the thin white or yellowish scales which are characteristic of eczema; or, if the affection is chronic, it will leave the parts of a dark reddish color, with a slight crust on them, like that often noted on the legs, in connection with ulcers, and known as chronic eczema rubrum. Not unfrequently this irritation is also found upon the thighs and scrotum of the male, and on the pudendum and peri- neum of the female, being often the result, in the latter, of the irri- tation caused by leucorrhoeal discharge. Etiology.—Eczema of the anus may be developed by any cause that will induce congestion and superficial inflammation of the skin; thus, it is frequently the result and attendant of hemorrhoidal tumors, the capillary congestion created by the enlarged rectal veins, as well as the ichorous matter which flows from such tumors as are ulcerated, creating precisely the same condition of the skin about the anus that is seen on the legs, and has already been alluded to as one of the sequelae of leg ulcers.1 Fissure of the anus, fistula in ano, prolapsus ani, &c, may also give rise to this disorder, though the irritation thus caused is not unfrequently regarded merely as a symptom of rectal disease, and treated accordingly, whilst it may be a distinct complaint. Diagnosis.—The presence of one or more vesicles in the neigh- borhood of the anus, with the characteristic itching and burning of eczema as seen elsewhere, usually suffice to render the diagnosis easy, when the parts are carefully examined by placing the patient on his back before a good light and then elevating and opening his thighs, so as to see clearly the entire perineum. When the examination is made from behind simply by opening the cheek of the buttocks, the folds of the skin, and the hair, &c, as found in the adult, often conceal the characteristic vesicles. Patients.—Adults, both male and female, who are fleshy, consti- pated, and subject to hemorrhoids or fistula, are those mostly affected, though such as are thin and of the tuberculous diathesis also suffer from the complaint. Prognosis.—The prognosis of eczema of the anus will depend 1 See page 132. 752 PRACTICE OF SURGERY. upon the cause of the irritation. Usually, the patient can be readily relieved of the complaint when it is acute; but unless tbe hemor- rhoidal congestion can also be removed, or when the disease is chronic, the prognosis as regards the cure should be guarded, the complaint being occasionally very difficult to cure, unless the func- tions of the rectum can also be restored to their normal condition. Treatment.—When this external irritation of the anus is the result of constipation, or of a varicose condition of the hemorrhoidal veins, or of external piles, the administration of an active mercurial purge is always beneficial, the bowels being subsequently kept in a soluble condition by the administration of sulphur and magnesia, so as to correct acidity, after which the chief reliance must be placed on local remedies. These local applications should be regulated by the extent and character of the inflammation. If the eczema is acute, and accompanied by much burning and a free serous dis- charge, nothing will afford greater relief than frequent bathing with lead water, or the application of pieces of lint wet with the same, the lint being retained by the use of a T bandage; but when the disease is more chronic in its character, and presents a dry, scaly appearance, with intolerable itching, the warm water dressing—that is, lint satu- rated with warm water, and covered by a piece of oiled silk—will prove most soothing; or the patient may steam the part by sitting over a vessel of hot water; but poultices of all kinds are objection- able, owing to their adhering to the hair, so that they become a source of irritation; whilst if the latter is shaved off, the suffering of the patient will be increased in a day or two by the friction on the short ends that will grow again. Muck relief from the itching may also be obtained from the following ointment:— R.—Hydrarg. sulphuret. flavns grs. xv ; Aconitiae grs. ij; Pulv. camphorae grs. v ; Axungiae Jj.—M. S.—Anoint the parts thoroughly, and rub it well in with a soft rag. The dry, scaly condition may also be benefited after steaming by anointing the part with the following ointment:— R.—Pulv. camphorae, Sodae carb., aa grs. x ; Glycerin Jj ; Axungiae §j.—M. FISSURE OF THE ANUS. 753 In the more chromic cases, especially if accompanied by a serous discharge, the following is also often very useful:— R.—Hydrarg. chlorid. mit. giss ; Pul. plumbi acetat. grs. x; Axungiae Jj.—M. S.—Anoint the parts twice daily. Should external or internal hemorrhoids exist at the same time, these should be appropriately treated, though even then the means above directed will prove highly useful. § 2.—FISSURE OF THE ANUS. When a small deep linear or elongated fissure forms on the mar- gin of the anus, and resembles very much the fissure seen on the lips in the condition usually spoken of as " chapped lips," it is designated zsjissure of the anus. Etiology.—Fissure of the anus may arise almost without any appreciable cause, but usually it appears to follow on constipation in patients who strain violently, and in whom there is a deficiency in the ordinary mucous secretion usually found in the pouches formed by the extension of the mucous coat of the bowel between that portion of its longitudinal muscular fibres that has been desig- nated as the "columns of the rectum." Under these circumstances, the passage of the hardened and dry faeces apparently creates an abrasion or split in the mucous covering on the very margin of the anus, which soon develops such a spasmodic contraction of the fibres of the external sphincter ani muscle, as keeps the fissure open, prevents its healing, and thus exposes this linear ulcer to a continued irritation, by which its edges become thickened and hardened from the effusion of lymph. The spasmodic affection of this muscle is so constant and marked that writers have been at a loss to decide whether the affection of the muscular fibre was a cause or a consequence of the ulcer; but as the muscle lies beneath the membrane, and the latter is most exposed to the irritating causes just alluded to, it seems reasonable to regard the muscular affection rather as a result than as a cause of the fissure. Patients.—Fissure of the anus is most frequently met with in adults being rarely, if ever, seen in children, whilst it is much '48 751 PRACTICE OF SURGERY. more frequent in females than in males, probably in consequence of the greater tendency of females to constipation. Symptoms.—Fissure of the anus first shows itself in the existence of a continued burning in one spot after going to stool, this burn- ing and pain soon becoming of the most excruciating kind, and being accompanied by such a spasmodic contraction of the sphincter muscle as causes the faeces to escape as a narrow, flattened, tape-like piece, which is not unfrequently streaked with blood on the side which has touched the fissure, this being subsequently followed by a slight serous or purulent discharge, which amounts only to a few drops. The patient also is often unable to locate precisely the pain, which is sometimes complained of all round the anus, and extends to the bladder and down the thighs, or into the back in the course of the nerves. When the anus is carefully inspected externally, little or no change may be noted, though sometimes an external pile may be seen, near which a subsequent examination of the rectum by a speculum ani will discover the linear indurated ulcer. Any attempt to dilate the anus, even by the introduction of the little finger, will show that the sphincter is spasmodically contracted, whilst the introduction of the nozzle of a syringe will be intolerable. Under these circumstances, the patient should be thoroughly etherized, and then the anus being dilated by the intro- duction of the anal speculum, the fissure, with its indurated edges, may be recognized by a cautious examination. Diagnosis.—Fissure of the anus, unless thus examined by a spec- ulum, may be confounded with internal hemorrhoids, stricture of the rectum, fistula, &c; but with the use of the speculum whilst the patient is in a state of anaesthesia the diagnosis may be rendered certain. Prognosis.—The prognosis under a judicious course of treatment is favorable, and the cure usually prompt. Treatment.—The indications for the treatment are to get rid of the induration—create a new and healthy ulcer and heal it as soon as possible. These indications may be best accomplished by the use of an anassthetic, by a thorough dilatation of the anus by means of a speculum, and by the application of a piece of caustic potassa to the surface of the fissure so as to cause it to slough out, the further action of the caustic being immediately checked by washing the part thoroughly with olive oil, and then keeping the bowels free by the use of laxatives, the patient being directed to take a pint of thick AFFECTIONS OF THE RECTUM. 755 and cold flaxseed mucilage before each stool, so as to protect the ulcer from the irritation of the faeces. The subsequent healing of the ulcer is usually readily accomplished by anointing the part with belladonna ointment, and by the occasional application of the nitrate of silver. Injections of the infusion of rhatany (krameria triandra) have been found to be highly useful, acting probably through its astringency. Rupture of the fibres of the contracted sphincter ani muscle by stretching it by the introduction of two fingers; or the division of the muscle by a subcutaneous section, are also said to prove useful by keeping the parts at rest, and permitting the approximation of the sides of the ulcer, and are worthy of trial, though the cauterization with the potassa is more certain in its results. § 3.—TUMORS OF THE ANUS. The anus, owing to its proximity to the genital organs, especially in the female, often becomes the seat of condylomatous tumors as the result of syphilitic infection. When noted they should be treated in the manner directed for the removal of syphilitic warts. Any other tumors of this region, except those which are due to hemorrhoids, should be treated by extirpation like other tumors elsewhere, being sometimes due to obstruction of the sudoriparous follicles, or to true polypoid or lipomatous growths, the first being connected with the mucous coat of the rectum, and requiring the same treatment as polypi of the nose. SECTION II. AFFECTIONS OF THE RECTUM. The affections of the rectum consist in the disorders which affect its mucous or muscular coats, its veins, and the cellular tissue exterior to the bowel. Some of these disorders, being only apparent at the anus might have been placed under the affections of the anus; but as their origin is in the rectum, it is more correct in a syste- matic arrangement to locate them under the head of affections of the rectum. 756 PRACTICE OF SURGERY. § 1.—PROLAPSUS ANI. As the mucous coat of the rectum is very movable upon its muscular coat through the intervention of the cellular coat, it facili- tates the escape of the faeces from the anus by protruding slightly over the edge of the sphincter ani muscle, as is well seen, though in a greater degree than in man, in the defecation of the horse. When thus protruded the action of the levator ani muscle again draws it within the sphincter, which closing firmly, retains it within its folds. But when from various causes the sphincter ani becomes very much relaxed, or the levator ani loses its power, or the cellular tissue becomes infiltrated with serum, the protrusion of the mucous coat becomes more marked and permanent, or the bowel itself becomes invaginated and forms a tumor at the anus, which is Fig. 251. A full view of the Appearance of the Parts in Prolapsus Ani, showing the Circular and Concentric character of the Folds of the protruded Mucous Coat. (After Miller.) known as prolapsus ani, or as "falling of the body," or sometimes is spoken of as " the body coming down." Etiology.—The causes creating this condition in adults may be either such as tend to relax and weaken the attachments of the rectal mucous membrane, or such irritation as creates straining, and forces the bowel outwards, or it may be due to the extension of irritation from the bladder or adjacent parts—or to inflammation as PROLAPSUS ANI. 757 after the tenesmus of dysentery. The various causes in children may be constant crying, straining long at stool, obstinate diarrhoea, dysentery, stone in the bladder, &c, whilst in the adult it also often ensues on constipation, on hemorrhoids, on the use of aloetic purges, or on the constant use of purgative enemata; the relaxa- tion of the anus is also created in men by the free use of tobacco. Symptoms.—After an effort at stool, a tumor is found at the anus, which is soft, pinkish, corrugated, and evidently covered by a mu- cous membrane which shows evidences of congestion if firmly con- stricted by the sphincter ani muscle, becoming darker and more purplish in its color, and inflamed, hot, and painful, if not soon replaced. When of long standing, the prolapsed portion becomes hard, firm, and resisting from the effusion of lymph into the sub- mucous cellular tissue, which renders it difficult to replace it, but when recent, the tumor will often disappear within the rectum by its own contraction, or may be readily replaced by the gentle pres- sure of the fingers. When a chronic, thickened and constricted tumor becomes more or less permanent in its position, congested, indurated, and difficult to reduce, and is then also violently con- stricted at the anus, it may inflame, suppurate, ulcerate, or slough off, as is sometimes seen in the chronic tumors of old people in almshouses and hospitals where the prolapsus has been long neglected. Patients.—Prolapsus ani is met with at both extremes of life, being often seen in children under three years, and also frequently developed in adults over sixty years of age. Diagnosis.—Prolapsus ani may be told from hemorrhoids or piles by the fact that the tumor in prolapsus is usually a mass formed of continuous and concentric circular folds around the anus, and pre- sents a villous like surface, whilst hemorrhoids are more or less distinct tumors, resembling in size and color the intestine of a chicken if distended with indigo water and tied every half inch or two inches in length. Hemorrhoids also do not create as bulky a tumor as prolapsus ani—are much more painful, and bleed more freely, and whilst the tumor of prolapsus is returnable into the rectum in mass—hemorrhoids require to be replaced one after an- other. Prolapsus ani is common in young children, but hemor- rhoids are not seen except in the adult. The fore-finger will also readily pass through the sphincter ani muscle without causing pain in prolapsus, as the anus is relaxed, whilst it is contracted and quite 758 PRACTICE OF SURGERY. painful in hemorrhoids. Condylomatous tumors being due to syphilis, can be told from prolapsus ani by the history of the case, and by the symptoms which have been already detailed. Prognosis.—The prognosis of a recent prolapse of the rectum is favorable, but in the old tumors of aged adults it should be guarded; for, though the tumor may be returned, the sphincter ani muscle is usually so much relaxed, that it is difficult, and sometimes impos- sible to prevent the reproduction of the tumor at the next effort at defecation. Treatment.—The indications in the treatment are, 1. To reduce the prolapsed rectum promptly; 2. To retain it within the sphincter ani; 3. To remove the cause of the disorder. 1. The reduction of the prolapsed portion of the rectum may usually be accomplished by placing the patient in the horizontal position, and anointing the entire tumor, as well as the fore or the first two fingers of the surgeon's hand with olive oil or lard; then, pressing upon the centre of the tumor, carry a fold of it up into the rectum within the spincter ani muscle with the fingers of one hand, and pushing up another fold with the other fingers, retain the first until the second is nearly within the sphincter, continuing the manipulation till the entire tumor is restored, when a piece of cerate should be placed over the anus, and held there for a.few hours by a compress and T bandage. The prolapsus of children does not usually demand so much manipulation, and, when once returned, does not require the employment of a compress, as it will remain reduced until the next effort at defecation. Much may be done, both in adults and children, to prevent the recurrence of prolapsus by re- quiring them to sit on a seat which is inclined at an angle of 45° to the horizon, so as to throw the weight of the intestines upon the abdominal parietes, and prevent the action of the muscles from compressing the rectum in a perpendicular line. The seat ur5on which they stool should also have a very small and narrow open- ing, not more than four or six inches wide for an adult, so as to support the cheek of the buttock, and thus aid in the lateral com- pression of the anus at the moment of defecation. If the prolapsus is due to constipation, laxatives should be constantly employed, whilst if it is due to the tenesmus of dysentery, injections of lauda- num will prove useful, ascarides and worms in the bowels being removed by an appropriate treatment. The retention of the bowel after its production may generally be accomplished simply by the FISTULA IN ANO. 759 use of a compress, or a pad attached to a vertical spring, which is fastened to a band around the pelvis, such an instrument being made by the cutlers, and often proving useful in the bad cases sometimes met with in old people. Sometimes it may become necessary to employ, for a few days, a rectal pessary, so as to give the mucous membrane an artificial support, especially if the sphincter ani is much relaxed. Should the tumor be very much congested and inflamed, it will be best to keep it constantly bathed with cold water for a few hours previous to attempting its reduc- tion, or it may even require the local abstraction of blood by leeches around the base of the tumor. In some cases benefit will be derived from injections of the infu- sion of rhatany, or weak solutions of the tiuctura ferri chloridi, in the proportion of twenty drops or a drachm to the ounce of water, the strength being regulated by its stimulation, which should never be sufficient to cause pain. The decoction of white oak bark, or an ointment of ten grains of tannic acid to the half ounce of lard, a portion of which is to be placed within the anus, is also often highly serviceable. When the sphincter ani and the verge of the anus are very much relaxed, an operation may be demanded, whilst the tumor may require the removal of a strip of the mucous membrane, or the application of caustic, or a ligature, for its radical cure in the chronic prolapsus of adults, as is described in the Operative Surgery, vol. ii. p. 334, 2d edition. § 2.—FISTULA IN ANO. Fistula in ano is the result of an abscess in the neighborhood of the rectum, the term fistula being generally applicable to all ab- scesses which are discharged by narrow pipe, or reed like canals. Etiology.—Any cause that will excite an inflammation around or in the rectum may, by creating a rectal abscess, become the cause of fistula in ano ; thus hardened faeces, by irritating the anus, or the congestion of the mucous membrane consequent on straining, or the continuance of hemorrhoidal tumors, or the lodging of foreign substances across the rectum, as pieces of undigested food—or par- ticles of bones, &c, taken in food—riding on horseback—as well 760 PRACTICE OF SURGERY. as external injuries from various causes, may all develop this con- dition. Symptoms.—Fistula in ano being always preceded by an abscess near the rectum, its earlier symptoms are those of abscesses, as pain, heat, and swelling about the buttock, with heat and irritation of the rectum, and severe pain on going to stool. If the abscess opens outwardly, it also presents the usual evidences of abscesses beneath the skin, as tumefaction, redness, pulsatile pain, ulcera- tion of the skin, and the escape of pus; after which the discharges may continue to become thinner and more sanious, so as to create excoriation and eczema of the margin of the anus, whilst the effused lymph on the borders of the abscess will give to the part a degree of density which prevents the sides of the abscess from collapsing, and thus creates a fistula. The orifice left by a fistula when it is external is usually small, being so small that it is sometimes diffi- cult to introduce a probe into it, whilst it often presents the teat-like prominence with the little pit in its centre that is characteristic of fistula elsewhere. Sometimes this fistula is exceedingly sensitive, the introduction of a probe causing great suffering, this being usual in the acute cases; but in the chronic, the parts are quite callous— the skin is purple and thickened, and there is little inconvenience caused by an examination of the fistula with a probe. Sometimes a fistula in ano is associated with the development of tubercles in the lungs, the origin of the anal abscess having apparently been the deposition and softening of tuberculous matter in the cellular tissue around the anus. As a general rule, this variety of fistula is less sensitive than that consequent on an ordinary phlegmon, and is also associated with the general symptoms of the tubercular diathesis. Flatus and fecal matter are often mixed in the discharge of any fistula in ano when it communicates directly with the rectum. Varieties.—Owing to the fact that the abscess which creates fistula may open at various points, surgical writers formerly de- scribed several varieties of this disorder, though all due to similar causes. Thus, when the abscess established an opening by pointing through the rectum, it was called an internal fistula. When it opened outwardly and near the anus, it was designated as an external fistula. When there was a direct communication from the skin into the rectum, it was spoken of as a complete fistula, and when it opened only inwardly or outwardly, it was described as an incom- plete fistula. When the abscess was disposed to point outwardly, but the skin had not ulcerated, the condition was also often alluded PROLAPSUS IN ANO. 761 to as blind fistula, a very incorrect term, as such a condition was only that of a phlegmon or abscess near the rectum which had not opened. In fact, many of the symptoms often assigned to fistula in ano, properly indicate only an anal abscess, no fistula, or pipe-like cavity existing. Diagnosis.—The history of the abscess, the slender depressed orifice of the fistula, the introduction of a probe, and the continued suppuration from one or more distinct points, suffice to render the diagnosis of fistula in ano quite easy if a thorough examination is made. Prognosis.—The prognosis of fistula depends upon circumstances, as one which is due to a tuberculous abscess, or is associated with tubercles on the lungs would be more serious, owing to the pul- monary complication, than one occurring in a better constitution; whilst a recent fistula would be more readily healed than a chronic one. Generally, however, the prognosis as respects the fistula itself is favorable, most of them being susceptible of being cured; but the time, as well as the subsequent condition of the parts, will depend upon the patient's general health, and on the ordinary steps of in- flammatory action in healing an indolent ulcer, the indurated fistula being nothing more. Treatment.—The treatment of the abscess that precedes fistula in ano is that of other abscesses, i. e., the application of heat and Fig. 252. A section of the Body showing the division of the Rectum and Sphincter Ani Muscle in the treatment of fistula in ano. (After Miller.) moisture, the early evacuation of the pus, and the removal of all irritation in the part, by perfect rest; by quieting the action of the 762 PRACTICE OF SURGERY. sphincter ani muscle, and by the free use of laxatives. When a true fistula forms, it is necessary to prevent the action of the sphincter ani muscle by dividing it, and then healing the fistula by such general and local means as will remove the induration of its edges, and favor the formation of granulations. The section of the sphincter ani muscle may be accomplished by introducing a bistoury, and cut- ting outwards, as shown in Fig. 252, or by the use of a ligature.1 The after-treatment is to be conducted by the application of such means as will hasten the formation of granulations, these being made to form from the deepest point before the edges of the skin are allowed to heal. § 3.—HEMORRHOIDS, OR PILES. Hemorrhoids (cw^a, blood, and p*«, I flow) is the name which designates that condition of the rectum which is accompanied by the presence of several small tumors, from which blood not unfre- quently flows. Seat.—The usual seat of hemorrhoids is the lowest extremity of the rectum, or the margin of the anus. Varieties.—Hemorrhoids are designated as internal and external, according as they are naturally formed within or without the sphincter ani muscle, though those which are usually internal may be protruded in defecation, and remain constricted by and external to the sphincter ani muscle. When the tegumentary or mucous covering of the tumor becomes fissured or ulcerated, they are also sometimes designated as open or bleeding piles, whilst those tumors which are not ulcerated or open on the surface, are usually spoken of as blind piles. Pathology.—As the position of the hemorrhoidal veins has been already described, it is only now necessary to state that all hemor- rhoidal tumors are more or less directly connected with some dis- eased action in these veins in the first instance, the tumors being formed in the simplest variety, by a varicose or dilated condition of the coats of the vein, covered by the mucous membrane or skin, resembling closely in their character the condition of varicose veins 1 For the details of these operations, see Operative Surgery, vol. ii. p. 341, 2d edition. HEMORRHOIDS, OR PILES. 763 in the leg. In other cases, the hemorrhoid is formed by effusions of lymph and blood into the subcutaneous cellular tissue, this forming the more solid and less vascular tumor generally seen in external piles. When hemorrhoids have existed some little time, and been frequently inflamed, the ordinary changes of inflammation are to be noted in and around them, such as induration of tissue, ulceration, suppuration, and an increased secretion, with a modification of the natural action of the mucous membrane. Sometimes the enlarged veins are so incorporated with the sphincter ani muscle that a few of its fibres will be found spread over or incorporated with the tumor. Etiology.—The local causes of hemorrhoids may be anything that will create engorgement and distension of the hemorrhoidal veins, as straining from constipation, pregnancy, constant sitting on warm cushions, whilst the excessive use of tobacco, which relaxes the anal muscles and favors congestion of the part, with a plethoric habit, or the congestion created by irregular menstruation, &c, may act as predisposing causes. Patients.—Hemorrhoids are seldom or ever seen in those younger than eighteen years of age, being generally met with in the prime of life, though they are not unfrequently found in those as old as sixty-five years. They may attack either sex, and especially those who lead sedentary lives, or are dyspeptic. Symptoms.—As hemorrhoidal tumors are due to vascular changes in the rectum, which induce inflammatory and neuralgic irritation, the earliest symptom of their presence is that of fulness and irri- tation, or soreness about the anus, which is especially marked for an hour or more after an evacuation. Soon these sensations become more distinct, creating the sensation of a foreign body being in the rectum, and giving rise to a feeling of dissatisfaction, or a repeated desire to stool, the pain extending towards the sacrum and spine, » or towards the bladder and down the thighs, from the nervous con- nections of the part. The faeces are now sometimes streaked with blood, or the paper is tinted, or about a teaspoonful of blood escapes towards the end of the stool, itching is also developed near the anus this being often due to eczema, whilst the parts are constantly moist, and the linen soiled with pus or blood. The escape of blood usually gives temporary relief, but, if often repeated, creates evi- dences of ansemia. At the next stool the tumors may be more engorged, and the patient will recognize their presence with the 764 PRACTICE OF SURGERY. fi nger. If they continue to be constricted by the sphincter ani, or any irritation increases the afflux of blood to them, they also become more tumid; hot, and painful, and if now inspected, will be found violet-colored, smooth, shining, and exquisitely painful to the touch. As the irritation continues, the sphincter ani participates in it, and becomes spasmodically contracted, causing the patient to scream with the shooting character of the pain, whilst defecation cre- ates horrible torture, the tumor then becoming much blacker and larger, and terminating sometimes—if left unreduced—in sloughing of the part after a day or two. Sometimes, on the contrary, the spasm passes off, and the tumor becomes less engorged, until, after 48 hours, it becomes flaccid, and the patient may be comparatively comfortable, or only suffer at the periods of defecation. The con- stricted condition, with the irritation and intense suffering just described, is usually said to be due to a fit of the piles. The long continuance of hemorrhoids usually causes great disorder of the digestive, circulatory, and nervous organs, the patient being liable to dyspepsia, flatulence, colic, and a sense of constriction, or of sinking about the umbilicus, whilst he is troubled with palpitation of the heart, a quick, irritable pulse, dyspnoea, and the other evils of anasmia. Not unfrequently his entire moral character is changed, becoming cross, peevish, irritable, and irascible, quarrelling with every one, and not unfrequently resorting to the use of alcoholic drinks or opium to deaden his sensibilities. Diagnosis.—The knotted character of the tumors; their position on the side, and not in the centre of the anus; their violet color, their bleeding, &c, generally render the diagnosis of hemorrhoids easy. Prognosis.—The prognosis of this disorder is decidedly favorable, unless complicated with bad prolapsus ani, in an old and broken- down patient, when it should be guarded; but I regard every case of hemorrhoids, not thus complicated, as susceptible of being cured, with safety to the patient, if Horner's operation is performed.1 Treatment.—The treatment of hemorrhoids may be either pallia- tive or radical. The palliative consists in administering, every day, before the patient goes to stool, an injection of a full pint of cold flaxseed mucilage, or of cold water, though the first is the best. Then the parts after defecation, should be well bathed in cold water, 1 See Operative Surgery, vol. ii. p. 339, 2d edit. HEMORRHOIDS, OR PILES. 765 the bowels kept free by mild purgatives, and some of the balsams, or terebinthinates, be occasionally administered. The following is a remedy which will often prove serviceable, especially when the tumors are ulcerated, and bleed, as it acts directly on the mucous membrane:— R.—Pulv. resinae ^j; Bals. copaibae fj ss; Mel despumat. ^irss.—M. S.—A tea or dessert-spoonful at bedtime, each night, till the bowels become free, and the irritation is relieved. Comfort will also be obtained from the use of anodyne and astringent ointments. R.—Pulv. acidi tannici grs. x; Pulv. plumbi acetat. grs. v; Ext. aconitum nap. 3ss ; Axungiaei Jss.—M. S.—Anoint the part thoroughly. When the tumors are external, attention should also be given to the existence of eczema of the anus, which should be treated as before directed. The radical treatment of hemorrhoids consists in destroying the tumors in patches, by the use of nitric acid, and in their entire re- moval by the wire ligature; both of which operations are fully de- scribed in the Operative Surgery, vol. ii. p. 337, 2d edit. In the ancient method of treating hemorrhoidal tumors, when they were removed by simple excision, frightful hemorrhages sometimes supervened; the accounts of which have created so much alarm in the minds of patients, that very many continue to suffer for years from hemorrhoids, rather than—as they suppose they must—risk their lives by an operation. It becomes, therefore, the duty of every medical man to disabuse them on this point, and to assure them that, by the operations now performed, they can not only be safely relieved, but radically cured. Out of nearly 80 cases that have been operated on, to my knowledge—many of whom have been in my own practice—not one has died, or been in danger of death, from Horner's operation; whilst in but one has it been necessary to operate on the second side, after the tumor had been removed by a previous operation on the other. 766 PRACTICE OF SURGERY. § 4.—IMPERFORATE RECTUM. It occasionally happens that infants are born with such imper- fections of the lower portion of the rectum, as prevents the escape of the contents of the bowels, or, in female infants, direct it through the vagina; and this condition is described as imperforate rectum. A similar condition of the rectum is also often accompanied by malformation of the anus, thus creating what is designated as im- perforate anus. This defect may be created by the rectum terminat- ing in a closed sac, an inch or an inch and a half above the peri- neum, or by a membrane closing the anus, and extending upwards, or by a fistulous communication between the rectum and vagina. In either case, operative measures will be promptly required, though the prognosis of the operation is positively unfavorable; only a few being entirely successful.1 § 5.—CANCER OF THE RECTUM. Malignant deposits in the rectum may occur at any point of the bowel, but are most frequently situated around it just above its in- ternal sphincter muscle. Etiology.—The causes of cancer of the rectum are any irritation of the part acting on a patient of the cancerous cachexia. Symptoms.—The local symptoms of cancer are, at first, those which have been described under the head of hemorrhoids. Some- times it commences by a tubercular like mass, which is hard to the touch, and only causes a sense of fulness; but as it pursues the course which has been detailed when considering malignant diseases generally, it creates an ulcer of the fungous class, which gives exit to an exceedingly offensive, ichorous, and often bloody discharge, causes intense pain, and, as the growth increases, diminishes the caliber of the rectum until, at last, the latter becomes almost entirely obliterated, and the patient dies of hectic, which is augmented by the additional suffering caused by the sympathetic irritation of the bladder, &c. Diagnosis.—When the rectum is examined by the finger, the the operation, &c, see Operative Surgery, vol. ii. p. 331, 2d edit. STRICTURE OF THE RECTUM. 767 position and hardness of the deposit, combined with the constitu- tional symptoms, will generally suffice to enable the surgeon to form a diagnosis; but if doubt yet exists, the examination of the rectum by a speculum ani will generally show the characteristic appearances of the cancerous deposit, and ulcer as described elsewhere. Prognosis.—The prognosis is unfavorable, the rectum being one of the most fatal and painful seats of cancer. Treatment.—The palliative treatment consists in the employment of such measures as will regulate the condition of the bowels, as mild injections, laxatives, and diet, with the additional use of iron and tonics; whilst the administration of narcotics both by the rec- tum and mouth afford the greatest palliation to the sufferings of the patient. It has been suggested to extirpate the lower portion of the rectum when this would remove the disease, and it has been occasionally done; but as there is no good result to be thus ob- tained, a judicious surgeon would not expose a patient to the risk of such an operation when he well knows that the disease must return. § 6.—STRICTURE OF THE RECTUM. Stricture of the rectum is often alluded to as a disease existing in- dependently of other disorders, though most frequently if is due to the growth of the carcinomatous deposits just alluded to. An indu- ration may, however, be caused by the syphilitic disorder of the bowel, which is due to unnatural intercourse, as is sometimes seen in Europe, or it may be created by a true tuberculous deposit in the cellular tissue, or in the adjacent glands, which, by forming tumors, may press upon and obstruct the caliber of the bowel. Very often, however, the stricture of the rectum, which is supposed to exist, consists merely of the spasmodic contraction of the sphinc- ter ani muscle that has been already described in connection with the subject of fissure of the anus. Symptoms.—The symptoms of stricture show themselves chiefly in the obstruction of the course of the faeces; in disordered diges- tion; in hemorrhoids; and in the development of fistula in ano. Treatment.—The treatment is chiefly palliative, consisting in the dilatation of the anus by the cautious use of bougies and in at- tention to the digestion, whilst the pain is relieved by the free use of anodynes. PAET XVI. AFFECTIONS OF THE BLOODVESSELS. CHAPTEE I. ANEURISM. The term aneurism {avtvpwsw, to dilate or distend) is one which is applied to a tumor formed in consequence of the distension of the coats of &n artery. This tumor may be created either by a dilatation of all the coats of the vessel, or by rupture of its inter- nal and middle coat and dilatation of its external layer; or by the rupture of all its coats and the formation of a tumor in the sheath of the vessel or in the surrounding cellular tissue. Etiology.—Aneurism may be the result of disease, as softening or hardening, in consequence of which the arterial coats give way; or it may arise from their being punctured from various sources. But whether this dilatation involves the coats of the vessel as a consequence of disease, or the coats are wounded, and the tumor formed by the sheath of the vessel, or the surrounding cellular tissue, the general term aneurism is equally applied. Varieties.—For the purposes of methodical study, all aneurisms may be divided into two principal classes, which are designated as 1, true, and 2, false aneurisms, though some authors have made a more elaborate classification, but the simpler one just stated is amply sufficient to meet the exigencies of the subject. By a true aneurism is meant one which is formed by the preter- natural expansion of all the coats of the vessel itself (Fig. 253), whilst under the same head are also placed such tumors in the course of the arteries as consist in a dilatation of one or more of its coats, the other being entirely ruptured. 49 770 PRACTICE OF SURGERY. Fig. 253. But when the arterial coats are broken either by a wound or other external violence, or in consequence of disease, and the blood escapes into the sheath of the ves- sel or into the surrounding cellular tissue, so as to form an aneurismal sac, this condition is placed in the second class and designated by the general name of false aneurism. Of these two classes there are some subdivisions which indicate the cha- racter, extent, and condition of the tumor. Thus, in true aneurism, when only a small portion of the length of the artery is enlarged, the tumor is designated as circumscribed, and this class of aneurisms are called circumscribed true aneurisms, but when only a portion of the artery is involved, the tumor is spoken of as a diffused true aneurism. False aneurisms, like the true, pre- sent also such varieties as are due to the extent of the disorder; thus, when the tumor is limited in its shape and involves but a portion of the limb, it is said to be circum- scribed ; but when the blood travels up and down the cellular substance of the part and forms a tumor of greater extent, the tumor is said to be diffused. Symptoms.—There are certain symptoms which are created by aueurisms wherever found, whether true or false, the first of which are due to the action of the tumor itself. Very generally, simple inspection of the tumor will show that it pulsates distinctly, the elevation and depression of the surface consequent upon its pul- sation being usually perceptible at some little distance. When the tumor is examined by the touch it generally gives an elastic sensation, and a pulsation can be distinctly felt which is syn- chronous with the pulsation of the heart, or has only such a varia- The Appearances of True Aneurism as formed by dilatation of all the Arte- rial Coats—fibrin having filled the Sac but left the Canal clear—showing how Nature accomplishes a Cure. (After Miller.) ANEURISM. 771 tion as is consequent upon the time which it takes for the impulse of the heart to reach the tumor. Aneurismal tumors vary also in size in accordance with the caliber of the vessel, the dilatation of the anterior tibial artery being sometimes not larger than a pea, whilst the tumor of a larger vessel may reach the size of an orange, or even larger. Another characteristic of all aneurisms is their diminution upon pressure, whether applied upon the tumor itself or higher up along the course of the arterial trunk which sup- plies it, or upon the main trunk of the limb upon which it has its seat. This diminution is, however, more marked in true than in false aneurisms. When, in such a test, the pressure is entirely re- moved, the tumor usually rapidly resumes its original size, but in the event of the treatment of the disease by means of a continuous pressure, as will be presently explained, this dilatation does not supervene upon the pressure. Aneurisms often produce considerable local pain if so situated as to press upon the nerves of the part, the pain varying in character and degree according to the amount of pressure and the connections of the tumor with the affected nerve. The same pressure upon the local nerves which produces pain may also create various muscular phenomena, such as cramp, spasm, &c. . The tumor itself, however, is usually free from pain, at least un- til it has attained such a size as to be painful from its mere tension. The skin over the tumor also remains for a long time unchanged, seldom presenting evidences of inflammation until the size of the tumor is such as to interfere with the capillary circulation; but when congestion supervenes a train of symptoms ensue which are similar to those which were explained in connection with the subject of tumors. When congestion of the capillary vessels of the skin in- duces inflammation in this tissue it soon induces ulceration and sup- puration, or sloughing, by which the aneurismal sac is opened, and violent and often fatal hemorrhages follow. As the tumor grows its pulsation often diminishes, so that it is no longer noticeable at a distance, though the touch will still recognize it even when quite feeble; at the same time the elastic character of the tumor diminishes, both these changes being due to changes within the tumor, which will be presently detailed. Should the aneurism be so situated as to produce pressure upon any portion of the skeleton, absorption, or even caries of the bone, may ensue. Should the veins of the part be pressed upon, other 772 PRACTICE OF SURGERY. well-marked symptoms will appear, and as the return of the blood to the heart will now be impeded, there will be more or less leak- age of its watery portions into the cellular tissue beneath the skin, which will produce oedema. Thus, for example, if the aneurism be situated in the iliac artery, and pressure is made by the tumor upon the iliac vein so as to impede the circulation in that vessel, oedema of the lower extremities will be the result. All aneurisms, moreover, are liable to terminate in two ways, either by death or by cure, nature being capable, under some in- stances, of accomplishing a cure. When a cure is accomplished by nature it is generally consequent upon changes within the sac, re- Fig. 254. Fig. 255. suiting from a deposition of lymph upon its walls (Fi*. 253)- this deposition being the consequence of inflammatory action, 'or a ANEURISM. 773 change in the circulation of the blood in the sac, this resulting in a laminated structure which gradually and layer by layer increases the thickness of the sac, until its cavity is closed. When the aneu- rism terminates fatally, it generally does so somewhat as follows: The aneurismal tumor grows larger and the sac thinner, owing to its constant distension from within, whilst the various structures between the tumor and the skin, as it first appeared, are removed by absorp- tion, when the pressure encroaching upon the skin, ulceration occurs, or sloughing takes place, and the cavity of the sac being opened (Fig. 254), blood escapes with a sudden gush, and the patient dies generally upon the spot. But although this is a very common mode of termination, and although it may be stated in round num- bers that nine out of ten of the cases of aneurism terminating fatally perish by hemorrhage, yet this is by no means universally the case, as a sac may form within the aneurism, as in Fig. 255. Death may also ensue from pressure upon the neighboring viscera; or it may be a consequence in aneurism of the arch of the aorta, or in- deed in aneurisms of the thoracic aorta generally, of pressure upon the thoracic duct, or on the heart and lungs, &c. &c. As might be expected from the nature of the disease, in every aneurism of considerable size, various pathological changes result, not merely in the parts affected, but even in the vessels at a con- siderable distance from the seat of the tumor, besides which we have various diseased conditions which are the result of pressure upon the surrounding parts. As regards the artery itself at the seat of the tumor, the aneu- rism may be formed by a uniform dilatation of all the coats, this being the simplest and most common variety of what are called true aneurisms, whilst in another va- riety, as described by Breschet, Figj256. of Paris, the dilatation involved merely the external and internal coats, the middle coat being en- tirely torn. In a third variety, the external and middle coat having given way, the internal coat protruded SO as to form the tumor; though A diagram of a True Aneurism of the _ ,. . Arch of the Aorta, the greater part of the from the delicacy Of this COat It Sac being filled with a clot, and the aper- Will readily be perceived that this ture of communication small^ ^^^ form must be exceedingly rare. 774 PRACTICE OF SURGERY. A much more common form consists in rupture of the internal and middle coat, whilst the external is so distended as to form the tumor. Diagnosis.—In diagnosticating an aneurism, the surgeon will be guided by the fact that there is a tumor which is elastic and pulsates, whilst he will be aided in the formation of his opinion by its position as well as by the history of the case. Auscultation will also afford him admirable aid in attaining his diagnosis; as upon putting the ear upon the tumor, two varieties of sound will be perceived, the bruit de soufflet, or bellows murmur, and the bruit de rape, or the rasping or sawing sound; besides which the peculiar aneurismal thrill or whirr will be perceived, the latter being also recognizable by means of the touch. The diagnosis between true and false aneurism is sometimes of importance, especially in regard to the treatment. Among the means by which it is to be made, not the least important is the history of the case. Thus, if the patient states that the tumor supervened upon violent muscular action and rapidly assumed the aneurismal characteristics, the surgeon might fairly be led to sus- pect a false aneurism; if, on the contrary, the tumor appeared gra- dually without any injury or violence done to the part, and espe- cially if the age of the patient is such as would lead one to suspect those diseases which act as predisposing causes, he might reason- ably regard the disease as a true aneurism. In making the diagnosis, therefore, the history of the case becomes of great im- portance. The surgeon will also be much aided in his diagnosis by a care- ful examination of the tumor itself, as such an examination will often reveal several points of importance. For example, if the po- sition and size of the vessel are such as to expose it to violent mus- cular action, it would be peculiarly liable to suffer from false aneu- rism, as in aneurisms of the popliteal artery, which are often the result of violence; while, on the contrary, in aneurisms found in connection with the arch of the aorta, with the innominata, or with the thoracic aorta, &c. &c, which involve vessels not exposed to muscular or other violence, a true aneurism will, as a general rule, be found. The depth of the vessel will also aid in the diagnosis, and, upon the same general principle, the artery least exposed to violence will be the least likely to suffer from false aneurism. But the best and most accurate mode of diagnosis between these two ANEURISM. 775 varieties is to be found in the effects of pressure upon the tumor. If the aneurism be a true one, and especially if it be seen soon after its formation, it will be observed that pressure made over the course of the affected artery between the tumor and the heart will diminish to a greater or less extent the size of the tumor, very promptly, as the pressure upon the vessel cuts off the supply of blood and thus causes the collapse of the aneurismal sac, and a diminution in the size of the tumor. This collapse of the tumor depends, however, somewhat on the thickness attained by the walls of the sac, as old aneurisms with a sac very much thickened, will collapse less perfectly than others which are more flexible. Pressure applied in precisely the same way over the vessel sup- plying a false aneurism does not, however, act with the same promptitude, because of the greater disposition in the false aneurism to the formation of clots, which, by blocking up the sac, prevent its collapse when the supply of blood is cut off. Etiology.—The causes of aneurism may be grouped into two general classes, the predisposing and the immediate. Among the predisposing causes may be mentioned the shape of the vessel, the points where it has a curvature being most apt to be affected. Old age is also a predisposing cause; and so are rheumatism and gout. So, also, the abuse of alcoholic drinks, old drunkards being said to be peculiarly predisposed; whilst sex has its influence, the disease being more common in the male than in the female sex, probably because man is exposed to more violent and continuous muscular exertion than woman. Various diseases in the coats of the vessels are also set down as predisposing causes. Among the immediate causes are wounds and injuries to the arteries, sprains, violent exertion, and mechanical injuries of all kinds. Prognosis.—The prognosis in the case of aneurism is generally serious, and should always be guarded. As a general rule, it may be set down that they will terminate fatally if left to nature, though this is not invariably the case, whilst the time which may elapse be- tween the first formation of the tumor and its fatal issue will vary considerably, depending upon the position of the aneurism, the con- stitution of the patient, etc. etc. The prognosis as regards operations should also be made guardedly ; very often they are successful, but very often, also, they fail, and no positive prognosis can be made under any circumstances. 776 PRACTICE OF SURGERY. Treatment—In carrying out the general treatment of aneurisms, the surgeon should pay attention to the state of the general circu- lation ; this being so regulated as to diminish the current of blood through the part, in order that, by diminishing its force through the tumor, it may favor the formation of a clot. In other words, the principles of Valsalva should be carried out, the patient being kept at perfect rest, whilst digitalis or aconite is given to diminish the action of the heart. The strong tincture of the root of aconite (Flemming's tincture) may be employed in the dose of one drop at first, and gradually increased if the patient seems to bear it, to two, three, four, or even five drops twice a day. Low diet, by its modi- fying influence over the action of the heart, may also be expected to prove useful in the general treatment, and so will occasional bleeding. But in bloodletting for aneurism, and especially in aneu- rism situated near the heart, care should be taken not to carry the abstraction of blood too far, lest the heart's action being once sus- pended in syncope, it never return. The local treatment of the palliative kind would consist in the application of cold and astringents. The cold, which may act by somewhat diminishing the circulation in the tumor, should be applied in the shape of bladders filled with pounded ice; or cloths wet with cold water, combined with astringents, may very properly be employed. But little permanent benefit can be expected from such applications, and they are only of service when an aneurism which cannot be tied threatens to burst; in such a case, life may possibly be prolonged for a few days by means of cold and of astringents. Pressure upon the tumor, or upon the artery supply- ing the tumor, is, however, a very important means not only in the palliative, but in the radical treatment. This pressure has for its object the diminution of the circulation through the sac to such an extent as to cause it to be filled up rapidly by the concentric laminae of lymph already alluded to; but it should be borne in mind that the object of the pressure is merely to diminish the circu- lation through the sac, not to interrupt it altogether. Pressure may be applied in the treatment of aneurisms in various ways. One manner is that which is spoken of as Guattani's method, from the name of the surgeon by whom it was first carried out, iu which the whole limb is bandaged, graduated compresses being first suitably applied over the tumor and the course of the vessel supplying it. ANEURISM. 777 Fig. 257. There are, however, serious objections to this plan of treatment, as it is difficult, if not impossible, to apply such a bandage with sufficient firmness to have any efficacy in the treatment of the complaint without interrupting the circulation in the whole limb. There are, moreover, few persons who can so accurately apply a bandage as to avoid making unequal pressure upon some one point, thus inducing neuralgic pains, oedema, &c.; and as it has been found far from being the most successful plan of treatment so far as the results of cases were concerned, it has been very generally aban- doned. Compression, as a remedial agent in the treatment of aneurism, has, however, been recently revived, though in a modified form, by the Irish practitioners, and particularly by Bellingham, of Dublin. This surgeon applied pressure in the course of the ves- sel, but so as only partly to interrupt the circulation through the tumor, making the pressure sometimes upon the tumor itself, but most generally at some little distance from the sac, upon the artery supplying the tumor, and between it and the heart, in precisely the same relative position that Hunter suggested the ligation of the ar- tery for aneurism. That the various modes of exercising pressure may be understood, it may be mentioned, in this place, though somewhat in advance of the subject, that Hunter suggested the ligature of the artery upon its sound structure at some little distance from the aneurismal sac, and between the tumor "and the heart, and that it is on precisely the same principle that compression is to be applied, the femoral artery being com- pressed in the treatment of popliteal aneurism, &c. &c (Fig. 258). Brasdor, on the other hand, applied his ligature on the distal side of the artery affected (Fig. 258). And so, also, may pressure be applied particularly in those cases in which it would be impos- sible to apply it between the heart and the tumor, and it will be readily understood that the circulation being thus cut off on the Bellingham's Clamp.—a. Compress for the artery. b, Point of counter-pressure. (After Miller.) 778 PRACTICE OF SURGERY. distal side of the tumor by pressure, a olot will form, organization radically cure the aneurism. Fig. 258. A diagram of Hunter's, Brasdor's, and Wardrop's Operations for the cure of Aneurism, compression being capable of acting at similar points. Another modification of the seat of the ligature was that of Wardrop (Fig. 258), who, when an aneurism existed upon a vessel which afterwards branched, applied his ligature to one of the branches on the distal side, expecting, by thus partially diminishing the circulation, to favor the formation of a clot. Thus, in an aneu- rism of the primitive iliac, Wardrop tied the external iliac, leaving the internal untouched, and pressure may be applied upon this prin- ciple, also, but not with such hopes of success as in the former methods. The most successful mode of making pressure is, however, to make it between the tumor and the heart, with which pressure upon the tumor itself may advantageously be combined. The means by which pressure upon the course of the vessel sup- plying the tumor can be effected, without checking the circulation through the whole limb, are various; one is through a tourniquet, which consists of two pads fixed upon shanks of steel, that are made to approximate each other by means of a screw, an instru- ment to which attention has recently been invited in the Eastern States, and which has been spoken of as a new invention, but which ANEURISM. 779 really is very old, and was formerly described as Signoroni's tour- niquet. This instrument, however, by its unvarying pressure upon a single point, is very apt to give such pain that it can seldom be borne. A much better plan of effecting this pressure, is by means of the instrument which has been above described as Bellingham's com- pressor (Fig. 257), an instrument which has proved so useful, that out of thirty-nine cases of aneurism treated by means of it, thirty were cured. I have employed this instrument with such success, that in every case of aneurism to which compression was applicable, I would try it before resorting to so extreme a measure as the ligation of the artery, an operation which, in such a case, I should not look upon as justifiable if compression had not been tried. In compressing, say the femoral artery, by means of Bellingham's plan, two instruments are necessary, each consisting of a steel spring, having at one extremity a pad, to compress the artery, which can be tightened by means of a screw, and, at the other, a larger pad, to act as a support, these instruments being placed upon the thigh so that they can be made to act alternately, the second being tight- ened as the first becomes painful, and the first then relaxed so as to keep up a uniform interruption of the current in the vessel; but the compression should never be violent enough to entirely interrupt the current of the blood, but merely to modify and diminish it. This pres- sure requires, if any success is to be derived from it, to be patiently persevered in for from ten to twenty days. Another form of compression, and one which is suitable to the brachial artery, is that made by a spring which is connected with a strap, so as to buckle around the limb whilst the pad is capable of being pressed upon the artery by means of a screw. It is applied in the same manner as the clamp of Bellingham. Pressure made upon the aneurismal tumor in this plan accom- plishes a cure by effecting the same changes as are created by nature; the circulation being diminished in force, not sufficiently to destroy the life of the limb, but enough to favor to the fullest extent the formation within the sac of the lamellated fibrin already alluded to. Another advantage of the treatment by compression is that it involves little risk, may be made therefore by the most timid practitioner, and, if unsuccessful, does not interfere in the least with subsequent operative measures. As tbe success of the treatment by compression will depend very 780 PRACTICE OF SURGERY. much upon the judgment that is shown in applying the force, it should always be borne in mind that the correct plan is to employ it so as to diminish the circulation, without interrupting it, the pressure being at all times judiciously graduated with a view to this object. It should, moreover, be recollected that continued pressure upon one point, even when slight, will endanger sloughing, and that this may take place to such an extent as greatly to complicate the case. The local symptoms should therefore be carefully watched, and the compression, when it becomes painful at one spot, be re- placed by pressure at another. The next plan of treatment is the application of the ligature, which, in its effects upon a diseased vessel, is the same as has been already described, in connection with the sound artery. It is not necessary, therefore, to repeat in this place what was said upon the action of the ligature in the arrest of hemorrhage from wounds (see p. 240), and these remarks will therefore be limited to such points as have not been previously mentioned, and have an immediate bearing upon the subject of aneurisms. In old times, when the action of a ligature on a sound artery was very imperfectly understood, surgeons performed operations which were based upon peculiar views, great anxiety existing lest the ligature should not come away; its removal being supposed to be the result of the softening of the ligature. But in the diseased artery, and especially in aneurismal dilatation, they rather feared its cutting through the vessel too quickly. Thus Scarpa used a broad ligature, surrounding the vessel first with a little cylinder of waxed linen or muslin, to prevent it from coming off too soon, and over this he tied his ligature, but not tightly enough to cut through the middle and internal coats. Now there are cases—as when an aneurismal tumor is at the same time complicated with ossification of the artery—in which it may be advantageous to resort to Scarpa's method, lest from the diseased condition of the arterial coats the ligature should come away before the clot is sufficiently firm, in consequence of which troublesome secondary hemorrhage may result. But a serious objection to his mode of operating will be found in the fact, that not unfre- quently the internal coat is not sufficiently compressed to produce adhesive inflammation, and the external coat, moreover, is a very long time in ulcerating through; the ligature, therefore, takes many days to separate; whilst, except in the case of disease in the arte- ANEURISM. 781 rial coats, the risks of secondary hemorrhage will rather be increased than diminished by this plan of treatment. Another mode of applying the ligature in the treatment of aneurism was that of the old Greek and Roman surgeons—a plan which sprung from the fear which they entertained, and which we at the present day know to be ill grounded, that putrefaction might be set up in the cavity of the sac, after the interruption of the cir- culation through it. Accordingly, it was their custom to ligate the diseased artery both above pig# 259. and below the sac, after which they laid the sac open, and turning out its contents, removed the clots, sometimes even applying to it the hot iron. By this plan, however, and especially by the application of the cautery, the danger of secondary hemorrhage was infinitely in- creased; and as we now know how unneces- sary was the fear of putrefaction in the con- tents of the sac, no surgeon at the present day thinks, as a general rule, of laying open the sac and incurring the consequent dangers of suppuration, suppurative phlebitis, or the oc- currence of secondary hemorrhage. Hunter, in England, who was about the first to modify the old operation, acted upon a differ- ent principle; his ligature being applied to the sound part of the artery at a considerable dis- tance from the tumor, and between it and the heart, his object being to cut off the current from the seat of the disease, by interrupting the circulation through the main arterial trunk supplying the tumor. In this manner, the supply of blood being taken from the aneur- ism, the sac collapsed, its walls adhered, and the tumor was gradually obliterated; the artery beneath the seat of ligature remaining as a solid cord, whilst the clot behind the ligature, between it and the heart, rose as high as the next anastomosing branch. Meanwhile, as the circulation through the tumor was cut off, that through the limb was carried on by means of the anastomosing branches, Fig. 259. The A view of the Enlarge- ment of the Anastomosing Vessels, showing how the collateral circulation is carried on after the appli- cation of a ligature, a. Point where the femoral artery has been ligated. (After Liston.) 782 PRACTICE OF SURGERY. principles advanced by Hunter, in his mode of operating, are those now generally recognized as correct in all operations for the liga- ture of arteries, when required by aneurisms or wounds. Thus every ligature causes a diminution or cessation of the circulation in the main trunk, and an increase of that in the anastomosing branches, the enlargement of the anastomosing branches, after the application of the ligature, securing to the limb its proper supply of the vital fluid, and thus preventing its mortification. The effects of this new course in the circulation are easily shown in any large artery: Thus, if a ligature be applied to the external iliac artery, the blood can no longer pass through the femoral to supply the limb; the vitality of the parts below the ligature is, therefore, at once diminished, as is shown by a diminution in the temperature, and in the sensation of the part; though both are merely temporary, as, after a few hours, the natural heat of the limb is re- stored, or it may even rise above the healthy standard, in conse- quence of the rapid enlargement of the anastomosing branches, and the irritation created by the operation. The anastomosing branches which enlarge to restore the circulation in the limb, vary, of course, with the artery that is tied, but in the case of the iliac artery they would be the external mammary and epigastric, with the various other connections between the branches of the internal iliac and the femoral on the back of the thigh. Brasdor's operation for aneurism, as has been already alluded to in connection with the subject of pressure, differs from Hunter's in principle, the ligature being applied on the distal side of the tumor, in consequence of which the blood accumulates in the aneurism, and a clot is formed, that fills the whole sac, and rises as high as the first anastomosing branch. Now, there are cases where this is the only operation applicable, or indeed justifiable; take, for example, the case of aneurism of the innominata, the application of the liga- ture being here a difficult operation, and one which every surgeon would not be able to accomplish; whilst its fatal results are well known. Here, Brasdor's operation would prove particularly useful. It sometimes happens that there are two arterial branches given off from the distal side of the aneurismal sac, the' enlargement occurring, for example, at the very point at which the artery branches. In such a case, should one of the two branches happen to be an anastomosing branch, it may follow that, after the per- formance of Hunter's operation, pulsation will be observed to recur ANEURISM. 783 in the tumor, if another ligature is not applied on the second branch. After-Treatment—The after-treatment of the wound made in these operations, is that of all operations; one end of the ligature being cut off, whilst the other is left attached to the vessel, so that it will hang out at one angle of the wound. This angle should also be kept open by a strip of lint, so as to favor the free escape of pus, whilst the rest of the wound should be healed as much as possible by the first intention. Prognosis of the Operations for Aneurism.—The dangers incidental to these operations are, 1st, the danger of mortification. In order to combat this, it is necessary for the surgeon to prevent, as far as possible, that loss of temperature in the parts supplied by the artery, which has been already alluded to as among the first conse- quences of the application of a ligature. Heat, therefore, is de- manded, but it should be very cautiously applied, lest, when the anastomosing branches have enlarged, violent reaction ensue, and this reaction itself become a cause of mortification. The limb, therefore, should be placed in a convenient position and surrounded with wadding or raw cotton, or with cloths wrung out of warm water; or bottles, filled with warm water, may cautiously be applied, the surgeon removing all these appliances so soon as pulsation below the tumor shows that the collateral circulation is fairly estab- lished. If the reaction runs high, the cold water dressing, or other means for the application of cold, may be demanded. 2d. Having escaped the danger of mortification, the next danger incurred after the ligature of an artery, is that of secondary hemor- rhage. The success of this operation depends not merely on its cutting off of the circulation by means of the ligature, but in the establishment of such inflammatory action as will result in the formation of a clot, and the complete closure of the ligated artery as high as the first anastomosing branch. Now it may happen that the ligature shall cut through the arterial coats too soon, before such a clot is properly formed, or circumstances may delay the formation of the clot till some time after the ordinary date, or the artery may be tied so near a large anastomosing branch that the clot will be too short to resist the force of the arterial current; in either of these cases, secondary hemorrhage will be established when the ligature comes away, and the patient die before aid can be extended to him. It therefore becomes a matter of some im- 784 PRACTICE OF SURGERY. portance to watch him carefully, with a view of arresting this secondary hemorrhage should it occur; and it is well to watch him closely from the moment at which the ligature is applied until the wound has nearly healed; but particular vigilance should be exer- cised from the fifth to the ninth, or even the fifteenth day. With these general observations, which are applicable to all the arteries, a brief examination may now be made of particular aneurisms, mentioning only such points as are peculiar in the symptoms, pathology, or treatment of each. As a general rule, it will be found that the large arteries of the body, particularly those near joints, and at their curvatures, are most liable to aneurisms. Thus, the aorta is most frequently affected; and, of this vessel, the portion generally dilated is its arch. According to the statements of reliable authors, aneurisms of the aorta are as common as aneurisms of all the other vessels of the body taken collectively. SECTION I. ANEURISM OF THE AORTA. Aneurism of the aorta will create symptoms that will vary ac- cording to the part of the vessel affected; but, as a general rule, it may be said that they will be those due to pressure upon the sur- rounding viscera. § 1.—THORACIC ANEURISM. Symptoms.—In thoracic aneurism the symptoms will be those of irri- tation of the bronchia and thoracic viscera. As the tumor increases in size, there are, therefore, usually seen changes in the voice and ob- struction in the respiration from pressure upon the trachea. There is also some modification of the pulse, as dissimilarity in that of the two wrists, with the other symptoms of derangement of the circulation due to pressure upon the great vessels near the heart. After a time a tumor gradually makes its appearance, and this may show itself at various points, but generally anteriorly, sometimes rising up behind the sternum, at others appearing anteriorly and pushing directly ABDOMINAL ANEURISM. 785 through the walls of the chest, the ribs being absorbed by the pressure exercised upon them. Or there may be evidences given of disease of the spine, the vertebrae being absorbed or becoming carious, also in consequence of the pressure, whilst the spinal mar- row itself may be so encroached on as to produce paralysis and other symptoms equally characteristic of spinal disease. The causes of death in -thoracic aneurism are not unfrequently rupture of the sac or pressure upon the heart or the thoracic duct; this latter cause of death being too much overlooked, as death undoubtedly sometimes occurs, in this case, from the interruption of nutrition. Treatment—The treatment of thoracic aneurisms will be stated under the next head. § 2.—ABDOMINAL ANEURISM. Symptoms.—The symptoms of abdominal aneurism are connected with its pressure upon the abdominal viscera, creating various de- rangements of the bowels, oedema of the lower extremities, and dys- pnoea on account of the interference of the tumor with the action of the diaphragm; whilst finally we may note the appearance of a tumor, which, as the patient becomes emaciated, will show itself more dis- tinctly globular, and pulsate strongly through the abdominal pari- etes. Treatment.—The treatment in both thoracic and abdominal aneu- risms can only be expectant, no operative measures being of any avail. The plan of treatment known as Valsalva's or Albertini's may be adopted, and consists, as has been already mentioned, in the reduction of the force of the circulation by means of bleeding, digitalis, aconite, and similar measures. But it must ever be borne in mind that an aneurism of the aorta will sooner or later prove fatal, and that death will very probably be instantaneous, being due to rupture of the sac and the conse- quent hemorrhage; these cases terminating in this manner quite as frequently as by pressure upon the surrounding parts. When, therefore, satisfied of the diagnosis, it becomes the duty of every surgeon, in a case of this sort, to inform the friends of the patient of his true condition, in order that he may make those worldly arrangements which it may be desirable for him to complete be- fore his death. 50 786 PRACTICE OF SURGERY. SECTION II. POPLITEAL ANEURISM. Popliteal aneurism, as its name indicates, is one of the external aneurisms, which is situated in the popliteal artery, just behind the knee-joint. Symptoms.—Popliteal aneurism, as a general rule, first attracts the attention of the patient by causing a numbing sensation, or sometimes a sharp cutting pain, in the limb, at the same time that the patient is conscious of a peculiar feeling in the part, as if some- thing had snapped or given way. Soon after, a very violent pain is felt, running down along the leg, which is sometimes accompa- nied with cramp and spasms in the calf of the leg as well as the muscles supplied by the posterior femoral nerves. Then a tumor gradually makes its appearance, and enlarges with more or less rapidity, presenting pulsation and all the various characters of the aneurismal tumor before described. As this tumor enlarges, a disposition on the part of the patient to flex the limb becomes apparent, because, when the limb is extended, the pressure of the tendons of the part produces a pain which is relieved when these tendons are relaxed. As a general rule, the tumor shows a dis- position to extend rather to the outer than to the inner side of the limb; and it does this because the greater prominence of the head of the tibia on the inner side of the limb interferes with its development in that direction. This fact should be borne in mipd, lest the surgeon, seeing the tumor protruding rather to the outer side than in the median line, should suppose the aneurism to exist rather in one of the branches of the popliteal artery—such as the peroneal—than in the popliteal itself, which is much more generally the seat of the disease. The tumor thus formed and situated may attain the size of a hen's-egg, or even larger, and pursue, if left to itself, the same course as aneurisms elsewhere. Treatment—The most judicious treatment in the case of popliteal aneurism is compression; the ligation of the femoral artery in pop- liteal aneurism being a justifiable operation only when compression has been fairly tried. The mode of making this compression, particu- larly the mode which has been recommended by Bellingham, of Dublin, is as follows: Prepare two clamps like that shown in Fig. FEMORAL ANEURISM. 787 257, and apply one on the femoral artery, near the groin, and the other on the same vessel, in the middle third of the thigh, apply- ing the pressure of one whilst the other is slack, and loosening the first, but tightening the second, when the first pressure causes the patient to complain. In applying this pressure, too much caution cannot be used, to prevent its becoming intolerable; and it should always be recollected—as essential to success—that it should be very gently made, so as to diminish, and yet not interrupt the cir- culation through the artery. Unless compression is made very lightly and gradually, it will cause such pain that the patient will not be able to sustain it. The time required will vary from eight days to several weeks, the secret of success being found in the slow- ness of the compression, which it is again stated cannot be too gradually or lightly applied. SECTION III. FEMORAL ANEURISM. Femoral aneurism may be seen at all points in the femoral artery, but occurs mOst frequently high up in the groin, because, as the artery is more superficial in this situation, it is more liable to in- juries from wounds, &c. &c. The wounds that give rise to femoral aneurism not unfrequently result from the practice of carrying in the pocket such a weapon as a pistol, which, exploding accidentally, creates a wound the after consequences of which are femoral aneu- rism. In some cases, this weapon has been made to explode by leaning over the table in playing billiards. Symptoms.—The symptoms of femoral aneurism are those of aneurism generally; thus, a tumor forms; its pulsations are felt; and the patient complains, as the tumor enlarges, of neuralgic pain due to the pressure upon the nerves. Treatment.—The treatment is most- judiciously carried out by means of pressure where pressure can be effected; this being made upon the external iliac artery within Poupart's ligament, by means of Sio-norini's tourniquet.1 But on account of the difficulty of mak- ing pressure properly, this treatment has not been so successful in 1 See Operative Surgery, vol. i. p. 218, 2d edit. 788 PRACTICE OF SURGERY. femoral aneurisms, particularly those high up in the groin, as it has been in popliteal tumors. It should, however, be tried, and if it fails, resort can then be had to the ligature of the external or even of the primitive iliac, although success is to be hoped from the former operation much more than from the latter. SECTION IV. ANEURISM OF THE CAROTID ARTERY. Aneurisms are also found in connection with the upper extremities as well as in the neck. In the neck the most common form is ca- rotid aneurism, which is generally seated near the bifurcation of the carotid artery. Symptoms.—The symptoms are first the formation of a tumor, this tumor being situated in the parotid region and unaffected by the efforts of the patient to swallow, whilst it does not rise when the larynx rises. The aneurismal tumor cannot, therefore, be con- founded with goitre, as the pulsation is distinct, and the seat of it different in reference to the median line of the neck. There are various symptoms found in carotid aneurisms which are due to the pressure upon the surrounding parts, as more or less altera- tion of the voice from pressure upon the larynx; or more or less alteration in the sense of hearing from pressure upon the nerves connected with these parts; whilst, as the tumor enlarges, it may press upon the trachea, so as to interfere with respiration, or by de- ranging the circulation in the brain, interfere with the functions of that organ. Diagnosis.—It is possible to confound this disease with certain other affections of a very simple character, such, for example, as enlargement of the lymphatic glands of the part, these being tied down by the fascia and made to press upon the artery, so that they will receive a certain amount of pulsatile character. In diagnosti- cating such tumors it will, however, be observed that pressure upon the vessel does not diminish the size of the tumor as in aneurism, and if one of these simple tumors be pushed off from the artery to one side, or raised up from it between the fingers, the pulsation in it will cease, which would not be the case in aneurism. Treatment.—The treatment of carotid aneurism is by means of VARICOSE ANEURISM. 789 the ligature,1 compression being uncomfortable, uncertain, and likely to do mischief by compressing the jugular vein or other important organs. Aneurisms of the superior extremities sometimes occur, and are to be treated first by pressure, and if that fails, by the ligature.2 SECTION V. ANEURISMAL VARIX. Aneurismal varix is produced by a wound of an artery through the vein which establishes a direct communication between the two vessels. The injury is very frequently a result of careless vene- section in the bend of the arm. As a consequence of this wound the vein is observed to be filled with arterial blood, distended, tor- tuous, and varicose. Diagnosis.—The history of the case will be very valuable in form- ing a diagnosis. If the tumor has occurred after bleeding, such an affection might be suspected. Treatment—The treatment most likely to afford relief is com- pression both above and below, as well as over the tumor. SECTION VI. VARICOSE ANEURISM. Another form of aneurism of the extremities is that which is designated as varicose aneurism, which is a false aneurism that is Fig. 260. A Varicose Aneurism, showing the Aneurismal Sac between the Artert and he Vein.__a. The artery, b. The vein. e. The aneurismal sac. (After Sir Chas. Bell.) ' See Operative Surgery, vol. i. p. 544, 2d edit. 2 Ibid., vol. ii. p. 355, 2d edit. 790 PRACTICE OF SURGERY. formed between the artery and the vein, and opens into both, the sac being formed by the cellular tissue between the artery and the vein. Both these forms of aneurism are to be treated upon the same general principles, and are chiefly liable to occur in the same position, especially in the bend of the arm. SECTION VII. ANEURISM OF BONES. There is another form of aneurism, the importance of which de- mands a more extended notice than can be given to the subject in this place, and that is aneurism in the bones, the nutritious artery becoming the seat of an aneurism which produces absorption of the cancellated structure of the bone, and finally a tumor, which has, to a certain extent, the characters of aneurism elsewhere. Treatment.—The treatment is that of aneurism elsewhere, as com- pression, or the ligation of the vessel concerned. SECTION VIII. ANEURISM BY ANASTOMOSIS. One other variety requires mention in order to complete the enume- ration, and that is the form known as nasvus maternus, aneurism by anastomosis, or by the jaw-breaking designation of Telangiectasis. This affection is due to an enlargement of the capillary vessels of the skin, and forms a tumor in whioh the arterial or venous ele- ment—though generally the arterial—predominates. It is the same affection as was designated as "aneurism by anastomosis" by Mr. John Bell. This tumor is usually supplied by one or more principal vessels, and the best treatment will be found to be extir- pation, provided its size is not very great, and there is sufficient sound skin adjacent to the tumor to permit of its being dissected out, without incising the vascular structure.1 1 See Operative Surgery, vol. i. p. 236, 2d edit. PART XYII. AFFECTIONS OF THE EXTREMITIES. CHAPTER I. INFLAMMATION OF THE THECA AND BURSA. SECTION I. PARONYCHIA. Paronychia (jtapa, by, and o^f, the nail), or the whitlow of com- mon language, is the term applied to certain inflammations of the fingers and toes, and especially of the first phalanges. Varieties.—Four varieties of the disease are usually made by authors for the purposes of methodical study. But as the affection presents itself to the surgeon, these forms not unfrequently compli- cate each other to a considerable extent:— 1. In the first variety, we have a very superficial inflammation upon the dorsal face of the finger; pus forming around the matrix of the nail, and resulting generally in the destruction of the connection between the nail and the soft parts, whilst the nail falls out. This variety, strictly speaking, should pass under the designation of onychia, which was the term uniformly applied to it by the old writers, and is the complaint which in common language is desig- nated as a felon, while to paronychia the popular term whitlow is applied. 2. In the second variety, pus is found in the cellular tissue, which constitutes the pulp of the extremity of the finger. 3. In the third, the inflammation travels still deeper, and is found to involve the theca or sheath of the flexor tendons (seldom of the 792 PRACTICE OF SURGERY. extensor tendons), a circumstance which is due probably to the fact that the palmar face of the finger is more exposed than the dorsal to violence from accidents and other causes likely to produce inflammation. 4. In the fourth variety still deeper parts are invaded, the pus being now found beneath the periosteum of the phalanx involved. When these varieties of the complaint are examined, it is easy to perceive that they differ from each other only in extent. In all the disease consists essentially in inflammatory action, resulting in the formation of pus, the position of the seat of the inflammation being all that constitutes the varieties of the complaint. The symptoms, therefore, under all circumstances, may be described as those of inflammation, and differ only in degree. Symptoms.—The symptoms of the first variety, which is a simple inflammation that is circumscribed in extent and superficial in position, are first, a burning pain and slight circumscribed swell- ing around the matrix of the nail. The disease, therefore, is found chiefly on the dorsal face of the fingers and toes, and the in- flammation and swelling seldom extend beyond the limits of the first phalanx. The skin covering the part goes through all the changes of color which would reasonably be anticipated in a super- ficial inflammation, becoming dark red from capillary conges- tion, then violet, and by and by, more or less bluish, according to the chronic character of the complaint. Owing to the thinness of the skin of the part, so soon as the pus is formed, it shows itself as a yellowish band, surrounding the root of the nail. At last, the distension causes the skin to burst; the pus is evacuated, and the loosened nail comes off, being elevated first from the matrix. The new nail is generally found beneath the old, as the latter is thrown off, or is soon afterwards formed. But it is often vitiated in character, being sometimes harder and more horny than the natural nail, or if not vitiated in character, often takes an unnatu- ral direction, becoming incurved, this incurving in the toe being not unfrequently a cause of what has been designated as "ingrow- ing of the toe-nail." Among the laboring classes, the symptoms of the complaint are more severe; and as the skin is thicker, the pus finds greater difficulties in the way of its escape. The pain is there- fore more violent, and the suffering and constitutional disturbance more marked. In the second variety, there is an increase of all the inflammatory PARONYCHIA. 793 symptoms, and especially of the pain, because there is here a dense cellular tissue, containing the delicate nervous filaments connected with the tactile papillae, and it is easy to perceive that when pus is effused in such a structure, violent pain must be the result. The swelling is, therefore, more dense and hard, the fluctuation more indistinct, and the pus frequently not perceptible until it has accumu- lated to some amount; consequently, in this variety, the matter has a greater opportunity to travel than in the last, and it may go to such an extent as to result in the formation of the third and fourth varieties, which will readily happen should it involve the theca of the tendon, or the periosteum of the bone. In the third variety, in which the theca of the tendon is involved, the pain is more severe, often quite excruciating and lancinating, going up as high as the axilla, and in this respect resembling the pain in the fourth variety. The swelling also is more marked, extending often to the second and third phalanges (Fig. 261), and even upon the palm of the hand, while the congestion and obstruc- tion in the capillary circulation may be such as to give rise to ery- sipelas. Fig. 261. Paronvchia of the Thumb, showing the Swelling and Disorganization of Tissue. (After Miller.) In the fourth variety the symptoms are the same, though, if pos- sible, in a still higher degree, there being more marked constitu- tional disturbance, the patient sometimes remaining for days unable to sleep, and in a high state of nervous excitement. In any of these varieties, as soon as the distension of the skin has gone beyond the point which its elasticity can bear, it cracks, or ulceration is established, and the pus is evacuated. With the pus comes away more or less of a slough, or "core," as it is called in common language, involving often the theca of the tendon or the 794 PRACTICE OF SURGERY. tendon itself, portions of which may also come away, after which the bone may become carious, or, necrosed, and the whole pha- lanx, or even the finger (Fig. 262), be destroyed. From the ulcer, Caries of the Phalanges, as the result of badly treated Paronychia. (After Miller.) fungous granulations begin by and by to sprout, and the condition which results is not unlike in appearance certain forms of malig- nant disease. In this general survey of the symptoms of the more severe forms of paronychia, those of the constitutional irrita- tion ought not to be neglected, being those of irritative or traumatic fever generally, to which allusion has already been made in connec- tion with the subject of inflammation. Etiology.—The causes of paronychia are often not very apparent; the disease being sometimes undoubtedly due to epidemic influ- ence. Within the last few years such an epidemic has spread through the United States, sweeping not only along the Atlantic coast but down the valley of the Mississippi, and affecting persons of all classes. Sometimes the origin of the disease can be traced to a blow; sometimes to the little loose piece of cuticle near the root of the nail, familiarly spoken of as "widows" or "old women." It may also be due to the sudden warming of the hands after exposure to cold, and hence coachmen who drive in cold weather are apt to suffer. Sometimes it is created by puncture, as by a sharp-pointed instrument, the third and fourth variety being especially due to such Causes. Waiters and cooks, from punctures by forks, &c, therefore frequently suffer from the complaint. Prognosis.—The prognosis will depend upon the variety of the disorder, and upon the time which has elapsed before it was seen by the surgeon. Thus, the inconveniences resulting from the first and second variety are comparatively slight compared with those which may ensue on the third and fourth. If the pus is allowed to travel it will do mischief, and the prognosis will become much more serious; and hence it is that the disease generally eventuates much more seriously if left to itself than if submitted to appropriate treatment. Under all circumstances, the prognosis, so far as a per- PARONYCHIA. 795 feet cure is concerned, should be guarded, the disease being very apt to result, especially in the last variety, in the loss of the joint. Treatment.—The indications in the treatment are vety simple, and may all be summed up under one head, and that is the early eva- cuation of the pus, and the free division of the tissues so as to pre- vent the inflammation from spreading and involving the neighboring parts. By the words "early evacuation of the pus," I mean its evacuation within forty-eight hours after the symptoms have be- come well marked; and this is not only the safest, but also the most efficient plan, being the only one likely to save the finger. In the milder form of the complaint, that, for example, which is connected with the root of the nail, or that which involves only the pulp of the extremity of the finger, if the patient is timid and dreads the knife, or the physician is unwilling to make an incision, the pus may be evacuated by creating an ulcer which shall perforate the integument, through the application of caustics, as suggested about the year 1800, by Dr. Perkins, who effected his object by means of a caustic consisting of white vitriol, corrosive sublimate, &c. &c. The same thing, however, may be accomplished by the caustic pot- ash and the integuments perforated in precisely the same way that we would form an issue, a piece of kid with a hole in it of the size of the intended eschar being first bound upon the finger and the caustic applied. When the slough comes away, the pus will be evacuated; but this mode of operating is both more tedious and more painful than the operation by the knife. Should the surgeon fortunately see the case before forty-eight hours have elapsed, which is rarely done, he might attempt to check the inflammatory action by antiphlogistic measures, as leeches freely applied, cold lotions, &c. But it must be admitted that these means present but little chance of success. Stimulating applica- tions are sometimes popularly employed by patients and their friends in the treatment of these cases, and it is easy to perceive how such applications act, as there is a dense unyielding tissue, seized by inflammation, which is increased and hastened to an issue by the formation of a slough, the pus being evacuated, and the patient relieved when it comes away. The common applications to whitlows, such as brown soap and sugar; shoemakers'-wax; soak- ino- the finger in strong lye—a lye poultice, &c, act upon the same principle. Another application which is stimulating from the am- monia which it contains, is one which is common in the country 796 PRACTICE OF SURGERY. among the lower classes, to wit, the cowdung poultice; human urine (chamber-lye) also probably derives its real or supposed effi- cacy from the presence of ammonia. But although these popular applications may at times, and when nothing better can be done, possess a certain amount of efficacy, the educated surgeon will never hesitate about the course which he ought to pursue, but will proceed at once to lay open the diseased tissues and evacuate the pus if any have formed. And this must be done boldly and without fear or hesitation. A very slight refer- ence to the structures concerned will show that such an incision is really a very simple operation, and one which does not involve the slightest danger, the course of the flexor tendon being directly along the centre of the finger, whilst the artery and nerve are on each side. If, then, the incision be made lengthwise and along the centre of the finger, there is no danger of wounding the latter organs. The in- cision should be made boldly down through the theca and tendon to the bone itself, and should extend the whole length of the phalanx affected. If more than one phalanx is diseased, several incisions should be made, the number of incisions corresponding with the number of phalanges involved; but one incision should not be al- lowed to extend the length of two or three phalanges, because as this would cross the joint, the capsular ligament might be opened and an inflammation created which might terminate seriously. The incision should be made with a scalpel or bistoury, the scalpel being prefer- able, and the importance of cutting through the periosteum, if the pus is forming between that membrane and the bone, cannot be over-estimated, for, as the phalanx derives its nourishment from the periosteum, and the pus separates the two, an accumulation of pus in this locality must terminate in caries or necrosis of the bone. If the patient dreads the pain of the operation, anaesthetics may be administered. The relief experienced after the operation is generally great and speedy. Indeed, the first night's rest the patient has experienced for some time is often that following the operation. Should, however, this not be the case, some anodyne may be prescribed. The after-treatment requires' attention; as the exuberant granulation must be guarded against. At first, warmth and moisture are the means to be employed, the finger being surrounded in a sheath of spongio-piline, made like a finger-stall, but if this cannot be obtain- ed, a flaxseed poultice may be substituted, and the whole covered ENLARGED BURS^I. 797 with oiled silk. Then, after a few days, when the suppuration has ceased, the granulations which begin to form from the bottom of the wound should be regulated in their progress by touching them with the nitrate of silver. The subject of Paronychia is one which demands careful atten- tion from the surgeon, as the loss of the joint which it very fre- quently involves is a serious matter, and can generally be avoided by proper treatment. Sometimes, however, notwithstanding the best treatment, more or less deformity, contraction of the finger, etc., will result from the complaint, and the surgeon should always advise the patient of this fact when undertaking the treatment of the case. SECTION II. ENLARGED BURS^E. A reference to the anatomy of the different parts of the muscular system shows that certain points where the muscles pass over bones, as well as the sheaths of certain tendons, are lined by synovial mem- brane and bursas or little sacs which contain synovia. These are found in connection with the tendons of the wrist-joint; with the tendon of the patella; with the muscles inserted into the trochanter major of the os femoris; with the ankle, etc. Now, at any of these points there may be such a modification of the action of the bursal syno- vial membrane as will lead to an accumulation of the fluid within the sac and the formation of a tumor. This complaint generally en- sues upon over-exertion, upon pressure, or upon any such causes as would develop chronic inflammation in a synovial tissue, and like chronic inflammation sometimes results only in an increased secre- tion of the parts; but sometimes it goes still farther and creates an effusion of lymph into the cavity of the sac, the partial organization of this lymph leading either to the formation of a solid tumor or to those peculiar cartilaginous rice-shaped bodies which are sometimes found in enlarged bursas, and of which there are several specimens in the Wistar and Horner Museum of the University of Pennsyl- vania. Symptoms.—The symptoms of enlarged Bursas are generally easily recognizable. Thus there is a tumor formed by the accumulation of matter within the sac, whether of synovia or of lymph, this tumor 798 PRACTICE OF SURGERY. being more or less globular in its shape, and generally presenting more or less fluctuation in it. Sometimes, however, the contents of the sac so distend it that fluctuation can hardly be perceived, and then it might be mistaken for a fibrous or other solid tumor. When the tumor exists about the wrist-joint, it is called a ganglion, and as it often possesses these solid characteristics, it has been mistaken for dislocation of the small bones of the wrist, particularly when the tumor ensued on some injury to the joint. Pathology.—The pathology of enlarged bursas may be compre- hended at a glance, as they consist essentially in the chronic irrita- tion or inflammation of a synovial membrane, with increased secre- tion or effusion of serum and lymph, and the consequent modifica- tions of the action of a serous tissue. Varieties.—Different names are given to these effusions in the bursas, according to the different localities in which they are found, as will now be explained. § 1.—GANGLION. A ganglion has all the characteristics and presents all the symp- toms which belong to the complaint elsewhere. Treatment.—The treatment of ganglion consists in getting rid of the contents of the sac, and this may be accomplished in two ways. 1. By such means as are calculated to check the irritation and pro- mote absorption, as friction of iodine ointment, or the parts may be painted with the tincture of iodine. Pressure has also been recom- mended, though individual experience has led me to the opinion that all such means are but temporary, and that pressure, by caus- ing inflammation, rather leads to the increase of the disease. The best mode of treatment is 2. To promote the evacuation of the con- tents of the sac by rupturing it with a blow, or by a subcutaneous puncture; when the sac having been ruptured, the fluid will escape into the surrounding cellular tissue and be afterwards absorbed. But a less painful and more surgeon-like mode of producing the same result is by means of a subcutaneous puncture with some suit- able narrow sharp-pointed instrument, such as a tenotome, or a cataract needle. housemaid's knee. 799 2.—housemaid's knee. Fig. 263. Housemaid's knee is the name given to the disorder when the en- larged bursa is that of the tendon of the patella. This is a disease quite common in England, but much rarer in this country, our ser- vant-girls using the scrubbing-brush with a long handle instead of going upon the knee to use the hand-scrub; hence the disease is rarely seen in the United States, and when it is, is generally found among the natives of the British islands. When the disease occurs, it shows itself at first in the shape of a slight thickening or enlargement on the knee, but this soon be- comes a tumor, which is sometimes flattened, though generally more or less spherical, and is seated just below the knee-joint, corre- sponding in situation with the position of the bursa. (Fig. 263.) It is not only a deformity from its appearance, but creates inconveni- ence by interfering with the action of the tendon, and preventing the proper flexion and extension of the leg. It has been known, moreover, to create such inflammation as to involve the knee-joint secondarily. Treatment.—The treatment is to be con- Enlarged Bursa over the -, L i ,, • „••!„ „_ +i,„4. nf Patella—Housemaid's Knee. ducted upon the same principle as that ot (After Miller>) ganglion, bearing in mind, however, the dif- ference in the size of the tumors, this tumor requiring to be evacuated by a small trocar and canula, so as to draw off the fluid, when pres- sure may be made with a view of bringing into contact the sides of the sac and causing them to adhere. Should, however, this plan fail as it will very often do, and the tumor reappear, one of two plans may be resorted to. 1. An incision may be made and the sac entirely dissected out; which should be carefully done, every means being taken to pre- vent the consequent inflammation from involving the knee-joint; whilst any portion of the sac that is adherent to the patella and left behind should be cauterized by the nitrate of silver, lest the tumor be reproduced. 800 PRACTICE OF SURGERY. 2. The sac may be again evacuated, and its cavity injected with tincture of iodine, with a view of producing adhesive inflammation. § 3.—FEMORAL BURSA. Symptoms.—When the bursa which exists in connection with the passage of the tendons of the glutei muscles over the trochanter major of the femur enlarges, the symptoms will be very much the same as those' of the complaint elsewhere, but the dense nature of the structures covering this bursa gives to the tumor such a degree of firmness that it is often mistaken for one of those fibrous tumors which are not uncommon in this part. Diagnosis.—A diagnosis, however, may generally be made from the presence of more or less obscure fluctuation; from the situation of the tumor corresponding with the normal position of the bursa, and, if all other means fail, by the use of the acupuncture needle. Treatment.—The treatment is to be conducted upon the principles already laid down. SECTION III. NEURALGIA. Neuralgia, or a functional disturbance of the nerves of the ex- tremities, is another complaint, sometimes requiring surgical treat- ment, as patients not unfrequently present themselves to the surgeon suffering under excruciating pain in these nerves. Symptoms.—The parts supplied by the nerves affected often be- come atrophied, and to the violent pain are superadded all the inconveniences resulting from loss of power. Etiology.—Yery often these symptoms are the result of a punc- tured wound in the nerve itself. This wound may have been made with a needle, with a fork in the hands of waiters, cooks, and others, or with any similar instrument. Treatment—The treatment is simple, and may be carried out by means of anodynes, judiciously administered, as frictions with aconite ointment, or the tincture of aconite, or similar remedies. But when these have failed, it will sometimes be found desirable to VARICOSE VEINS. 801 cut down upon the main trunk and divide it, or even to remove a small portion of the nerve by incision. The treatment of neuralgia by division of the affected nerve has been required in various por- tions of the body; thus it has been performed in connection with the supra-orbital nerve, as well as with the facial nerve, &c. &c.; but in all these cases the principles guiding the surgeon are the same, and the only differences in the methods of operating will be those necessitated by the anatomy of the parts.1 SECTION IV. VARICOSE VEINS. Another complaint of the extremities which requires special attention from the surgeon is that designated as varicose veins, a disease which, from its frequency, from the inconveniences resulting from it, and from the dangers attending the operations which have been recommended in its treatment, demands careful study. The term varices, or varicose veins, derives its origin from the Latin verb variare, to turn, and indicates the tortuous and twisted condition into which the enlarged veins are thrown. The veins affected are generally understood to be those of the extremities, the disease, when existing elsewhere, being spoken of under some special designation. Thus, when the veins of the rectum are enlarged, it is known as hemorrhoids, or piles; when the veins of the scrotum are affected, it is called varicocele; whilst the term varices is most generally limited to the form which is found in the external veins of the lower extremities. Etiology.—Varices are generally due to some obstruction in the course of the veins—such as the pressure exercised upon the iliac vessels by the gravid uterus during pregnancy, or certain other tumors, as enlargement of the liver or spleen; tumors within the abdomen; impacted fasces in the rectum, &c. &c; or that created on the saphena or femoral veins by hernia. It has also been caused in the upper extremities by the pressure of the edge of a desk upon the forearm of a patient, and I have seen a well-marked case of it 1 See Operative Surgc-ry. vol. i. p. 242, 2d edit. 51 802 PRACTICE OF SURGERY. in the upper extremity which was due to this cause, in the person of the editor of a newspaper. As the superficial and the deep-seated veins inosculate freely, they both usually participate simultaneously in the complaint, though the external are the most evident; and this should be particularly remembered, as it will serve to show the ultimate inefficiency of certain operations which have been highly recommended for the cure of this disorder. Symptoms.—After the disease has existed for some time it begins to exert an influence over the whole system, but is first shown in a disturbed local circulation, the veins of the part carrying the blood sluggishly to the heart, owing to the continuance of the ob- struction which has produced the disease, whilst as the arteries of the limb continue to supply it as freely as ever, an effusion of the more liquid portions of the blood takes place into the super- ficial cellular tissue, from which swelling and thickening of the whole limb result. Meantime distension renders the coats of the vein itself, and often the skin immediately covering it, thinner and thinner, until at last it bursts, and a troublesome hemorrhage is the result, or ulceration may be established, and the condition formerly described as varicose ulcer ensue. With regard to the general symptoms, they are often well marked; thus the patient first experiences a tingling or itching in the skin of the limb, which is followed by an irritation that often shows itself in the form of eczema rubrum, many cases of this latter dis- order being due to the irritation of varicose veins, and to the in- terference of the distended veins with the capillary circulation of the affected limb, he also is often troubled with a sense of weight and fulness. When the limb is examined, a change will be at once noticed by the surgeon in the appearance and course of the veins, and as these vessels have become tortuous and knotted, they can be felt beneath the skin, giving to the fingers very much the sensation of a bundle of worms in a bag; besides which their tor- tuous and knotted appearance can be readily discerned by the sight (Fig. 264). The limb itself is also swollen and thickened, and gives evidences of effusion beneath the skin. Prognosis.—The prognosis is favorable as regards the effects of the complaint upon the health and life of the patient, but unfa- vorable in respect to the permanent cure, for, though the disease may be relieved and rendered supportable, yet I know of no method VARICOSE VEINS. 803 likely to effect a radical cure; nor have I found that any of the plans of treatment, or even of the severe and dangerous operations which have been devised for the purpose, have ever succeeded in effecting a cure, without a return of the affection at some subse- Fig. 264. quent period. If the complaint is left to itself, the chief inconvenience will be the ultimate formation of the va- ricose ulcer, the principal danger from which will be the hemor- rhage to which it may give rise. Treatment. — The chief indica- tions in the palliative treatment are, 1. To support the coats of the veins; and, 2. To check the dis- position towards hemorrhage. The palliative treatment con- sists in the use of cold bathing, with a view of diminishing the activity of the circulation; in frictions of such substances as are likely to modify the effusion of lymph into the cellular tissue; such, for example, as mild mer- curial ointment rubbed upon the limb, or advantage may be de- rived from the use of iodine oint- ment Or of the tincture Of iodini A view of the Position and Tortuous . eo Character of Varicose Veins on the inner painted upon the part, &C. &C.; side of the Left Leg., (After Liston.) whilst such lotions may be em- ployed as will harden the skin, and enable it in the end to act the part of a bandage. Advantage may possibly be derived in certain cases from an imitation of the practice of certain of the veterinary surgeons in the cases of " bog spavin" in the horse, in which a hot iron is ap- plied in several places so as to sear the skin, in order that the contraction of the cicatrices consequent upon the operation may so contract the tissue as to cause it to exercise pressure upon the distended veins. 804 PRACTICE OF SURGERY. But perhaps the safest and most efficient way of treating varicose veins, and a method which does quite as much permanent good as the many painful and dangerous operations recommended in this complaint, is the application of equal and judicious pressure by means of bandages, laced stockings, gaiters, and similar appliances. Of these, the best contrivance is the elastic stocking, which consists of a stocking properly shaped, and formed by the inter- weaving of silk with the fibres of caoutchouc. This stocking should be rather tight than- otherwise at first, as, after it has been worn for some time, it is apt gradually to become too loose to answer a good purpose. If, however, the expense or difficulty of obtaining this article should be an objection, a very excellent sub- stitute may be made of brown holland by any seamstress; but a buckskin tongue should be placed under the lacing to prevent the cord which laces it up from welting the skin, a very important point in the result, as, in a bad case of varicose veins, the most trifling welting may lead to ulceration, hemorrhage, &c. With this simple plan as much may be accomplished as by any other method yet devised, though it will not effect a cure, the patient being obliged to continue the use of his elastic or laced stocking for years, perhaps for life. On account of the length of time which the disease as thus treated lasts, and on account of the expense of the apparatus necessary to carry on the treatment, surgeons at different periods have recommended various operations, these operations being stated at length in the Operative Surgery,1 but I must enter my protest against the performance of any of those which incise the veins, and can conceive of no case so severe as to justify the risk of such operations, and my objection to them is still further increased by the fact that they can rarely or ever accomplish more than a temporary relief, owing to the free anastomosis between the deep and the superficial veins. Such an anastomosis may be readily proved by injecting the veins after death, and any one who wishes to test the value of the so-called radical cures of varicose veins can easily do so on the dead body by tying the saphena major both at the knee and in the middle of the calf, and then injecting a vein in the foot with a fine injection, when he will find the superficies of the limb finely mapped out with the injecting material that has run in all directions around the ligated veins. 1 Operative Surgery, vol. ii. p. 351, 2d edit. CLUB-FOOT. CHAPTER II. CLUB-FOOT. Talipes, or Club-foot, is a very common complaint, and one which, as it generally makes its appearance at birth, or in young children, causes great anxiety to parents. This deformity presents certain details applicable to the whole class not only of club-feet, but of deformities in general; and a very slight examination of the subject will demonstrate, that club-foot has many points in common with strabismus; with spinal curvature (muscular); with certain forms of torticollis, with club-hand, and all other similar deformities. Before, then, we proceed to study the symptoms and treatment of the disease in question, it is right that allusion should be made to some of the points connected with the action of the muscles, which are common to all deformities. As deformities from muscular action are due to the general law that the two sides of the body are equal, and that the muscles of each side have an equal amount of power, due allowance being made for the slight predominance of those of the right side over those of the left, on account of their being more exercised, there are certain general principles" applicable to their treatment which should be here alluded to. For instance, it is well known that where the muscles of one side are contracted, those of the opposite portion are usually lengthened; and that where those of one side are overacting, those which oppose them must be acting with diminished power. In all these cases, therefore, it will become the duty of the surgeon not only to overcome this excessive action and weaken the power of the contracted muscles, but also to stimulate and favor the contractile power of the elongated muscle, whilst he hardens the skin on those points where pressure is to be made, in order that it may be better borne. These principles apply to all deformities as well as to those which are included under the head of club-foot. Symptoms.—Club-foot is a deformity in which there is more or 806 PRACTICE OF SURGERY. less deviation in the axis of the foot in one of several directions: thus the toes may be depressed, and the heel elevated; or, the toes may be turned inwards or outwards, or various modifications and combinations of these conditions may be present. Etiology.—The causes of club-foot are varied, and by no means thoroughly understood. By the older writers, this affection was ascribed to various causes, all more or less absurd; thus, it was supposed to be due to the fact that, during pregnancy, the mother had seen something disagreeable, or suffered so as to induce a con- traction in the toes of the foetus, and this absurdity is still popularly believed in, as I was once told by a lady of high education, that a club-foot in her child, to which she called my attention, was caused by her having stumped her toe when about her third month of pregnancy. By some it has been ascribed to unnatural or irregular contractions of the uterus upon the foetus, and by others to the umbilical cord having accidentally been wound around the limb; and this latter may sometimes have really been the active agent in producing the deformity, though the general cause applicable to nearly every case of congenital club-foot, is want of proper inner- vation, and the student who would truly understand the pathology of this disease, must start with this idea. The fact that so many infants with club-foot also show more or less deviation in the spinal column, laterally, and even sometimes suffer from spina bifida, or harelip, would point out the fact that, in the majority of these cases, there is more than a mere local dis- order. My own impression is, that the position in utero, so much spoken of in connection with this subject, has little to do with the complaint, and that the cause of the deformity is generally to be sought in the spasm of the muscles created by disorder of the nervous system. Varieties.—Five varieties of the complaint have been made by authors:— 1. The first and simplest is designated as pes equinus, because the individual laboring under the complaint when he comes to walk, walks as a horse does, upon the end of the phalanges, the heel being elevated and the toes depressed. This variety, though sometimes existing alone, is very generally more or less combined with those which will next be brought into consideration. 2. The second variety is the reverse of pes equinus; as here we have a depression of the heel and an elevation of the toes, so that PES EQUINUS. 807 the patient stumps along upon his heel, this being the variety known as pes calcaneus. 3. The third variety is one of the most common, and is that in which there is a turning inwards of the metatarsal bones and of the toes, as well as an elevation of the heel; and this form has received from writers the designation of varus. 4. The fourth variety is called valgus; and here the toes and the supporting metatarsal bones are turned outwards; this condition being, therefore, directly the reverse of varus; but, like it, gene- rally combined with more or less elevation of the heel. 5. The last variety is pes plantaris, a deformity in which there is a doubling under of the toes beneath the sole of the foot, so that the individual walks upon his instep, or upon some part of the upper portion of his foot. That much may be done towards remedying these various con- ditions by mechanical means, will readily be understood by any one who will reflect upon the great changes produced by pressure and bandaging upon the foot of the Chinese lady, and it is there- fore but reasonable to suppose that means so potent in the pro- duction of deformity in the sound limb cannot but be useful, if judiciously applied to the case of one that is diseased. SECTION I. PES EQUINUS. In taking up the special consideration of these different varieties of club-foot, attention may first be given to pes equinus, as the con- traction of the gastrocnemius and soleus muscles, or a certain amount of pes equinus, not unfrequently complicates varus and valgus. In order that the student may understand readily this or any other variety of club-foot, a brief allusion to the structure of the healthy foot will be useful. Anatomical Relations.—In the foot we have the articulation of the bones of the leg with the astragalus, which bone articulates below with the os calcis, and forwards with the scaphoides; whilst the os calcis which projects posteriorly and inferiorly, forms the heel, and gives an insertion to the tendo-Achillis. This bone articulates ante- riorly with the cuboid, which supports the fourth and fifth rneta- 808 PRACTICE OF SURGERY. tarsal bones; whilst the scaphoid articulates anteriorly with the three cuneiform bones which support the first, second, and third metatarsal bones. Any of the varieties of club-foot alluded to, after it has existed for a short time,.will cause displacements of these bones of the tar- sus, so that the articulating surfaces shall be much modified, or it may even go to such an extent that the appropriate articulating facets of the bones shall no longer present to each other. Besides these changes in the bones, the modifications in the action of the muscles themselves require special study. Thus, in pes equinus, we have an over-action in the gastrocnemius and soleus, which induces a shortening in these muscles, which draws up the heel by means of the insertion of the tendo-Achillis into the os calcis (Fig. 265). The antagonistic muscles, on the other hand, are lengthened. As a re- sult, changes must necessarily be experienced in the limb, the tibia no longer resting upon the articulating surface of the astragalus, owing to the violent extension of the foot, but being seated upon this bone posteriorly to its usual articulating face, or forming a new arti- culating surface upon the os calcis itself. Like displacements also occur in the relations to each other of all the tarsal bones, as can very readily be understood. We have then in a case of pes equinus first, a deviation in the nor- mal contractility of the muscles concerned; then a deviation in the articular faces of the bones, which are no longer presented properly to each other; next various de- viations in the ligaments of this part, these becoming irregularly stretched, in order to accommodate the bones in their new posi- tion. When all these facts are taken into consideration, it will be understood that mechanical means for the treatment of such a deformity can only overcome it if used patiently, and for a long time, it being ab- solutely essential to a cure, that some treatment should be persevered in until the extended and relaxed ligaments, and the new faces of the bones have resumed their normal relations, a fact which should not be lost sight of, in all cases of club-foot. Fig. 265. Position of the Foot in Pes Equinus in the adult. (After Miller.) PES EQUINUS. 809 Post-mortem Appearances.—A dissection of a case of pes equinus shows that, among the muscles, the gastrocnemius and soleus, with the plantaris and the plantar fascia, the tibialis posticus, and the peronei muscles, and especially the peroneus longus, are all more or less contracted, their antagonistic muscles being weakened, relaxed, and extended. Treatment.—A judicious surgeon, in carrying out the treatment of pes equinus, will therefore continue to use for some time such mechanical means as tend to restore the equilibrium of the over- balanced muscles of the foot, and overcome the deformity, and either .trust entirely to them or combine it with such operative measures as shall have for their object the division of the contracted tendon and the subsequent elongation of the effused and organized lymph that unites its divided extremities. The mechanical means adapted to the treatment of simple pes equinus may be resolved into such measures as will elevate the toes and bring down the heel, and are usually designated as the club-foot shoe, or as the club-foot apparatus. Of these, there are a great variety, most of which are modifications of the old shoe of Scarpa, though the progress of the mechanic arts has now furnished several specimens of a very neat mechanism, and efficient action. That made by Kolbe will be again alluded to (Figs. 273, 274). In preparing the patient for wearing any of these, the surgeon should harden the skin by bathing it in strong oak-bark tea, in order that the pressure necessary to effect his object, and which must necessarily be kept up for some time, may not cause a trou- blesome ulceration in the foot. Then, with a view of increasing the efficacy of the mechanical measures, and saving much valuable time—valuable because while the deformity exists the bones are becoming more and more difficult to shift from their abnormal position—it may be advisable to practise the division of the tendo- Achillis as the most powerful of those concerned in the production of this deformity. The division of this tendon may be accom- plished1 by a little knife, which is designated as a tenotome, and which is introduced flatly beneath the skin between it and the tendo-Achillis, and then turned so as to cause its edge to present towards the tendon, when the foot being put upon the stretch, the tendon will be brought up against the knife and divided, by forcibly 1 See Operative Surgery, vol. ii. p. 354, 2d edition. 810 FRACTICE OF SURGERY. extending the foot, the division of the tendon being recognized by an audible snap. The limb being now left at rest, the ordi- nary changes of subcutaneous wounds ensue, such as the effusion of blood, the liquid portions of which are by and by absorbed, after which there is an effusion of lymph, which becoming organized, unites the two cut extremities of the tendon. This new tissue, when first formed, is elastic and extensible, and if at this period mechanical measures are applied, the heel may gradually be brought down, and the deformity overcome in a few days. But the rationale of this plan of treatment should never be lost sight of; for, if the surgeon ignorantly brings the heel down, by mechanical means, immediately after the division of the tendon, non-union may be the result, or so much new structure may be formed, that the in- creased length of the tendon will be greater than is desirable to restore the equipoise of the limb, and the patient be lamed for life, being thus rendered unable to contract his gastrocnemius muscle sufficiently to raise the heel from the ground. Fig. 266. View of a Foot after the Heel is brought down in Pes Equinus. (After Miller.) The surgeon should, therefore, delay about five days after the operation of tenotomy before mechanical means are employed, and only apply them very gradually at first. If the heel be brought down one line a day, in less than two weeks it will have descended PHALANGEAL VARIETY OF PES EQUINUS. 811 an inch. Gradual extension, therefore, is amply sufficient, and it is only by such pressure and patient perseverance that the cure can be accomplished. After the heel is thus brought to the ground, the patient, though well able to walk, will generally present some deviation of the foot, if it is closely examined (Fig. 266). § 1.—PHALANGEAL VARIETY OF PES EQUINUS. In connection with pes equinus, it is necessary to allude to what is called the phalangeal variety of that complaint. This is simply the variety of the disease seen in children who have never walked; children, for example, under twelve months of age: and in connec- tion with this subject I would allude to one cause which sometimes produces pes equinus in children who had originally perfectly healthy feet, and that is the practice, now fortunately going some- what out of fashion, but recently very popular, of amusing children by suspending them in the apparatuses popularly called "baby jumpers." In this the child was suspended from a hook in the ceil- ing, by a little contrivance which surrounded the body, and was so arranged that it could barely touch the floor with its toes. Then the suspending cords being elastic, the least motion of the child produced a dancing up and down, which seems to have delighted equally the infant and the mother or nurse who had it in charge. But in consequence of the foot being kept constantly extended, and the heel elevated, more than one instance has occurred, within my own knowledge, in which a spasmodic contraction of the muscles in the back of the leg took place, and a temporary pes equinus was produced. SECTION II. PES CALCANEUS. The second form of the complaint to which attention may next be given is precisely the reverse of pes equinus. Here the toes go up and the heel comes down, so that the patient walks exclusively 812 PRACTICE OF SURGERY. upon his heel, producing the deformity described as pes calcaneus, or that which is popularly called hook- as- 267- ed-foot. It is a comparatively rare form of deformity. The os calcis here sustains the weight of the body, and the muscles on the back of the leg are preternaturally elongated, while those upon its front are preternatu- rally contracted; the muscles whose contractions have most effect in pro- ducing the deformity being the exten- sor communis, the extensor proprius a side view of the Right Foot in pollicis, and the tibialis anticus. This Pes Calcaneus. (After Nature.) l ' form of the complaint is very marked in some instances, and is sometimes carried to such an extent that the anterior face of the os calcis looks upwards instead of forwards. In these cases there are, of course, modifications of the articulating surfaces of the os calcis and of the bones connected with it, as the os calcis no longer articulates in the normal manner with the cu- boid, whilst the bones of the tarsus are generally displaced. Of course, there are also changes in the ligaments of the part, caused by the changes in the position of the bones; thus, the ligaments upon the bottom of the foot will be found to be elongated, while those on the dorsal surface will be shortened. Treatment.—More may be done in the treatment of this complaint by prompt mechanical means than in most of the other varieties, as the form of the foot enables the pressure adapted to the treat- ment of pes calcaneus to be so readily borne that this form pre- sents few difficulties if treated at an early period of life. In order to bring the foot down, such measures as were directed for the re- lief of fracture of the o's calcis, may be resorted to. SECTION III. VARUS. In Varus, the toes and metatarsal bones are turned inward (Fig. 268), and the heel is almost always elevated, showing that the com- plaint is combined with a certain amount of pes equinus. The VARUS. 813 changes in the bones and ligaments, in this form of the complaint, are very marked, and due often to an arrest of development in the bones of the tarsus, this being conjoined not unfrequently with a deficiency of calcareous matter in the bones concerned, so that they readily bend, a condition well illustrated by a specimen in the Wis- Fig- 2.68. Fig. 269. Fi". 268.—Outside view of Varus in the adult, the deformity not very marked. (After Mille°r.) Fig. 269.—View of the Imperfect Development and Displacement of the Bones in Varus. (After Miller.) tar and Horner museum, of the University of Pennsylvania, a fact which should be borne in mind in connection with the treatment. The principal muscles contracted in this form of the complaint are the gastrocnemius and soleus, tibialis anticus, and the plantaris and plantar fascia, the latter presenting strong lines, which can be dis- cerned through the skin, and may be felt distinctly in the sole of the foot the latter being turned inward instead of downwards. The tibialis posticus and adductor pollicis are moreover contracted, while the peronei and other muscles antagonistic to those just named are generally lengthened. As the disease continues and the child begins to walk, certain changes will be noticed in the external tissues, consequent upon pressure. Thus, there is thickening of the skin, and a true hypertrophy at the point at which it comes in contact with the 814 PRACTICE OF SURGERY. ground. Sometimes a bursa (Fig. 270) forms between the thick- ened skin and the deeper-seated parts. Fig. 270. Fig. 271. Fig. 270.—Outside view of Varus, showing the Bursal Pad or Tumor upon which the patient walks, this pad presenting a full, rounded, cushion-like point of support. (After Nature.) Fig. 271.—View of the Sole of the Foot in a marked case of Varus, showing the contrac- tion of the plantar fascia, &c. (After Nature.) SECTION IV. VALGUS. Fig. 272. Valgus is a very rare form of club-foot. The disposition here is to turn the toes and metatarsal bones outwards; and it is, therefore, * just the reverse of varus. The changes produced by this deformity are readily understood: thus there is a perfect flattening down of the tarsus (Fig. 272), the sole of the foot becoming as flat as that of a negro, whilst there is the total loss of that fulness of the instep which exists in the white man. Valgus is also more common in the negro than in the white man, and among the several ne- groes known to me who labor under this complaint, almost every case is combined with a marked degree of weakness of intellect, the patient being moreover knock-kneed, in connec- tion with the inclination of the foot outwards. The muscles contracted in this variety are those antagonistic to the muscles contracted in varus. They are generally the peronei muscles, es- pecially the peroneus longus and the A front view of Valgus, showing the eversion of the toes, and the inversion of the Heel, with the flat tening of the Instep. (After Na- ture.) TREATMENT OF ALL THE VARIETIES OF CLUB-FOOT. 815 muscles of the same group, whilst there is an elongation of the plantar fascia and of most of the muscles contracted in varus. The changes affect here principally the astragalus and the cuboides among the bones of the tarsus. SECTION V. PES TALUS OR PLANTARIS. This last variety of club-foot is a very rare one, and is called pes talus or plantaris, the foot being so deformed that the patient walks upon the dorsal surface of the toes, of the metatarsal bones, or of the tarsus; in other words, walks upon the top of the foot instead of the sole. Sometimes it is combined with varus, and then the joint of the little toe, with its metatarsal bone, becomes the point of support when the patient walks. SECTION VI. TREATMENT OF ALL THE VARIETIES OF CLUB-FOOT. In the treatment of any of these varieties of club-foot, much may be done, while the infant is yet in the arms, and too tender to be treated by mechanical contrivances or by operative means, if the nurse, by proper manipulations with her hand, will draw the toes up carefully from time to time if the form of the affection be pes equinus, or bend the instep outwards, if it is a case of varus. As the child approaches the age at which mechanical contrivances can judiciously be applied, say from six to twelve months old, the skin should be hardened by soaking it in oak-bark tea, as above directed, in order that it may be better enabled to bear the pressure of any of the forms of apparatus which may be deemed best in the treatment of the complaint. In any of these varieties, where the heel is elevat- ed, operative measures—as the division of the tendo-Achillis, before alluded to—may be demanded. After which, or from the first, if operative means are not used, some mechanical apparatus will be required, these being persevered in for many months, and a firm support,'in the shape of a stiff boot, worn for years subsequently. • 816 PRACTICE OF SURGERY. One of the best forms of apparatus for the purpose of extension, and which is perfectly adapted to pes equinus, if uncomplicated with varus, is a modification of Scarpa's shoe, which can be made to ad- just itself, by means of a screw, to any angle of inclination required. (Fig. 273.) When this contrivance has been fastened to the foot, by means of properly adjusted and padded straps, the motion of Fig. 274. Fig. 273.—A view of Kolbe's Club-Foot Apparatus.—This ingenious instrument is applicable to all the forms of Club-Foot, but especially to Pes Equinus, the position of the foot being changed by means of the key attached to the figure, thus presenting one advan- tage over some other forms of apparatus, that, when the key is removed, the friends cannot displace the angle of the apparatus, although they can remove it entirely from the foot. It also can be worn whilst the patient walks about, which is not the case with some other forms of the adjusting-shoe. (After Nature.) Fig. 274.—Three-quarter view of Kolbe's Adjusting Shoe for Varus.—This ap- paratus is especially applicable to Varus, and may be adjusted to any angle of the foot, and deviation of the heel, by means of a universal joint, though it will not permit the patient to walk.—1. Pivot for key to move the joint. 2. Joint which revolves three-quarters of a circle laterally and antero-posteriorly. (After Nature.) These forms are made at No. 45 South Eighth Street, Philadelphia. Fig. 273. the screw, changing the position of the sole to which the foot is strapped, can be made to bring the foot gradually into any position TREATMENT OF ALL THE VARIETIES OF CLUB-FOOT. 817 which may be required, whilst the child will yet be able to walk about, as the apparatus is so jointed as to permit it. For varus, and especially for a case in which no effort has been made to bring the metatarsal bones into the proper line, a special apparatus will prove useful, and sufficient to accomplish the cure, without tenotomy, or any incision of the plantar fascia. As in this form of club-foot it is desirable that the patient should not walk, lest one of the pads, formed by the bursa, be created, and subse- quently make a deformity, an apparatus similar to that shown in Fig. 274, may be required, and Mr. Kolb& has so arranged this shoe, that it may be adapted to almost any length of leg, or any inclina- tion of the foot. If a finished apparatus cannot be obtained, a ruder article, upon the same principle, might be fashioned, under the surgeon's direc- tion, at any blacksmith-shop in the country; and a very little me- chanical ingenuity will often produce one that will prove quite as useful as that furnished in the cutler's shop. Much good may be accomplished, in the simple cases of pes equi- nus, by surrounding the foot by a handkerchief, binding another around the calf, and then connecting the two together by a third, or by a bandage or string, which from day to day might be tight- ened ; or strips of adhesive plaster or bandages might be employed, in the same way, instead of handkerchiefs, so as to draw the toes towards the tibia. After from six to nine months' careful use of such an apparatus, the patient may wear an ordinary shoe, with club-foot, or side irons, if the foot has been brought to its correct position. But generally the apparatus will be required to be worn by a child a full twelve- month, before shoes can be well adapted to it. No greater error, however, can be committed in the treatment of club-foot, than an anxiety to establish a prompt cure. The reduction of the deform- ity must be very gradually accomplished, and maintained by a con- tinuous perseverance in the use of an appropriate boot for years, whilst the child is growing. It is therefore generally advisable to explain these facts to the parents before commencing the treat- ment. 52 INDEX. PAGE Abdominal aneurism 785 Abscess, acute 89 of antrum 624 of the septum narium 617 Abscesses 88 acute, constitutional treatment of 94 diagnosis of 91 evacuation of 93 prognosis of 91 puncturing of 94 symptoms of 91 treatment of 92 cold or chronic 95 symptoms of 95 treatment of 96 Action of ligatures 240 Actual cautery 245 Acute abscesses 89 or healthy ulcers 113 causes of 114 treatment of 114, 115 Adhesion 82 Adhesive plaster 251 Adipose tumors 221 Affections of antrum Highmori- anum "23 of cheek 626 of lips 626 of mucous membranes 702 of rectum '55 of skin «03 of throat . 627 Albertini, treatment of aneurism 785 Albugo 582 Alopecia # '£} Amaurosis ^ Ankyloblepharon 5bJ Anchylosis 544 apparatus for 54° of elbow-joint 547 of knee-joint 548 PAGE Aneurism, abdominal 785 by anastomosis 790 of aorta 784 of bones 790 of carotid artery 788 of femoral artery 787 of popliteal artery 786 Aneurismal varix 789 whirr 774 Aneurisms 769 Ankle-joint, luxation of 534 compound 536 Anodynes, in inflammation 73 Anthrax, constitutional symptoms of 152 diagnosis, prognosis and treat- ment of 152 local symptoms of 151 Antidotes for poisons in stomach 635 Antrum Highmorianum, affec- tions of 623 abscess of 624 Anus, affections of 749 eczema of 750 fissure of • 753 tumors of 755 Application of leeches 65 of tourniquet 243 Ardor urinae 660 Arteries, coats of 236 Arthritis 541 Artificial haemostatics 240 Astragalus, luxations of 536 Atheromatous tumors 224 B Balanitis 658 Bandaging 123 Barton's bandage for fracture of lower jaw 343 bran dressing 446 820 INDEX. Barton's— page fracture of radius 381 handkerchief 433 Baynton's plan of treating ulcers 122 Bed, preparation of a fracture 327 Bellingham's clamp for treating___ aneurisms 777 plan of treating popliteal aneu- rism 779,787 Benignant tumors 217 Bites of rabid animals 265 of serpents 202 Bladder, affections of 717 Blear-eye 565 Blind fistula 761 Boils 149 Bond's splint for fracture of radius 386 Bony tumors 480 Boyer's dressing for fractured hu- merus 369 for fracture of leg 431 for fractured patella 423 Brasdor's clavicle bandage 360 operation for aneurism 782 Bubo 691, 697 Burns 155 cicatrices from 162 diagnosis and prognosis of 158 Dupuytren's classification of 156 seat and symptoms of 157 treatment of 159 C Calculus 721 Cancer 177 of bone 483 of eyeball, symptoms of 190 treatment of 191 of lip, etiology, diagnosis, prog- nosis,and treatment of 192 symptoms of 191 of mamma 195 prognosis of operation for 200 symptoms, etiology, diag- nosis of 195 treatment of 196, 201 of parotid gland 194 prognosis and treatment of 194 of penis 202 of rectum 206, 766 of skin, diagnosis, prognosis, and treatment of 186 symptoms of 185 of submaxillary glands 194 of testicle 203 of tongue, 193 etiology, diagnosis, prog- nosis, treatment of 193 Cancer— page use of caustics in 186 Cancerous ulcer 183 Carbuncle, constitutional symp- toms, diagnosis, prognosis and trecitnient of 152 local symptoms of 151 Carcinoma, contagiousness of 178 etiology of 177 microscopical characters of 178 Caries 458 of cranium 460 of vertebrae 463 Carpus, fractures of 390 Cataract 587 Catarrhal deafness 610 Catoptric test 590 Causes of dry gangrene 143 of humid gangrene 141 of indolent ulcer 119 of redness in inflammation 49 of unhealthy or chronic ulcers 117 Caustics, use of in cancer 187 Cautery 245 Cephalsematoma 293 Chancre, laws of 692 seat of 689 Changes of temperature in body as a means of diagnosis 25 Channelling process, diagram of 81 Characters of granulations 85 Cheek, affections of 626 Chilblains, symptoms* and treat- ment of 164 Chondroid tumors 225 Chordee 660 Chronic otitis 600 Cicatrices from burns 162 Cicatrization 86 Circocele 734 Circulation as means of diagnosis 29 Clamp suture 250 Clap 685 Classification of tumors 218 of ulcers, Mr. Miller's 113 Sir Everard Home's 112 Clavicle, fractures of 354 Clove hitch 517 Club-foot 805 Coaptation of fractures 331 Coats of the arteries 236 Cold abscesses, Bonet's method of evacuating 98 entrance of air into 96 evacuation of, by caustic 99 local treatment of 96 puncturing of 97 symptoms of 95 treatment of 96 INDEX. 821 Cold— as a haemostatic agent effects of Colles' fracture of radius Collodion Colloid cancer PAGE 244 163 383 251 215 Color of face as means of diagnosis 22 of skin, as means of diagnosis 24 Complete fistula 760 Compound fractures 445 rules for 126 luxations of shoulder-joint 508 Compression of the brain 298 Concealed chancre 695 Concussion of brain 295 of spinal marrow 349 Condylomatous tumors 704 Congenital luxation of hip-joint 528 Conjunctivitis 575 Constitutional results of gonor- rhoea 681 symptoms of mortification 139 Continued suture 248 Contused wounds 256 Cooper's apparatus for fracture of olecranon process 396 Corneitis 581 Corpuscular lymph cell, view of 79 Counter-irritants in inflammation 67 Coxalgia 549 Cranium, fractures of 332 structure of 333 Crepitation 40 Crepitus in fractures 318 Critchet's plan of treating ulcers 122 Cups in inflammation 66 Curvature of spine 462 Cystitis 674 D Dacryocystitis 571 Deafness 606 catarrhal 610 from dryness of the ear 608 from excess of wax 607 nervous > 612 Defecation as a means of diagnosis 35 Definitive callus 322 Deglutition as a means of diagnosis 33 Depressed fractures of cranium 335 Dessault's bandage for fracture of clavicle 357 dressing for fracture of ole- cranon process 395 for fractured patella 422 splint for fracture of middle third of femur 412 Diagnosis by diminished size of a region - 23 by enlargement of any region 23 by hearing 41 by means of excretions 27 by means of mastication 33 by means of modified sensa- tions in a part 25 by means of physiognomy 21 by means of posture of patient 20 by means of respiration 32 by means of variations in size of parts 23 by recumbent position 20 by relaxed condition of ex- tremities 20 by sitting posture 20 by sight 36 by smell 43 by taste 42 by touch _ 38 by variation in length 23 from change of structure 37 from changes in temperature 25 from circulation 29 from color of face 22 of parts 37 of skin 24 from defecation 35 from deglutition 33 from derangement of nervous system 35 from digestion 33 from form of parts 37 from hiccup 34 from hunger ' 34 from thirst 34 from vomiting 34 of burns 158 of cancer of lip 192 of mamma 195 of penis 203 of rectum 206 of testicle 204 of erysipelas 109 of fungus haematodes 212 of hectic fever 104 of humid gangrene 141 of senile gangrene 147 Diagram of channelling process 81 of fusiform enlargement 81 Digestion as means of diagnosis 33 Dilatation of permanent stricture 688 Diseases of the bones and joints 313 of the ear 595 Dislocations * 489 Displacement in fractures 317 of latissimus dorsi muscle 499 52* 822 INDEX. Displacement— page of the lens 591 Dissecting wounds 270 Distichiasis 567 Dorsey's dressing for fractured patella 423 Dry gangrene 140, 143 Block's experiments on 145 causes of 143 class of patients who suffer from 143 seat of 146 symptoms of 144 suture 249 Dupuytren's classification of burns 156 splint 440 Ear, diseases of 595 Earache 601 Ecthyma 135 Ectropion 568 Eczema of anus 750 rubrum 133 treatment of 134 simplex 132 Effects of cold 163 of hemorrhage 246 of inflammation 75 of wounds on the arteries 236 Effusion of pus 87 Elbow-joint, anchylosis of 547 Encanthus 570 Encephalocele 301 Encephaloid cancer 207 Enchondromata 483 Encysted tumors 223 Enlarged bursae 797 Ensheathing callus 323 Entropion 567 Epididymitis 668 Epiphora 571 Epithelial cancer 186 Erysipelas 167 diagnosis of 169 etiology of 168 of the scalp 291 prognosis of 170 seat and symptoms of 167 treatment of 171 Etiology of cancer of lip 192 of tongue 193 of carcinoma 177 of erysipelas 168 of hectic fever 103 of inflammation 56 Evacuation of acute abscesses 93 Evacuation— page of cold abscesses 98, 99 Examination of internal organs as means of diagnosis _ 29 Excretions, as a means of diagnosis 27 Exostosis 481 External otitis 597 pathology 17 Eye, affections of the appendages 561 foreign bodies in 562 Eyeball, cancer of 190 diseases of 574 medullary carcinoma of 214 Eyelids, wounds of 563 Facies Hippocratica 22 False aneurisms 770 joint 325 membrane, formation of 78 Farcy 274 Fatty tumors 221 Felon 791 Femoral aneurism 787 bursa 800 Femur, fracture of 397 head of 398 neck of, within the capsul 3 398 middle third of 411 shaft of 409 Fibro-cellular tissue, view of for- mation of 79 Fibrous polypi 620 tumors 221 Fibula, fracture of 437 luxation of 533 Field tourniquet 244 Fissure of anus 753 of cranium 335 Fistula in ano 759 lachrymalis 572 Fit of the stone 726 Flexible splint 411 Foreign bodies in ear 604 in nostril 617 in pharynx 627 Fox's apparatus 361 Fracture bedstead 328 box 428 mattress 328 of neck of femur, without the capsule 406 of shaft of femur 409 Fractures in general 315 of bones of leg 426 of both bones of forearm 377 of carpus 390 INDEX. 823 Fractures— page of clavicle 354 of condyles of femur 418 of humerus 374 of cranium 332 of femur 397 of fibula 437 of humerus 367 of inferior maxilla • 341 of malar bone 341 of metacarpus 391 of middle third of femur 411 of nasal bones 337 of olecranon process of ulna 393 of os calcis 442 of os hyoides 346 of patella 419 of phalanges of fingers 392 of foot 444 of radius 381 of ribs 351 of scapula 365 of shaft of humerus 371 of sternum 353 of superior maxillary bone 340 of surgical neck of humerus 368 of tarsus 441 of vertebral column 347 reduction of 330 treatment of 326 varieties in 316 Fragilitas ossium 485, 487 Frog-face 621 Frost-bite, treatment of 165 Fungus cerebri 299 haematodes 207 diagnosis of 212 of the dura mater 299 Furuncle 149 seat, symptoms, diagnosis, prognosis and treatment of 150 Fusiform enlargement, diagram of 81 G Ganglion 798 Gangrene 136, 139 Gerdy's apparatus for patella 425 Gibson's bandage for fracture of lower jaw 344 Glanders 274 Gleet 672 Glover's suture 310 Gonorrhoea 658 in the female 678 Gonorrhoeal ophthalmia 578 Granulations 84 characters of 85 page Gravel 717 Groin, enlargement of glands of 698 Guerin's treatment of lateral curv- ature 473 Gunshot wounds 276 H Haematocele 733 Haemostatics, artificial 240 natural 237 Handkerchief bandage of groin 699 Hard polypi 620 Harelip suture 248 Hartshorne's splint for femur 417 Hays' splint for fracture of radius 390 Healing of wounds 230 Hearing, as means of diagnosis 41 of crepitus 41 of gurgling 41 of the whirr 42 of tone of voice 41 Heat, in inflammation 50 causes of 51 Hunter's experiments on 50 Hectic fever 100 appetite, thirst and emacia- tion in 102 diagnosis, prognosis and treat- ment of 104 etiology of 103 pulse in 101 symptoms of 101 Hemorrhage from wounds 235 Hemorrhoids 762 Hernia 639 cerebri 301 irreducible 642 reducible 641 strangulated 644 Hey's luxation of the knee 532 Hiccup as a means of diagnosis 34 Hip-joint disease 549 Hordeolum 564 Horner's splint for fractured femur 415 Hospital gangrene 148 symptoms of 14$ treatment of 149 Housemaid's knee 799 Humerus, condyles, fracture of 374 fractures of 367 shaft of 371 surgical neck of 368 Humid gangrene, causes of 140 diagnosis, prognosis, treat- ment 141 mortification or gangrene 139 824 INDEX. PAGE Hump-back 463 Hunger as a means of diagnosis 34 Hunter, experiments on inflamma- tion 48 operation for aneurism 781 Hunterian chancre 691 Hutchinson's splints 432 Hydrocele 729 of neck 631 of the cord 730 Hydrophobia 266 Hypopion 585 Ichor, sanies, sordes 87 Imperforate anus 766 rectum 766 Impetigo figurata 134 symptoms of • 134 treatment of 134 Incised wounds 254 Incomplete fistula 760 Indolent ulcer 119 causes, seat and edges of 119 granulations, pus and pain of 120 treatment of 121 Inferior maxilla, fracture of 341 Inflammation, application of moxae in 68 causes of heat in 51 redness in 49 constitutional treatment of 70 counter-irritants in 67 curative or regulating treat- ment of 62 by local antiphlogistics, evaporants, irrigation 62 effects or products of 75 effusion of lymph in 77 of serum in 76 etiology of 56 exciting causes of 56 experiments of Hunter on 48 Paget's experiments on 58 predisposing causes of 56 prophylactic treatment of 61 proximate or essential causes of 57 redness in 47 results of 61 symptoms of 47 use of anodynes in 73 of cups in 66 of issues in 67 of leeches in 64 of moxae in 68 Inflammation— PAGE of sedatives in 74 of seton in, 68 varieties of 46 venesection in 70 Inflammatory fever 54 symptoms of 54 Injuries of brain 295 of bones and joints 313 of soft tissues 229 Internal otitis 598 Interrupted suture 248 Iritis 584 Irreducible hernia 642 Irrigation, in treatment of inflam- mation 63 Irritable bladder 674 ulcer 116 Issues, use of, in inflammation 67 K Kidneys, affections of 717 Knee, luxations of 530 Hey's luxation of 532 Knee-joint, anchylosis of 548 Kolbe's apparatus for anchylosis 548 for club-foot 816 Laced stocking in varices 804 Lacerated wounds 255 Lachrymal apparatus, affections of 570 Lagophthalmus 568 Lateral curvature of spine 463, 471 luxation of elbow 512 Leeches, application of 65 in inflammation 64 preservation of 64 Lens, displacement of 591 Leucoma 582 Levis's clavicle apparatus 363 Ligature, action of 240 Line of demarcation in gangrene 138 of separation 138 Lip, cancer of 191 Lipoma 222, 613 Lips, affections of 626 Liston's long splint 407 Lumbar abscess 464 Lupus 614 Luxation of ankle-joint 534 of fibula 533 of head of femur on the pubes 524 into the foramen thyroi- deum 526 INDEX. 825 Luxation of femur— page into ischiatic notch 527 of patella 529 Luxations 489 of astragalus 536 of both bones of forearm 509 of carpal bones 515 of clavicle 497 of elbow-joint 508 of head of radius 512 of hip-joint 518 of humerus • 500 of inferior maxillary 492 of knee 530 of knee-joint 528 of metacarpal bones 516 of metacarpal bone of thumb 516 of os magnum of os pisiforme of ribs of ulna of vertebrae of wrist Lymph, effusion of treatment of organization of Lymphatic tumors M 515 515 496 513 494 513 77 85 80, 82 226 PAGE Nasal bones, fractures of 337 Natural haemostatics 237 Nebula 581 Necrosis 475 Nephritic colic 724 Neuralgia 800 Nocturnal emissions 710 Nodes 454 Nose, affections of 612 Nostril, foreign bodies in 617 Malar bone, fracture of 341 Malgaigne's apparatus for patella 424 Malignant deposits 176 pustule 275 Mastication as a means of diagnosis 33 Mayor's clavicle handkerchief 360 scapulo-dorsal handkerchief 154 Mclntyre's thigh splint 407 Measurement in fracture of femur 403 of parts in diagnosis 23 Medullary carcinoma of the eyeball 214 sarcoma 207 Melanosis 216 Melicerous tumor 224 Metacarpus, fractures of 391 I Microscopic characters of fungus haematodes • 210 Modelling period of fractures 325 j Modified sensation, as means of i diagnosis 25 | Mollities ossium 485 | Morbus coxarius 549 Mortification 135 j local symptoms of 136 J varieties of 139 j Moxae, application of J38 Mulberry calculus 722 0 Olecranon process of ulna, frac- tures of 393 Onychia 791 Ophthalmia, gonorrhoeal 578 purulent 578 scrofulous 579 tarsi 565 Organization of lymph 80 Os calcis, fracture of 442 hyoides, fractures of 346 Osteo-malacia 485 Osteo-sarcoma 483 Ostitis 455 Otalgia 601 Otitis 590 Otorrhoea 602 Oxalic acid gravel 720 Ozaena 615 Paget, experiments on inflammation 58 views on healing of wounds 233 Pain in inflammation 51 Pannus 582 Paraphymosis 659 Paronychia 791 Parotid gland, cancer of 194 Patella, fractures of 419 luxation of 529 Pathology of abnormal growths 175 external 17 surgical 45 Penis, cancer of 202 Periostitis 453 Permanent stricture 683 Pernio, symptoms and treatment of Pes calcaneus equinus plantaris 164 811 807 815 826 IXDEX. PAGE 815 695 117 811 392 627 720 659 Pes— talus Phagedenic chancre sore Phalangeal pes equinus Phalanges, fractures of Pharynx, foreign bodies in Phosphatic gravel Phymosis Physick's modification of Des- sault's splint Physiognomy as a means of diag- nosis Piles Poisons in stomach antidotes for Poisoned wounds Polypi narium Polypus of the antrum of the ear Popliteal aneurism Pott's gangrene symptoms of treatment of caries Preparation of sponge Preservation of leeches Pressure, in arrest of hemorrhage 242 Process of repair in soft tissues 229 Prognosis of cancer of testicle of erysipelas of hectic fever of humid gangrene of operation for cancer of breast Projectiles Prolapsus ani 413 21 762 632 635 259 618 625 605 786 146 147 471 247 64 204 170 104 141 200 278 756 Prophylactic treatment of inflam- mation 61 Prostatitis 673 Provisional callus 322 Pseudarthrosis 446 Psoas abscess 464 Psorophthalmia 565 Pterygium 580 Ptosis 569 Punctured wounds 258 Puncturing of acute abscesses 94 Pus, of the effusion of 87 Pus-cells, a view of 87 Pyemia 105 symptoms of 106 treatment of 107 Pyogenic membrane 89 Quilled suture 249 R PAGE Rabies canina 266 Radius, fractures of head of 381 luxation of 512 Rectum, cancer of 206 Recurrent bandage of head 292 Red gravel 719 Reducible hernia 641 Reduction of fractures 330 Reid's plan of reducing luxation of femur 521 Respiration as means of diagnosis 32 Results of inflammation 61 Rhinolithes 616 Ribs, fractures of 351 Risus Sardonicus 22 Rupia 135 Salter's apparatus for fracture 430 Sarcomatous tumors 219 Scapula, fractures of 365 Scarpa's plan of treating aneur- isms 780 Scirrhus, general appearance of 181 symptoms, constitutional, and treatment of 183 symptoms, local, of 182 Sclerotitis 580 Scrofulous conjunctivitis 579 ophthalmia 579 Secondary syphilis 701 Sedatives in inflammation 74, 75 Semeiology, surgical 19 Senile gangrene 146 diagnosis of 147 symptoms of 147 Sequelae of ulcers 131, 132 Serum, effusion of 76 Seton, application of 69 Shoulder-brace 470 Sight, as a means of diagnosis 36 Simple sarcoma 219 Sketch of the arrangement of blood- vessels in granulations 84 Skin diseases 132 Sling of the chin 345 Smell as a means of diagnosis 34 Smith's (H. H.) apparatus for un- united fracture 450 Soft polypi 618 Spanish windlass 244 Special wounds 253 Specific ulcers 128 Spermatocele 735 Spermatorrhoea 709 INDEX. 827 PAGE Sphacelus 137 Spina-bifida 474 Spina-ventosa 483 Spinal concussion 349 curvature 466 meningitis 350 Spiral reversed bandage 127 Sponge, preparation of 247 Spongio-pileine 92 Sprains 537 Staphyloma 583 Starch bandage 435 Sternum, fractures of 353 Sting of insects 260 Stone_ 717, 721 Strabismus 572 Strangulated hernia 644 Stricture of the rectum 767 of the urethra 681 Structure of bones 313 Stye 564 Styptics 245 Sublingual gland, cancer of 194 Subluxation of inferior maxillary 494 Submaxillary gland, cancer of 194 Superior maxillary bone, fractures of 340 Surgical pathology 45 semeiology 19 therapeutics 17 Suspended animation from cold 165 Sutures 248 Swelled testicle 668 Swelling in inflammation 53 Symblepharon 570 Sympathy 35 Symptoms of burns 157 of cancer of eyeball 190 of mamma 195 of penis 202 of skin 185 of testicle 204 of carbuncle, constitutional 152 local 151 of chilblains 164 of dry gangrene 144 of eczema simplex 133 of erysipelas 167 of furuncle 150 of hectic fever 101 of hospital gangrene 148 of inflammation, local 47 of medullary carcinoma 207 of mortification, constitutional 139 local 136 of pyemia JU« of scirrhus, constitutional ic-o local i82 Symptoms— PAGE of senile gangrene 147 Syphilides 703 Syphilis 655, 689 in the female 700 Tactus eruditus 27 Talipes 805 Tarsus, fractures of 441 Taste as a means of diagnosis 42 Tertiary syphilis 708 Testicle, affections of 729 cancer of 203 Tetanus 287 Therapeutics, surgical 17 Thirst as a means of diagnosis 34 Thoracic aneurism 784 Throat, affections of 627 Thumb, luxation of metacarpal bone of 516 Toe-nail ulcer 129 diagnosis and prognosis of 130 treatment of 130 Tongue, cancer of 193 Torsion, in arrest of hemorrhage 242 Torticollis 630 Touch as a means of diagnosis 38 Tourniquet of Petit, application of 243 Treatment of acute or healthy ulcers 114, 115 of burns 159 of cancer by caustics 186 of eyeball 191 of lip 192 of mamma 196, 201 of penis 203 of rectum 206 of testicle 205 of tongue 193 of carbuncle, constitutional 155 local • 152 of chilblains 164 of club-foot 815 of dry gangrene 146 of eczema rubrum 134 of effusion of lymph 85 of epithelial cancer 186 of erysipelas 171 of frost-bite 165 of furuncle 150 of hectic fever 104 of hemorrhage 246 of hospital gangrene 149 of humid gangrene, constitu- tional 143 828 INDEX. Treatment— page of humid gangrene, local 142 of impetigo figurata 134 of indolent ulcers 121 Baynton's method of 122 Stafford and Critchet's method of 122 of medullary carcinoma 213 of pyemia 107 of scirrhus 183 of suspended animation from cold 166 of toe-nail ulcers 130 of tumors 226 of unhealthy ulcers, constitu- tional 118 local 117 of varicose ulcers 129 Trichiasis 566 Tubercles of testis 736 of vertebrae 464 Tuberculous tumors 226 Tumors, adipose or fatty 221 benignant 217 fibrous 221 of anus 755 Twisted suture 248 U Ulceration 108 of posterior nares 022 view of Cuvier, Paget, and Miller on 108, 109 views of Hunter on 109 Ulcer of the toe-nail 129 Ulcers, acute or healthy, defini- tion of 113 causes of 114 treatment of 114, 115 definition of 111 due to active unhealthy in- flammation 116 due to chronic unhealthy in- flammation 119 Mr. Miller's classification of 113 sequelae of 131 Sir Everard Home's classifi- cation of 112 specific 128 unhealthy or chronic 115, 110 causes, and local treatment of 117 constitutional treatment of 118 edges, pus and seat of 110 varicose 128 Ulna, luxation of 513 Union by adhesive inflammation 84 by first intention 83, 231 Union— by scabbing process by second intention of wounds Uniting bandages period of fractures Ununited fracture PAGE 231 84 247 253 324 446 Valgus 814 Valsalva, treatment of aneurism 785 Varices 801 Varicocele 734 Varicose aneurism 789 ulcers 128 treatment of 129 veins - 801 Varieties of mortification 139 Varus 812 Venereal warts 677 Venesection 70 operation of, with spring lan- cet 72 with thumb lancet 71 Vertebral column, fractures of 347 View of corpuscular lymph cell 79 of formation of fibro-cellular tissue 79 of pus-cells 87 Vomiting as a means of diagnosis 34 W Wardrop's operation for aneurism 778 Warts 677 Wens 223 White swelling 541 Whitlow 791 Wounds from diseased animals 273 healing of 230 Paget's views on 233 of the abdomen 308 of the chest 305 of the face 301 of the genito-urinary organs 311 of the head 291 of the intestines 309 of the neck 304 of the regions of the body 290 of the scalp 291 union of 247 Wry-neck 630 X Xerophthalmia 517 44iSZ